Bridging the digital divide
Keywords: triangle of health, health economics, elderly, digital divide
University of Amsterdam Bachelor thesis
Health economics Second semester 2013
Supervisor: Evert-‐Jan Velzing MSc Querijn Hollemans 0483273
Abstract:
Human health is a complex phenomenon and consists of three elements. This research provides a model to determine and explore health-‐influencing factors. The elements of physical, mental and social well-‐being form together a continuum that determine the
overall health of a human individual. The determinants of the element of physical well-‐being consist of a biological and physical environmental factor. The determinants of the element of mental well-‐being consist of autonomy, competence and relatedness. The determinants of the element of social well-‐being consists of social acceptance, actualization, coherence contribution, and integration. Inputs of health can be grouped according to the factor(s) they stimulate or distinguish.
People are living longer and life expectancy will continue to improve in coming decades. Thus, our society is ageing and ageing comes along with age related and health influential complications like social isolation and the digital divide. Online social integration is a start to bridge the digital divide, and stimulates the social element of the triangle of health, and therefore it stimulates the overall health of an elder individual.
Chapter Index:
Page:
1. Introduction
4
2. Literature Review
5
2.1.Three elements of health
5
2.1.1. Physical well-‐being
5
2.1.2. Mental well-‐being
7
2.1.3. Social well-‐being
7
2.1.4. Triangle of health
3. Theoretical Model
12
4. Analysis
16
4.1. Ageing process
16
4.2. Online integration
17
5. Conclusion
20
7. References
22
1.Introduction
Over the past decade, there has been heated debate on the socio-‐economic
consequences of population ageing. The trends are clear. People are living longer and life expectancy will continue to improve in coming decades according to the Organisation for Economic Co-‐operation and Development (OECD report 2010). In 2011, the population of the Netherlands counted more than two and a half million (15,6 %) citizens that were over 65 year of age (CBS, 2012). This group of elderly will grow over the coming years and in 2040, one out of four Dutch citizens has more than 65 years of age, and one out of ten has more than 80 years of life experience. And this longevity, or life expectancy of the Dutch population keeps growing. One of the consequences of an aging population is that the older generation is at an increased risk of social isolation (Windle, Francis & Coomber, 2011). This happens through life due to age related changing events such as mental disabilities, physical disabilities, retirement or loss of partner, friends and relatives (Forbes & Thompson, 1990). The research question of this thesis concerns a solution for the social isolation of the elderly:
How can modern communication technology decrease the social isolation, improve the health and reduce the costs of the care for elderly within the Netherlands?
As a hypothesis for this research is defined as: modern communication technology can cause a decrease of social isolation, improve the health and a reduction in the demand and thus, in costs, for elderly related healthcare. To form a solid foundation for this research, this research starts with a literature review. Mainly, to gain a better insight, the research topic must be divided into smaller parts. First, the population of this
research needs to be determined. Second, a general understanding of health, ageing and the social development and social complexities of the ageing process is made clear. Then, a model is used to simplify reality and to demonstrate what health means in an
economical context. After that, analysis of the effects and relation of social isolation is made to fulfil the research request.
2. Literature review
First, we need to determine what human health is. Because human beings are complex and social creatures (Wilson, 1978), it appears that health cannot be seen as the simple absence of illness and infirmities (Grad, 2002).
2.1.Three elements of health
Health, as described by the World Health Organization in 1946, is a state of complete physical, mental and social well-‐being. This definition of the World Health Organization implies that health consists of the correlation of three elements: the state of the physical, the mental and the social well-‐being of a human individual (Grad, 2002). A complete state of good health would be enjoyed when these three elements are positively fused into a perfect match (O’Donnel, 1989). Because health is a complex phenomenon with many dependencies, inputs and relations to study (Pope & Mays, 1995) and it is widely accepted that the inputs of health consist of numerous origins, namely: biological, behavioural, psychosocial, physical environmental, in public services and in socioeconomically situational aspects (Lock, 2000), a model, that represents and clarifies the elements of health, will serve a helping hand. This model groups the inputs and uses the three elements of health as a solid foundation to explain the influences of the several health relating inputs. First the elements and the nature of the associated inputs will be explained.
