Tackling social isolation among the elderly

• Social isolation, referring to a lack of contact with family, friends or other people, brings more than a feeling of loneliness^{1Loneliness refers to the subjective feeling of being alone, regardless of the amount of social contact. Social isolation, by contrast, is the objective state of having few social connections and can often lead to loneliness in some people. See World Health Organization (2021).}; it also poses profound public health risks, especially to the elderly. Studies have found that social isolation can be as damaging to health as smoking and obesity – it is related to an increased risk of heart disease by 29% and stroke by 32%, and is also linked with higher rates of mental health problems such as depression and suicides in older age, thereby placing a burden on the health system, in addition to imposing stress on individual elderly suffering from isolation.^{2Ibid and see Centers for Disease Control and Prevention (2021) and National Academies of Sciences, Engineering, and Medicine (2020).}
• The World Health Organization ("WHO") has cautioned that social isolation among the elderly ("elderly isolation") is a public health concern that has been made more salient by the COVID-19 pandemic.^3Ibid. With social distancing measures remaining intact in Hong Kong, several studies have pointed to a rising prevalence of elderly isolation, as the group is particularly prone to diminished social ties and support networks.^{4See City University of Hong Kong (2021) and Lingnan University (2020).} In 2020, Hong Kong reported 438 elderly suicides, the highest number since records began in 1973.^{5In 2020, Hong Kong recorded 438 suicides among people aged 60 or above, representing an increase of 4.8% from 2019. This group also saw the highest suicide rate across all age groups – with nearly 22 people died of suicide per 100 000 population. See The Samaritan Befrienders Hong Kong (2021).} Alarmed by these trends, some Legislative Council Members have called for heightened government efforts to address the issue of elderly isolation.^{6See GovHK (2021) and 民建聯(2018).}
• Social isolation is generally considered challenging to tackle, as it cuts across many different issues.^{7See Gov.Scot (2018), Gov.UK (2015) and Queensland Alliance for Mental Health (2021).} To address this problem specifically among the elderly, WHO and some studies have suggested the adoption of a multi-pronged strategy focusing on: (a) bridging the digital divide to prevent social exclusion of the elderly; (b) creating living environments conducive to intergenerational connectedness; and (c) harnessing remote/technological innovation for provision of elderly care, among others.^{8See for example World Health Organization (2021) and Day et al. (2020).} This issue of Essentials first discusses relevant measures in Hong Kong before examining how some ageing societies – New York in the United States ("US"), Germany and Singapore – have proactively provided relief to the elderly suffering from social isolation with various interventions in line with WHO's recommendations, especially in the era of pandemic.

