Abstract
Aims:
Independent living among older adults is a global political goal aimed at reducing government spending on health and care services. This study investigates the prevalence of having someone to rely on for help when needed among community-dwelling adults aged 70 and older.
Methods:
The study sample comprised population-based data from 24,289 adults aged 70 or older participating in the Trøndelag Health Study (HUNT4). Standardized prevalence of having someone to rely on for help if needed in total, and from family, friends, or neighbors was estimated using Trøndelag county as the standard population. Prevalences were additionally stratified by gender, age, living situation, activities of daily living (ADL), and utilization of home-based services.
Results:
Standardized results showed that overall, 97.3% reported having someone to ask for help if needed, of whom 92.5% relied on family, 31.7% on friends, 23.1% on neighbors. The youngest men living alone had fewer to rely on compared to those living with others. Moreover, living alone was associated with relying less on family and more on friends and neighbors. Factors associated with relying on family members were female gender, younger age, cohabitation, no ADL problems, and no home-based services. Along with education, these factors also correlated with relying on friends for help.
Conclusions:
Keywords
Introduction
Aging is associated with functional decline, increased risk of reduced health and various losses that can impact one’s independence. Perceived social support has long been considered an important coping resource [1]. However, as we age, it is common to experience the loss of a spouse and friends, and retirement from work often involves separation from colleagues and a decrease in income. The consequences of age-related changes and losses include an increased vulnerability to social isolation [2], diminished physical and mental health [3], and a greater need for guidance, support and help from others [4].
“Aging in place” refers to living in one’s own home as one grows older [5] and is an important policy response to the increasing share of older people in most countries [6]. As part of the governmental strategies for aging in place, older people are encouraged to seek formal and informal support from their local community, family, friends, and neighbors, if needed, to facilitate independent living [7]. To enhance the health and functional ability of older adults, as well as promote, maintain, and improve independence and independent living, the United Nations and the World Health Organization have initiated the global “Healthy Ageing framework.” This framework includes “The Decade of Healthy Ageing,” which acknowledges the importance of community support in optimizing functional ability among older adults [8, 9]. However, studies on social networks or support in older adults’ local communities in relation to aging in place are rare, despite the assumption that it has a significant impact [5, 10, 11]. This scarcity means that our understanding of older adults’ actual and perceived access to informal help is limited. Anticipated support is the belief that help will be provided by someone if needed [12]. In particular, older adults with low socioeconomic status, cognitive impairment, and physical disability have been reported to experience barriers to developing strong social networks [13]. Existing research indicates that in high-income countries, individuals aged 50 and above, particularly males, those of younger age, those living alone, and the socioeconomically disadvantaged, appear to have a higher risk of different kinds of unmet needs and a lack of support [14].
The aim of this study was to investigate the prevalence of having someone to rely on for help if needed among community-dwelling older adults in Norway, specifically, from family, friends, or neighbors. This study was conducted using a large population-based dataset that included over 24,000 participants aged 70 years or older living at home.
Materials and methods
The Trøndelag Health Study
Since 1984, extensive data in the Trøndelag Health study (HUNT) has been collected from participants residing in the former county of Nord-Trøndelag through questionnaires, clinical measurements, and biological samples. HUNT data has been collected in four study waves, and is one of the largest and most comprehensive population-based health studies globally [15]. In 2018, the two counties Nord-Trøndelag and Sør-Trøndelag were merged into Trøndelag county. The fourth wave of HUNT (HUNT4) included both Nord-Trøndelag and Sør-Trøndelag and was conducted during the period 2017 to 2019 in Nord-Trøndelag and in 2019 in Sør-Trøndelag. The HUNT4 data collection for Nord-Trøndelag was conducted similarly to previous HUNT surveys. Participants completed Questionnaire 1 (Q1) at the examination station, while Questionnaire 2 (Q2) for the different age groups was completed at home and returned by mail. Data for Sør-Trøndelag was collected primarily through a web-based survey, with exceptions for the examinations of 1745 residents aged 70 years or older in Trondheim, and the provision of paper copies of the questionnaire to older adults who requested them. Nord-Trøndelag is mostly rural, but Trøndelag county, which includes both Nord-Trøndelag and Sør-Trøndelag, encompasses the large city of Trondheim. The HUNT4 study, which is conducted in both Nord- and Sør-Trøndelag, is generally considered representative of Norway [16].
Study sample
Figure 1 illustrates the structure of the included study sample, comprising participants from both Nord-Trøndelag and Sør-Trøndelag aged 70 years or older. A total of 53,004 inhabitants in Trøndelag aged 70 years and older were invited to participate in the HUNT4 study: 19,374 in Nord-Trøndelag and 33,630 in Sør-Trøndelag. We estimate that the overall attendance at HUNT4 for participants aged 70 and older was 45.8%. Among these, 24,289 participants were community-dwellers who lived at home, not in any type of institution, and had completed the HUNT4 question: “Do you have anyone who could give you help if you needed it?” The available total sample included 9418 participants from Nord-Trøndelag and 14,871 from Sør-Trøndelag.