2.1.1. Physical well-‐being
The element of physical well-‐being is essentially influenced by two factors: inputs of the physical environment and by inputs with a biological root (Sherwood, 2004; Prüss-‐ Üstün & Corvalán, 2006). The physical environmental factor describes the healthiness or the level of hostility of the physical surroundings, or environment of the human body. Some inputs of the physical environment can be described as the air that we breathe, the food that we eat, the water that we drink and the house that we live in (Prüss-‐Üstün & Corvalán, 2006). Basic needs, such as safe water, clean air and safe housing supply more health (Prüss-‐Üstün & Corvalán, 2006). The results of behavioural inputs, based on lifestyle, customs and traditions can be seen as influences of the physical environment (Knoops et al., 2004). A balanced diet, regular exercise, smoking, drinking, how we cope
on a daily base are all examples of health affecting inputs of the physique (Belloc & Breslow, 1972). Furthermore, the inputs of public services define the physical
environment (Aday & Andersen, 1974; Adler et al., 1994). The quality and accessibility of medical care, education, leisure and health policies can be seen as inputs to determine the health of the physical environmental factor (Aday & Andersen, 1974; Adler et al., 1994). For example, low educational levels have a relationship with poor health and the accessibility of medical services influences health as well (Aday & Andersen, 1974; Adler et al., 1994).
The biological factor describes the presence of health in the biology of a human
body on several levels. The human body functions in five levels of structures, from processes organized from a chemical level to the anatomy of the whole body (Sherwood, 2004). The first level is the chemical level (Sherwood, 2004). This level concerns
specific atoms and molecules that form the building blocks of the human body. For example, how the ageing process decreases DNA repair genes (Pan et al, 2004). The second level is the cellular level (Sherwood, 2004). On this level, the cell functions as a fundamental component of life by arranging and packaging the non-‐living components of the chemical level, as in a human skin cell (Dimri et al., 1995). The third level is the tissue level, where similar cells are grouped into primary types of tissue (Sherwood, 2004). An example can be found in the reduction of bone marrow cells under the influence of the ageing process (Stenderup, Justesen, Clausen, & Kassem, 2004). The fourth level is the organ level (Sherwood, 2004). On this level, several primary types of tissue are organized to form an organ (Sherwood, 2004). The fifth level is the body system level, where groups of related organs are organized into body systems
(Sherwood, 2004). The body systems of a human consist of the circulatory, the digestive, the respiratory, the urinary, the skeletal, the muscular, the integumentary, the immune, the nervous, the endocrine and the reproductive system (Sherwood, 2004). The sixth level is the organism level (Sherwood, 2004). Here, the body systems are combined together into a functional and whole body (Sherwood, 2004). The functioning of a body system depends on the functioning of other body systems; inputs for the physical
element can be done at all five levels (Sherwood, 2004). For example, regulation of blood pressure depends on coordinated responses among the circulatory, urinary, nervous and endocrine systems (Sherwood, 2004). Less presence of diseases and infirmities in any structural level of the human body means a healthier physique (Margolis, 1974).
2.1.2. Mental well-‐being
The element of mental well-‐being concerns the complete state of an individual human mind (Jahoda, 1958). This complete state involves two factors, the mental illness and the mental health, that form a complete continuum (Keyes, 2002). The factors of Mental well-‐being are determined by the complete condition of symptoms that are marked by pleasure or sorrow, happiness or unhappiness, life satisfaction or dissatisfaction and the functioning or malfunctioning of an individual’s mind (Keyes, 2002). The perception and valuation of the condition of these symptoms is complex, because they are both
operationalized by measurements of subjective well-‐being of a human individual, as someone’s perception and evaluation might be different from the perception and evaluation of someone else’s (Andrews & Whithey, 1974; Keyes, 2002). Mental well-‐ being is influenced by a variety of inputs that are related to the status and the promotion of the mental health, the prevention of mental disorders, and the treatment and
rehabilitation of people affected by mental disorders (Keyes, 2002). Important
fundamentals that define the status of mental well-‐being are postulated as: competence, autonomy and relatedness (Ryan & Deci, 2000). When there is satisfaction of these fundamentals, mental health enhances, but when these are dissatisfied; there is a rise of mental illness (Ryan & Deci, 2000). In short can be said that a person who is mentally healthy is one who maintains close contact with reality (Jahoda, 1958). Subsequently, the role that mental well-‐being plays, is fundamental for the social well-‐being (Ryan & Deci, 2000).