• As Hong Kong's population ages^{9It is estimated that by 2039, one in three persons in Hong Kong will be aged 65 or older, up from the 2019 level of about one in five being an elderly. See Census and Statistics Department (2020).} and the size of family shrinks, the latest By-census survey in 2016 showed that the number of households with only one elderly occupant had surged 54% compared with a decade ago.^{10The latest round of population census was conducted in 2021, but the results have yet to be released. See Census and Statistics Department (2018).} Overall, there were 152 500 elderly living alone in 2016, accounting for 13% of the elderly population. The number of households with all members being elderly also rose above 300 000, making up 12% of total households.^11Ibid.
• According to a 2015 global study of elderly health in 97 places, Hong Kong ranked the highest in life expectancy and fared well in most aspects of physical health. However, the city ranked a meagre 79th in mental health.^{12In the study, mental health of the elderly was measured in terms of their psychological well-being. See Chinese University of Hong Kong (2018).} A more recent local study has made similar observations – mental health was not only rated the poorest performing indicator in the health domain, but it was also on a deteriorating trend over the past few years.^{13See Jockey Club Age-friendly City (2020).} With a growing number of elderly living alone, it is concerned that elderly isolation, and hence their mental health, may become a more acute issue, especially amidst the COVID-19 pandemic. While Hong Kong has no targeted policy to address social isolation in general and elderly isolation specifically, it has put in place measures in various policy domains that help prevent or alleviate this social problem:
  • (a)
    Bridging the digital divide: The Government has strived to enhance digital literacy of the elderly, such as through an outreach scheme to fund social services organizations for teaching 7 300 elderly people during 2018-2021 on using video call software to stay connected with families and friends.^{14Other initiatives include the launch of a digital learning portal and provision of over 100 free training courses for 3 200 elderly people to acquire new digital skills since 2019. See Innovation and Technology Bureau (2021).} Since using the LeaveHomeSafe mobile app has become mandatory at more venues from December 2021, the Government has worked with partner organizations to give out free smartphones and basic mobile service to 20 000 underprivileged elderly.^{15See The Hong Kong Jockey Club (2021).} However, there are concerns that this one-off initiative might still be inadequate, considering that one-third of the elderly population – or some 450 000 elderly people – are not smartphone users.^{16Government data in 2020 showed that 31.9% of Hong Kong's 1.4 million elderly persons (aged 65 or above) did not have a smartphone. Compared with 2018, it has dropped by 10.9 percentage points from 42.8%. See Census and Statistics Department (2021) and 香港經濟日報(2021).} As poor digital literacy or lacking access to smartphones among the elderly might hinder social interaction, there are suggestions on scaling up the digital inclusion effort and exploring elderly-friendly alternatives to complement the use of the LeaveHomeSafe app.
  • (b)
    Allocation priority for intergenerational living: Staying close to family members is considered key to the elderly's psychological well-being. To encourage young people to maintain closer ties with their elderly parents, the Government offers priority to subsidized and public rental housing applicants with elderly family members, although these schemes are subject to quotas or flats available for allocation.^{17Under the "Priority Scheme for Families with Elderly Members", Home Ownership Scheme applicants choosing to stay with elderly family members in the same purchased flat will be allocated priority in flat selection, subject to a quota (which was set at 2 100 flats in 2020). As for public rental housing ("PRH") applicants, those opting to live in one flat or two nearby flats to take care of their elderly family members can have their waiting time shortened by six months under the "Harmonious Families Priority Scheme". Based on the average waiting time of six years for PRH general applicants (including those applying with elderly family members) as at end-December 2021, applicants under the Priority Scheme would still need to wait over five years to be allocated a flat. Meanwhile, existing PRH tenants can apply for transfer to the same estate where their elderly parents/children currently reside for mutual care.} In 2014, the Hong Kong Housing Society completed its first multi-generational housing project, with a view to enabling two generations of a family to stay in the same building for companionship. Yet multi-generational living remains a nascent concept, currently with limited supply and options in the market.^{18For example, the only multi-generational housing project launched by the Hong Kong Housing Society so far is the Harmony Place, which comprises only 60 elderly rental units and 214 flats for sale. Meanwhile, a private multi-generational housing project involving 1 500 units are reportedly under construction. See Hong Kong Housing Society (2020) and 信報(2021).}
  • (c)
    Social services/community support through elderly care: Guided by the principle of "ageing in place", the Government offers through day care and district elderly community centres a wide range of community care services, from nursing care and health education to social/recreational activities.^{19The Government has a policy of providing community care services ("CC Services") to help the elderly age at home or in their own communities (as opposed to in unfamiliar settings e.g. nursing homes and hospitals), partly due to the perceived benefits of CC Services on mental and physical health. CC Services are not just provided at centres but also at home for frail elders to cover services such as personal/nursing care, escort and meals delivery. For detailed analysis on CC Services, see Legislative Council Secretariat (2021).} Yet the COVID-19 pandemic has worsened elderly isolation due to a disruption in some elderly services, prompting calls for swifter responses to mitigate the effects of social distancing on mental health of the elderly.^{20See Lingnan University (2020) and 香港01(2020).}