Flow chart of the included study sample including participants aged 70 years and older from the fourth wave of the Trøndelag Health Study (HUNT4) with participants from Nord-Trøndelag (NT) and Sør-Trøndelag (ST).
In addition, aggregated registry data on gender, age group, and educational level weights for Trøndelag county in 2019 were obtained from microdata.no and used for the standardized analysis to account for potential selection bias in the sample, as younger individuals, women, and those with higher education were overrepresented.
Variables
Self-reported HUNT4 items from Q1 (education) and Q2 (living situation, activities of daily living (ADL), and home-based services) for participants from Nord-Trøndelag, along with the equivalent items from the primarily web-based questionnaires completed by participants in Sør-Trøndelag were used in this study.
Outcome variable
The outcome variable “Do you have anyone who could give you help if you need it?” included the dichotomous response categories: “yes” or “no.” Those responding “yes” were asked to indicate whether this help could come from family, friends, neighbors, or a combination (multiple responses were possible).
Covariates/stratifying variables
The analyses were stratified by gender, age, education, living situation, problems with personal ADL (PADL) and instrumental ADL (IADL), and utilization of formal home-based help services and home-based nursing care. Gender and age were registry-based and age was grouped as 70–74, 75–79, 80–84, and 85 years and older. Education was self-reported and grouped as primary, secondary, or tertiary education. Participants were asked whether they lived alone, with a partner, or with children. This information was used to dichotomize the living situation variable into “Living alone” (for the response “lived alone”) or “Living with someone” (for all other responses). Self-reported disability was assessed using ADL, which was based on the question “Can you, without the help of others, do the following daily tasks?” The PADL items included 1) move around indoors on the same floor, 2) go to the toilet, 3) wash yourself, 4) take a bath or shower, 5) dress and undress yourself, 6) get in and out of bed, and 7) eat. The IADL items included 1) do heavier housework, 2) pay bills, 3) take medication, 4) go outside, 5) do the shopping, and 6) take the bus. The response categories were 1 = yes and 2 = no. A composite score with three groups was created: 1. No problems with PADL or IADL, 2. Only IADL problems, and 3. PADL problems. Formal home-based help and nursing services were assessed with the questions “Have you had home-help services in the last 12 months?” (yes/no), and “Have you received home nursing care in the last 12 months?” (yes/no), respectively. A composite score with three categories was created: 1. No home-based services, 2. Home-help services only, and 3. Nursing home services.
Statistical methods
Stata 18 was used for the analyses. The prevalence of having anyone to ask for help by gender, age, education, living situation, ADL, and utilization of health care services was estimated. Self-reported and registry data for educational level were harmonized before standardization, and standardized prevalences were estimated using the direct method. In the crude analyses, differences between groups were tested using the chi-square test, while in the standardized results, differences between groups were tested using a modified F-test. To model standardized prevalence across multiple dimensions, weighted binominal regression analysis applying an identity link was applied (Stata code: svy: glm having_someone_to_ask_for_help i.age_group##living situation##gender, family(bin) link(identity) nolog), again using Trøndelag county by age, gender, and education as the standard population. This method was used over more default methods such as logistic regression, because we focus on absolute numbers rather than relative measures. Statistical significance was set to 5%.
Ethical considerations
The study was approved by the Norwegian Regional Committee for Medical Research Ethics (reference number 2019/149). Participants in the HUNT surveys gave written informed consent.
Results
Having someone to rely on for help when needed
Standardized results for Trøndelag showed that 97.3% had someone to ask for help when needed, with no significant differences across age groups, educational levels, or ADL status (Table I). Slightly more woman than men reported having someone to rely on for help when needed (97.6% among women and 97.0% among men; F-test: p < 0.01), as did cohabitators compared to those living alone (98.4% compared to 95.3%, p < 0.01), those in Nord-Trøndelag compared to Sør-Trøndelag (97.6% compared to 97.2%, p < 0.01), as well as according to home-based services; 97.5% among those receiving no services compared to 96.1% for those receiving home-help services only, and 97.0% for those with home nursing care (p < 0.01). Crude results were similar to standardized results (Table I).
Crude and standardized* prevalence of having someone to rely on for help when needed, frequencies (%), N = 24,289.
Standardized to the population in Trøndelag in 2019 according to age, gender, and education, using the direct method.