2.1.3. Social well-‐being
The element of social well-‐being is determined by the presence or absence of a social life, or environment and the way that individuals are functioning within this environment (Keyes, 1998, Keyes, 2002; Wilkinson & Marmot, 2003). Social well-‐being flourishes when the public and social criteria that we use to evaluate our functioning within our social environment are optimized (Keyes, 2002). The benefits of a social environment deliver a fundamental necessity for social well-‐being, or more thoroughly, social well-‐ being gains profit from social integration and social bonding, a sense of belonging and interdependence, consciousness and a collective fate (Keyes, 1998). Additionally, the social well-‐being of an individual is also dependent of the self-‐judging, the judging of
someone's circumstance and someone’s functioning within society (Keyes, 1998). There are five social factors that form together a structural determination of social well-‐being, or how we function within the social environment (Keyes, 1998). The structural
division of social well-‐being into social integration, acceptance, contribution,
actualization and coherence has revealed good validity and reliability and is confirmed by several studies with representative samples (Keyes, 1998). Consequently it is used to describe the five underlying inputs for the element of social well-‐being. The first factor of social well-‐being is called social integration, and defines the relationship of an individual with the society and community (Keyes, 1998). The integration grows stronger if individuals feel that they are having more in common with and belong more to other members of their social environment (Keyes, 1998). The quality of social ties between persons, or the social network, depends on the social well-‐being of the individuals in question and can be measured by the relationships’ accessibility,
complexity, density, durability over time, frequency, geographic proximity, homogeneity, intensity, size, strength and symmetry (Berkman, 1984). For example, how we relate to our family, friends, communities and culture is one of the determinants for the input of social integration (Berkman, 1984). And people with more support from families, friends and community live and are healthier (Berkman, 1984). The second input is called social acceptance, which is analogue to self-‐acceptance (Keyes, 1998). People who feel good about their own personalities and accept both good and bad aspects of their selves demonstrate good self acceptance and good mental health (Shepard, 1977), which is a necessity for good social health (Ryan & Deci, 2000). The input of social acceptance is distinct by the ability to accept parts of society (Keyes, 2002). Therefore social acceptance of others can be seen as the social complement to self-‐acceptance (Keyes, 1998). The third input is called social contribution (Keyes, 1998). The input of social contribution reflects the evaluation of the social values (Keyes, 1998). It involves the principle that someone is a worthy and vital member of society that contributes to the public goods (Keyes, 1998). For example, socio-‐economically contribution is rooted in our employment and social status, people who are working are healthier than
unemployed people; especially when they have more control over their working conditions (Benavides et al., 2000). A higher income is associated with better social health as well; the bigger the difference between the rich and the poor people, the bigger the difference reflected in social health (Kawachi, Kennedy, Lochner & Prothrow-‐Stith,
1997). The fourth input is the encounter of social actualization (Keyes, 1998). The input of social actualization is reflected by the evaluation and understanding of the potential of society of improvement, growth and development (Keyes, 1998). Socially healthy people envision more that they socially profit from social improvement than socially less healthy people (Keyes, 1998). Social coherence is the fifth input (Keyes, 1998). The inputs for social coherence consist of the degree of awareness to understand and obtain the meaningfulness of the situations in life (McCubbin, Thompson, Thompson & Fromer, 1998). The ability to care about the world we live in and to understand the things that are happening around us is the input for this factor; the more socially coherent, the more the social environment is seen as meaningful and understandable (Keyes, 2002). Individuals with social coherent capabilities keep the social coherence, even when they are faced with unplanned and traumatic life events (McCubbin, Thompson, Thompson & Fromer, 1998).
2.1.4. Triangle of health
Now that there is an understanding of the three elements and the underlying inputs, a model can be created to demonstrate the relations between the elements. Since health involves three elements, namely: the state of the physical, the state of the mental and the
state of the social well-‐being of a human individual (Ryan & Deci, 2000; Grad, 2002; Sherwood, 2004)), and to demonstrate their relations, the form of a triangle is chosen as
a basis. The several inputs for health are categorized into groups according to the element they influence. A basic sketch of the physical, mental and social element of well-‐
Figure 1. The triangle of health. The triangle of health shows the three
elements of well-‐being and their inputs that correlate to the health of a human being.
The inputs of the triangle of health can be ordered respectively to the element they influence, to explain their nature. The inputs of the of the element of physical well-‐being relates positively to human health itself, when the inputs of the physical element
stimulate the physical health self (Belloc & Breslow, 1972). Besides, the physical element could stimulate the other elements; physical improvement stimulates the element of mental well-‐being with more self-‐acceptance, cognitive functioning and the reduction of mental illnesses (Taylor, Sallis & Needle, 1985). The social element benefits from
& Needle, 1985). Contrary, negative inputs of the physical element are damaging for the well-‐being of the other elements (Belloc & Breslow, 1972; Taylor, Sallis & Needle, 1985).
How the influences of inputs of the element of mental well-‐being and the element of the physical well-‐being relates is primarily evident in the area of chronic conditions (Moy, 2009; Goldberg, 2010; WHO, 2004). Positive inputs of the mental element can increase the element of physical well-‐being, by increasing desire for physical activity, nutritious food, social life and social support (Lin et al., 2003; Goldberg, 2010; WHO, 2004). Negative inputs in mental health can cause a decrease of the physical well-‐being, due to a decrease in desire for physical activities and nutritious food (Lin et al., 2003; Goldberg, 2010; WHO, 2004) and the social element as well by the decrease of social integration (Moy, 2009; WHO, 2004).
Positive inputs of the social element promote the element of mental well-‐being
(Johnson, 1991). And negative social inputs decrease the mental well-‐being, for example, when people are incompetent of social integration and lacking social support, negative affects the mental well-‐being are demonstrated (Schaeffer, Coyne & Lazarus, 1981; Johnson, 1991). The inputs of the social element could influence the physical element as well; social inputs are related to have an effect on the cardiovascular, endocrine and immune system of the human body, either positively with positive inputs, or negatively with negative inputs (Uchino, Cacioppo & Kiecolt-‐Glaser, 1996).
Mental, social and physical health conditions have additive effects on the overall well-‐being (Collingwood, 2010). When physical and mental illness are combined, they can have twice the effect of decrease in social health, than one of these conditions alone (Collingwood, 2010).
3. Theoretical Model
Now that there is an impression of what health concerns and that the inputs of the elements are defined, it is time to take the following step of this research: to apply the triangle of health into an economic model.
Health, through an economically scope, can be seen as a durable capital stock,
“that yields output in healthy time”(Grossman, 1999). Individuals inherit an initial amount of health that depreciates during the process of ageing (Riley, 1998). Health capital could be seen as capital of a firm and health as an outcome of an investment in health (Grossman, 1972). These investments can be grouped analogue to the elements and seen as the inputs of the health triangle.
Traditional demand theory in economics tells that each consumer has a utility, or
preference, function to choose alternative combinations of goods and services in the market (Grossman, 1972). And expenditures of goods and services cannot exceed the available income (Grossman, 1972). The consumers are assumed to choose the combination of goods and services that maximizes their utility function (Grossman,
1972). According to Grossman (1972), the utility function U
of a typical consumer,
occurring across time, can be described in formula as:
U = U ( ϕ
0H
0, … , ϕ
nH
n, Z
0, …, Z
n)
(1)
With the inherited stock formulated as H0 (Grossman, 1972). Hi reflects the stock of
health in the ith time period (Grossman, 1972). ϕi describes the service flow per unit
stock and hi = ϕiHi is the total consumption of health promoting inputs (Grossman,
1972). Zt is total consumption of other commodity in the ith period (Grossman, 1972).