Standardized results for the overall question of whether respondents had someone they could ask for help if needed indicated no interaction between age and education for either men or women (Figure 2(a)). The same applied to ADL (Figure 2(b)), and home-based services (Figure 2(c)). However, for living situation (Figure 2(d)), there was an interaction with age: the differences regarding the overall outcome question were especially pronounced among the youngest age groups (there was a significant two-way interaction for living alone*age: p < 0.001 in men and p = 0.02 in women). This interaction was more pronounced in men, and there was a significant three-way interaction for living alone*age*gender, p = 0.04). Among the youngest men living alone (aged 70–74), 88.5% reported having someone to ask for help when needed, compared to 98.2% among men living with someone at the same age. In the oldest age group (85+) this difference according to living situation was only 3.0 percentage points (Figure 2(d)).
Prevalence of having someone to rely on for help when needed (%), in total and from whom, by age and one of the following: (a) education, (b) ADL, (c) home-based services, (d) living situation. Standardized to the Trøndelag population in 2019 according to age, gender, and educational level.
Having someone to rely on for help when needed from family, friends, or neighbors
Standardized results showed that the respondents mostly relied on help from family members, and less from friends and neighbors: 92.5% relied on help from family members, 31.7% from friends, and 23.1% from neighbors (39.0% from friends or neighbors). Slightly more woman (93.1%) than men (91.9%; F-test: p < 0.01) relied on help from their family. The youngest more often reported having someone in the family to rely on (p < 0.01), as did cohabitators (95.6%) compared to those living alone (86.7%; p < 0.001), as well as those without ADL difficulties (92.9%) compared to only PADL difficulties (91.4%) or those with IADL difficulties only (91.4%; p < 0.01). Furthermore, there were differences regarding having someone in the family to rely on for help when needed according to home-based services: 93.2% among those receiving no services, 88.0% for those receiving home-help only, and 89.8% for those with home nursing (p < 0.01). Among those who had someone to ask for help when needed, 1.0% reported none of these options, suggesting either a missing response or an alternative source, such as municipal or private services.
Standardized results also showed that more woman than men relied on help from friends (32.9% of women and 30.2% of men; F-test: p < 0.01). There was a distinct age gradient, where the youngest relied on help from friends more often than did the older adults (39.5% for the 70–74 year olds, 32.5% for those aged 75–79, 25% for 80–84 year olds, and 19.7% for the 85+ group; p < 0.01). Other factors associated with relying on help from friends were high education (46.7% for tertiary education compared to 22.7% for primary education; p < 0.01), living alone (34.6% for living alone compared to 30.4% among cohabitators; p < 0.001), address in Sør-Trøndelag (p < 0.01), no ADL difficulties (p < 0.01), and no home-based services (p < 0.01) (Table I). The youngest more often relied on help from neighbors than did the older adults (p < 0.01), as did those with higher education (p < 0.01), those without ADL difficulties (p < 0.01), and those living alone (p < 0.01) (Table I).
Discussion
This large study of older community-dwelling participants in Trøndelag county in Norway, found that nearly all reported having someone they could ask for help when needed. The majority relied on support from their family, while some also reported that they could ask for help from friends and neighbors. The overall figures were similar for both women and men, as well as across age groups, educational levels, and reported levels of problems in ADL. The population-based data from the county of Trøndelag used in the present study is considered representative of the Norwegian population according to age, gender, and education [16]. Therefore, this study suggests that most older adults in Norway expect to get help when needed from someone in their social network.
A recent population-based German study on prevalence of social isolation [17] assessed by the six-item version of the Lubben Social Network Scale, which includes one item about how many relatives one feels close enough to call on for help [18], reported that more than 20% in the 70–79 age group felt socially isolated [17]. The diverse results, based on the analysis of different but related constructs in two different studies, are not directly comparable but illustrate complex relationships and may indicate differences between the countries. Nevertheless, the results of the present study support that aging in place and healthy aging policies seem viable in Norway at the current time, especially in terms of access to informal help promoting independent living. However, despite Norway having a comprehensive social welfare system, the future policy framework is a topic of widespread debate [19], particularly due to the aging population and the strain this can place on informal caregivers [20].
Potentially vulnerable groups were detected in this study. Those living alone were far more likely to lack someone to ask for support when needed compared to those living with others. This was particularly pronounced in men in the youngest age group. To report not having anyone to turn to for help may indicate a lack of social networks and difficulty in reaching out to potential sources of support. These findings are consistent with theories of masculinity that suggest men may struggle more than women to seek assistance from others [21]. Moreover, a Norwegian report by Statistics Norway (in Norwegian only) from 2022 found that men who live with someone receive more formal care from the municipality compared to men who live alone, while for women who live with someone it is the opposite case [22]. Further investigations are warranted to learn more about possible associations, including those concerning the age gradient found among men. Nonetheless, the present results suggest that older people who live alone, particularly men, face a higher risk of having a suboptimal environment for aging in place due to the lack of someone to rely on for help when needed.