The variable n is normally fixed (Grossman, 1972), but here it is used as a dependent variable that is generated in the model and, therefore, a variable whose value is changed or determined by other relationships in that model (Grossman, 1972). Or in other words,
n is an endogenous variable (Grossman, 1972). Length of life depends on the quantity of
Hi that maximize utility, conditioned by certain production and resource constraints
where health-‐promoting inputs rely on (Grossman, 1972). “Net investment in the stock of health equals gross investment, minus the decrease, or the depreciation of health” (Grossman, 1972). In formula:
H
i+1– H
i= I
i-‐ δ
iH
i (2)
In this formula is Ii the gross investment and δi the rate of depreciation during the ith
period (Grossman, 1972). The depreciation rate depends on many health influential factors, such as ageing, illness and sudden events like accidents, but also on health promoting inputs of the triangle of health (Grossman, 1972). To stay healthy, consumers produce gross investment in health and in the other human conveniences, or
commodities with the utility function according to a set of nonmarket, or household production functions (Grossman, 1972), converted into formula:
I
i= I
i(M
i, TH
i; E
i) , Z
i= Z
i(X
i, T
i; E
i)
(3)
Here, Mi stands for medical inputs that promote health and Xi for the goods and services
that provide inputs in the production in commodities (Grossman, 1972). Zi, THi and Ti
are inputs of time. And Ei is the stock of competencies, knowledge, social and personality
attribute, or human capital (Schultz, 1961; Grossman, 1972). The efficiency of the
production of human capital is determined by the specifics of: Ii in health promotion and
Zi in the nonmarket commodities (Grossman, 1972). Expected can be that an effect of
change in the efficiency of the production process in the nonmarket sector of the economy works the same as in market economies (Grossman, 1972). Now that there is an understanding of the Grossman model for health, the elements of the triangle of health can form an addition for the household production function.
Derived from Grossman’s household production function we can separate the
investment of nonmarket commodities into the three elements of the triangle of health, I presume for the investment in the physical element of well-‐being:
P
i= (A
i, T
i; E
i)
(4)
Where Pi stands for the investment in the physical element, Ai describes the inputs of the
physical element, Ti is an input of time and Ei is the stock of human capital (Grossman,
1972). The inputs of the physical element (Ai ) are divided into two groups: inputs of the
Üstün & Corvalán, 2006). For the investment in the mental element of well-‐being the formula would be:
R
i= (B
i, T
i; E
i)
(5)
Where Ri stands for the investment in the mental element, Bi describes the inputs of the
mental element, Ti is an input of time and Ei is the stock of human capital (Grossman,
1972). The state of the mental element involves two factors, the mental illness and the mental health, that form a complete continuum (Keyes, 2002). The inputs of Mental well-‐being are determined by symptoms as pleasure or sorrow, happiness or unhappiness, life satisfaction or life dissatisfaction and the functioning or
malfunctioning of an individual’s mind (Keyes, 2002). And finally, for the investment in the social element of well-‐being:
S
i= (C
i, T
i; E
i)
(6)
Where Si stands for the investment in the social element, Ci describes the inputs of the
social element, Ti is an input of time and Ei is the stock of human capital (Grossman,
1972). There are five basic social factors that form together a structural determination of social well-‐being (Keyes, 1998). The inputs of social well-‐being are grouped into forms of social integration, social acceptance, social contribution, social actualization and social coherence. Together, the inputs of the three elements of health produce the complete status of health (Grad, 2002) in formula:
Z
i= Z
i(F
t( P
i+ C
i+ S
i), T
i; E
i)
(7)
Here, term Ft is added. This term can be defined as a factor that determines the translation of
the combination of investment into an certain amount of health in a certain period. For specific and useful outcomes, a certain measurement instrument needs to be selected (Mokkink et al. 2010). What can be said about formula (7) is that the elements of health form a linear relation to wards the investment of the commodities, which according to equation (3) produces more human capital, that makes the health production more efficient (Grossman, 1972). So any input that promotes the well-‐being of at least one element of the triangle of health, adds efficiency to
the production of health (Grossman, 1972). According to equation (2), there is a linear relation between the investment in health and the health status of an individual (Grossman, 1972). Now there can be said, according to equation (2), when the depreciation rate is standardized or not negatively influenced by the health promoting inputs, that any health promoting input, delivers more health for a human individual. Finally, according to equation (1), an individual can
maximize his or hers utilization of the inputs of the triangle of well-‐being by choosing the
healthiest options (Grossman, 1972).
A sidestep, 40 years later:
In literature of health economics (Becker, 1965; Ben-‐Porath, 1967; Mincer, 1974) Grossmans’ approach (1972) is linked to health of human beings and branded as the human capital model and according to this theory increases in a person’s stock of human capital, raise his productivity in the market sector of the economy, where he produces money and in the nonmarket sector, where he produces commodities that enter his utility function (Kaestner, 2012). Human capital is the stock of competences, knowledge, social, personality and physical attributes and relates to therefor to the three elements of human well-‐being (Mincer, 1958). The human capital is comparable with the physical means of production (Becker, 1965), or factories and machines. Investments in the human capital can be done through education, training, medical training and all sorts of activities that yields output in the human capital stock (Kaestner, 2012). To include the gap between health as an output and health
stimulating inputs as production basis, Grossmans’ (1999) uses the household production function of consumer behaviour (Becker ,1965; Lancaster ,1966); Michael & Becker,1973). This model creates a division between the fundamental objects of choice (commodities) that enter the utility function and the goods and services in the market (Grossman, 1999). The commodities that are used in this research are the health stimulating influences: “Since goods and services are inputs into the production of commodities, the demand for these goods and services is a derived demand for a factor of production” (Grossman, 1999). Therefore, the demand for health influencing inputs is derived from the fundamental demand for human health (Grossman, 1999). The adaption of Zweifel (2012), forty years after its original introduction, argued that the Grossman model is incomplete and needed an addition for “ex ante” (stimulants for preventing bad human health) and “ex post” (stimulants that
rehabilitate human health) investments in health (Kaestner, 2012). In this form, the production function of health would be:
Ht+1 = Ht + πtIt – δtHt – ρt+1(It)λt+1(mt+1)Ht
=
Ht+1 = πtIt + Ht [1 – δt -‐ ρt+1(It)λt+1(mt+1)]
H is stock of health; I is investments in health;
π is a parameter that translates the efficiency of the investments into health; δ is the rate of depreciation of health;
ρ is the probability of the occurrence of an adverse health event; λ is the loss of health stock due to unfavourable;
4. Analysis
In this chapter the effects of the aging process and social isolation are analysed. To determine the situation that elderly face, the aging process and the effects of this process are defined first.
4.1 The aging process
The process of aging of humans can be defined as any chronological change in a human being (Bowen & Atwood, 2004). This definition contains any change, associated with loss or gain of function (Bowen & Atwood, 2004). Analogue can be said that ageing concerns change in health of human beings over time (Riley, 1998).
The process of aging influences several inputs of the elements of well-‐being. The reduction of the physical well-‐being caused by less activity, infirmities and sicknesses like coronary heart disease, heart failure and cancer are often connected to the aging process (Moen, Dempster-‐McClain & Williams, 1992). The influences of aging on the human brain are commonly known as: fat deposition within the brain cells, which delays and slows their functioning. The loss of brain cells that die and that are not replaced, makes the brain smaller with age (Diamond, 1978). Other physical conditions that can affect the functioning of the physique, such as stroke, are associated with age related inputs as a change in diet, obesity and sedentary lifestyle choices (Chiuve et al, 2008). The possession of a healthy well-‐being of the human physique plays a role for a healthy
Within the Netherlands there are more than 2,6 million elderly (15,6 % of total population), with an age of more than 65 years (TNS / NIPO, 2010). Research indicates that 51 % of this group is feeling lonely and socially isolated (TNS / NIPO, 2010). This group of lonely and social isolated consists of more than 1,3 million elderly (TNS / NIPO, 2010). About 52% of the group of elderly lives alone (CBS, 2012) and 170.000 elderly are residents of health care institutions (SCP, 2007). Almost 30% of the nursing home residents are feeling lonely and socially isolated (Nivel, 2008). About 6,8 % of nursing home residents, more than 10.000 elderly, do not receive visits ever (Nivel, 2008). Estimated is that 15% of the elderly is vulnerable to a decrease in physical and mental health and due to social
constraints and therefor demand healthcare ( SCP, 2012). More than 140.000
elderly with serious health constraints do not receive health care (SCP, 2007). In
2012, the Dutch government has spent 18,1 billion Euros on elderly related health care (CBS, 2012); this is 7% of the total amount of the Dutch state budget (257,4 Billion Euros) (CBS, 2013). In 2040, it is expected that the population of elderly will grow towards 4,6 million, of which 2,3 million are expected to feel lonely and socially isolated (RIVM, 2013).