We have not found any comparable Norwegian or international studies. However, a related study based on the same data as the present analysis, found that having someone to confide in was associated with greater independence in ADL for adults aged 70 and above, but it did not include measures of whether the respondents lived alone or not [23]. Family members were the most relied on source of support in this study, although this reliance was less common among older individuals living alone. Previous studies have shown that older adults with children receive more help when needed compared to childless older adults [24], and proximity to one’s network is also important for the level of received informal support [13].
We do not know whether people with higher educational levels have more friends or friends nearby than those with lower levels, but almost half (47.2%) of those with the highest level of education in this study reported having access to support from friends when needed, compared to slightly less than a quarter (23.7%) among those with the lowest educational level. These results demonstrate significant demographic differences in relying on help from friends, indicating large variations in the diversity of social networks among different groups of older adults in Norway, and different prerequisites for independent living.
The proportion of participants expecting help from neighbors when needed was relatively low compared to help from family or friends, and evenly distributed among sociodemographic groups. This finding highlights the importance of the current emphasis on safety, stability, and suitability of the “place” in aging in place among older adult [6]. As discussed by Yarker et al., the relational perspectives of “place” in the concept of aging in place is gaining more attention due to the uneven capacity to support aging in place for older people residing in different communities and neighborhoods [6]. For many older people, it is not feasible to move or invest in an age-friendly place. Differences in locations and housing opportunities when aging in place can contribute to increased inequality among groups of older adults and an increased risk of social isolation, particularly for those who are already disadvantaged. An investigation into actual neighborhood assistance among individuals aged 50 years or older in 17 European countries (the SHARE study) found that approximately 6% reported providing help to others, while 4% had received help in the last 12 months [25]. Data from Norway was not included.
The overall prevalence of individuals who reported having someone to rely on for help when needed was similar among participants receiving home-based services, home-based nursing care, and those who did not receive any form of home-based assistance. However, in our study, individuals receiving home-based services or home-based nursing care relied less on their family or friends for support. These results can be interpreted in several ways. One interpretation is that the welfare system is effective, providing public support to those with home-based services who do not have others to rely on. Another interpretation is that it is natural to expect less support from family and friends when you are provided with home-based services. It may also reflect that those aged 70 and over who receive home-based services have fewer friends and family members to ask for support when needed than those without home-based services.
Strengths and limitations
Strengths of this investigation include the appropriate internal validity of the HUNT Study for the current research aim and the use of standardized analyses to adjust for the overrepresentation of younger individuals, women, and those with higher education in the sample. Due to the standardized analyses, the results are considered fairly generalizable to the Norwegian population.
However, regarding potential limitations, the impact of the different data collection methods in Nord-Trøndelag and Sør-Trøndelag on the results remains uncertain. Moreover, although the HUNT Study is generally considered representative of the Norwegian population, encompassing both typical rural and urban Norwegian areas [16], we lacked information on the prevalence of having someone to rely on for help when needed among the HUNT4 non-responders. Among individuals aged 80 and over in HUNT4, home nursing and nursing home residency were more common among non-participants [16]. Other population-based studies have reported that compared to participants, non-participants may tend to engage less in social activities such as charity work [26]. Therefore, a potential limitation of this study could be a slight overestimation of the availability of someone to rely on for help when needed.
Another limitation of this study is that it does not investigate the willingness of potential caregivers to provide support. Consequently, the results cannot be used to determine the actual access to support among older adults, or specifically from family, friends, or neighbors. A recent study, using longitudinal data from nine countries (N = 955), found that the willingness of potential caregivers to provide support is not stable. For many, it may decrease over time and even fluctuate between weeks [27].
Conclusion
This study implies that most adults aged 70 and older in Norway have someone to rely on for help when needed, which is positive for healthy aging and aging in place policies. However, older individuals who live alone, particularly men aged 70–74, seem to be at a higher risk of not having an optimal environment for aging independently. This is due to having fewer people who they can ask for help compared to others of the same age, whether it be family, friends, or neighbors.
Footnotes
Acknowledgements
The Trøndelag Health Study (HUNT) is a collaboration between HUNT Research Centre (Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology), Trøndelag County Council, Central Norway Regional Health Authority, and the Norwegian Institute of Public Health.
Author contribution
The authors confirm contribution to the paper as follows: study conception and design: BHS, EML; analysis and interpretation of results: BHS; draft manuscript preparation: BHS, EML. Both authors reviewed the results and approved the final version of the manuscript.
Data availability
Data from the HUNT Study used in research projects are available upon request from the HUNT Data Access Committee (hunt@medisin.ntnu.no) to research groups who meet the data availability requirements.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Norwegian Directorate of Health as part of the project “Funksjonsfriske leveår blant eldre i Norge” (Functionally healthy life years among older adults in Norway).