mental well-‐being and vice-‐versa (Chrousos & Gold, 1998). The well-‐being of the mental element can be described as the ability and gradation of staying in touch with reality (Jahoba, 1958). And at first glance, age is an influential factor for the state of mental health, as it is a variable that intersects the biography and history of a human being (Ferraro & Wilkinson, 2012). This is also one of the principles of the social element (Keyes, 1998). A social life can prevent depression and stimulate mental abilities (Crooks et al, 2008). Elderly are specifically vulnerable to social isolation, because the aging process comes along with loss of family and friends, loss of mobility and loss of income (Windle, Francis & Coomber, 2011). Several researches about the quality of life (Bowling, Farquhar, & Browne, 1991; Bowling, 1995 & Shahtahmasebi & Scott 1996) indicate that elderly rank the social ties with friends and family very high. Other research shows that social isolation, or the lack of meaningful and sustained
communication and social network (Victor et al., 2000) is a common and major problem faced by elderly (Forbes & Thompson, 1990). It is commonly known that the social element has powerful effects on physical and mental health (Berkman et al., 2000). Summing-‐up: the relationship between aging and a reduction in health is multi
dependent, as biological, lifestyle and social inputs have an influence on the elements of well-‐being (Belloc & Berslow, 1972; Berkman, 1984).
4.2 Online integration
A majority of the Dutch elderly feels lonely and is socially isolated (TSN/ NIPO, 2010). Several researches indicates that online social support, attention and communication works beneficial for the social health and reduces social isolation of an elder individual (Swindell, 2000; Wright, 2000; Bradley & Poppen, 2003; Pfeil, 2007, Sum et al., 2008; Nimrod, 2011; Erickson & Johnson, 2011; Zickuhr & Madden, 2012). Other research teaches us that social isolation could cause serious health treating conditions, such as negative effects on the physical element of well-‐being trough the cardiovascular, endocrine and immune system of the human body (Uchino, Cacioppo & Kiecolt-‐Glaser, 1996), and on the mental element by forming depressions (Crooks et al, 2008). An improvement in health implies in theory a reduction in healthcare demand as well, because people want to obtain health, not necessarily healthcare (Grossman, 1972).
Since the rise of the Internet, information and communication technologies
has marked our communication, leisure and household activities (Zickuhr & Madden, 2012). Already 56% of the group of elderly within an age range of 65-‐75 years appears to be using the Internet (CBS, 2012), still a lot of elder individuals are missing out on the possibilities of this digital revolution (Millward, 2003). Elderly are a few steps behind on the younger age groups in using the Internet (van Dijk & Hacker, 2003). For the elderly that have bridged the digital divide, going online seems to become more and more a routine part of their lives (Zickuhr & Madden, 2012). About one third uses Internet on a daily basis (Zickuhr & Madden, 2012). Primarily, the elderly use email for online
communication (Bradley & Poppen, 2003). To get the elderly more involved online, the encouragement comes mostly from family or friends (Tak & Hong, 2005). This
encouragement is worth the try: the elderly that enter and use the digital world, review the learning process as enjoyable and it assists them in keeping an active mind while they access new information according to their personal interests (Clarke et al., 2002; Hill & Weinert, 2004). The systematic use of the Internet for keeping in touch with social ties and gaining social support from family and friends (Bradley & Poppen, 2003; Nimrod, 2011), is related to life enriching factors (Swindell, 2000; Wright, 2000), less stress and less social isolation (Erickson & Johnson, 2011; Pfeil, 2007 & Sum et al., 2008). Online communication provides the opportunity to connect to like-‐minded people
(McMellon & Schiffman, 2002). Online integration allows elderly to receive and provide social support (McMellon & Schiffman, 2002). Specifically those who suffer from a certain age related diseases or who are housebound, online social platforms give the opportunity to meet elderly who are in similar situations and take part in satisfactory social interaction (McMellon & Schiffman, 2002). Also, opportunities to interact socially with like-‐minded people and the exchange of social support and companionship have been proofed to be health-‐beneficial (Kanayama, 2003; Pfeil, 2007 Pfeil, Zaphiris and Wislon 2009). The most important benefits for elderly who integrate online can be described in the first place as, acquiring more social contacts, social activities and a wider social network (Age platform Europe, 2010). For example, the online integration could be an important tool to maintain and strengthen the link between the older and younger generation and also specific elderly related online communities (McMellon & Schiffman, 2002; Age platform Europe, 2010). Secondly, that online integration provides access to all sorts of digital
services (McMellon & Schiffman, 2002; Age platform Europe, 2010). For example having the ability to use online banking, shopping, public services and voting systems
(McMellon & Schiffman, 2002; Age platform Europe, 2010). This benefits specifically the elderly who are living in a remote area or with mobility problems (McMellon &
Schiffman, 2002; Age platform Europe, 2010). And thirdly, that online integration avoids overmedication, provides the elderly with information about certain diseases – which helps elderly suffering from age related diseases-‐ and bridge the gap between home and the care institute (Age platform Europe, 2010). In this range, online integration could be a good opportunity to relieve the load on the shoulders of the caregivers and provides them with more time for face-‐to-‐face communication (Age platform Europe, 2010). To determine whether modern technology can cause a decrease in the demand for
healthcare with a decrease in social isolation, the need for research in the field rises. For example one can think of reasons, linked to social isolation and hunger for social
attention to visit health care supplying institutions. A solution to this can possibly be found in the integration process of the elderly within the digital society, by bridging the digital divide (Swindell, 2000; Wright, 2000; Bradley & Poppen, 2003; Pfeil, 2007, Sum et al., 2008; Nimrod, 2011; Erickson & Johnson, 2011; Zickuhr & Madden, 2012). To do this, several barriers needs to be crossed, namely: no-‐access to the internet, not having interest and lacking operational skills of personal computer devices with mouse and keyboard (Millward, 2003). These barriers could probably be crossed by introducing more user friendly interfaces, deliver access to the Internet and gaining interest from the elderly’s point of view (Millard, 2003). All distributed from trustworthy
environments such as the health care institutions. The institutions self by providing workshops, the installation of wireless access points for Internet, selecting and delivering senior-‐proof-‐digital-‐communication-‐devices, could do this. It appears that there is a need for such a social intervention (Findlay, 2003). Summing up, online
integration causes a promotion of the well-‐being of the social element and therefore it is beneficial for the overall well-‐being of elderly (Keyes 1998; Swindell, 2000; Wright, 2000; Keyes, 2002; Bradley & Poppen, 2003; Pfeil, 2007, Sum et al., 2000; Nimrod, 2011; Erickson & Johnson, 2011; Zickuhr & Madden, 2012). A promotion in health implies a reduction in healthcare demand and healthcare costs, because people want to be healthy and not receiving healthcare (Grossman, 1972).
5. Conclusion
To discuss the outcome of this research, the research question -‐ How can modern
communication technology decrease the social isolation, improve the health and reduce the costs of the care, for elderly within the Netherlands? -‐ is divided into three
components.
The first component -‐ does social isolation have negative effects on health? -‐ Is answered by research that indicates that social isolation causes serious health treating conditions, such as negative effects on the physical and mental element (Uchino, Cacioppo & Kiecolt-‐Glaser, 1996; Crooks et al, 2008).
The second component -‐ does modern communication technology decrease social isolation? -‐ is answered by several researches that indicates that online social support, attention and communication works beneficial for the social health elderly (Swindell, 2000; Wright, 2000; Bradley & Poppen, 2003; Pfeil, 2007, Sum et al., 2008 ; Nimrod, 2011; Erickson & Johnson, 2011; Zickuhr & Madden, 2012). The systematic use of the Internet for social reasons, is related to cause less stress and less social isolation and stimulates social integration (Swindell, 2000; Wright, 2000; McMellon & Schiffman, 2002; Kanayama, 2003; Erickson & Johnson, 2011; Pfeil, 2007 & Sum et al., 2008 (Bradley & Poppen, 2003; Nimrod, 2011).
And the third component -‐does health improvement of elderly implies a reduction in healthcare demand? -‐ is difficult to answer, because on first sight, a
promotion of the well-‐being of the social element is beneficial for the overall well-‐being of elderly and therefore, logically it seems to imply a reduction in the demand for
healthcare and subsequently in healthcare costs. Because people want to be healthy and not receiving unnecessarily healthcare (Grossman, 1972, Keyes 1998; Swindell, 2000; Wright, 2000; Keyes, 2002; Bradley & Poppen, 2003; Pfeil, 2007, Sum et al., 2008; Nimrod, 2011; Erickson & Johnson, 2011; Zickuhr & Madden, 2012). But health is a complex phenomenon (Wilson, 1978), and certain deceases, infirmities or any health depreciating inputs are not determined by any social factor. It is hard to say till what extent healthcare could be prevented or even substituted with online social
interventions and integration. Online integration should not be replacing the human contact completely; it should be complementary to human contact. For sectors like social and healthcare services, the issue with the workforce should be conducted like that and