• In Singapore, it was estimated that 40% of those aged 75 or above were not smartphone users in 2020.^{21See Infocomm Media Development Authority (2021b).} Seeing that the digital divide is a key driver of elderly isolation during the COVID-19 pandemic and that more elderly people are at risk of social isolation^{22Between 2016 and 2019, the number of Singapore residents aged 65 or above who lived alone rose 44% to reach 67 600, which represented 11.6% of the elderly population. In 2019, there were 400 reported suicide cases in Singapore, of which 122 cases involved people aged 60 or above (i.e. 14 cases per 100 000 elderly population). See Ministry of Health (2021).}, Singapore has pledged to strengthen digital inclusion with the following major initiatives:
  • (a)
    Improving digital literacy: The telecommunications regulator, Infocomm Media Development Authority, has rolled out the Seniors Go Digital programme in over 40 community hubs since 2020. Under the programme, 1 000 digital ambassadors have been deployed to provide one-on-one coaching sessions for interested elderly people aged 60 or above to acquire digital skills essential to their daily living under social distancing – from connecting a smartphone to Wi-Fi, to using WhatsApp and scanning QR codes for TraceTogether, a COVID-19 contact tracing app.^{23See Gov.sg (2020).} Over 200 roving counters have also been set up to bring digital training closer to the elderly in the community. Estimated to cost the government S$361,000 (HK$2.1 million) in 2021, the programme has reached out to some 100 000 elderly people.^{24It should be noted that this programme is partially backed by government funding and contributions from community and corporate organizations (e.g. telecom providers), as well as support from volunteers (e.g. the digital ambassadors are comprised of both full-time staff and volunteers). See also Infocomm Media Development Authority (2021a).}
  • (b)
    Enhancing digital access: Singapore runs the Mobile Access for Seniors scheme to offer subsidized smartphones and data plans to low-income elderly citizens. While a similar initiative is seen in Hong Kong, Singapore's scheme is regularized and tied with one-stop training and technical support for the elderly under the Seniors Go Digital programme. Eligible elderly citizens^{25To be eligible, one must (a) be at least 60 years old; (b) be recipients of selected government assistance (e.g. public rental housing tenants); and (c) have learnt at least one basic digital skill through the Seniors Go Digital Programme.} who have completed the programme can get a smartphone for as low as S$20 (HK$114), bundled with a S$5 (HK$29) monthly plan offering 5GB of data. After collecting their phones, the elderly receive onsite technical assistance, such as on how to turn on the phone and insert a SIM card. This scheme has benefited over 7 900 elderly people since its launch in 2020.^{26See Infocomm Media Development Authority (2021c).}

    Furthermore, Singapore has introduced the Bluetooth-enabled token as an alternative to the TraceTogether app specifically for vulnerable elderly, considering that some might still have difficulty using smartphones, even when provided with technical assistance. Designed to be light, easy to use and wearable, these tokens have been distributed to at least 10 000 elderly people who are physically frail, lack family support and/or do not use digital devices.^{27Each token has a unique QR code and works by exchanging Bluetooth signals with other tokens or mobile phones running the TraceTogether app nearby. To check-in upon visiting a venue, users can simply have their token's QR code (printed at the back) scanned at the venue. See Government Technology Agency (2020).}

• While digital technology holds promise in helping the elderly maintain social connections amid the COVID-19 pandemic, it is considered that intergenerational relationships play a crucial role in combating elderly isolation and enhancing their mental health in the long-run.^{28See University of Hong Kong (2019).} In some developed places, particular attention is paid to how different innovative living arrangements and provision of elderly services can help achieve intergenerational connectedness. Salient measures are highlighted below:
  • (a)
    Offering incentives to foster closer family ties: Singapore's Housing and Development Board ("HDB") has in place a number of housing policies conducive to intergenerational harmony. Besides giving priority to applications with elderly family members^{29Singapore has priority schemes for various groups. For example, the Multi-Generational Priority Scheme allows married children and their parents to get two new Build-To-Order HDB flats in the same precinct (e.g. same floor of a building). The Senior Priority Scheme gives priority to eligible elderly to buy a two-room HDB flat to live near their married children (within four kilometres).} like its Hong Kong counterpart does, HDB offers considerable financial aid to encourage families to live closer together for mutual care and support. For example, through the Proximity Housing Grant, Singapore citizen families receive a S$20,000 (HK$115,000) grant when they buy a resale HDB-subsidized flat to live within four kilometres of their parents/married children.^{30The grant is halved for singleton buyers. See Housing and Development Board (2022).} Those buying a resale HDB flat to live together with their parents or children receive an enhanced amount of S$30,000 (HK$173,000). Since its launch in 2015, the grant has benefited nearly 40 000 households, involving an estimated sum of over S$700 million (HK$4.0 billion).^{31See Today Online (2021) and Data.gov.sg (2022).}
  • (b)
    Promoting intergenerational home-sharing: The concept of intergenerational home-sharing has also emerged in some places, especially to cater for those who are childless or unable to get close to their immediate families. In Germany,^{32In Germany, it is estimated that the number of people aged 67 or above will grow by 22% from 16 million in 2020 to 20 million in 2035. A separate survey conducted during COVID-19 showed that one in four older adults (aged 50 or above) reported feeling lonely. See Statistisches Bundesamt (2021) and European Parliament (2021).} the Living for Help ("Wohnen für Hilfe") programme helps match elderly hosts who can provide free accommodation for sharing with students/young professionals, who in return offer company and assistance with daily tasks such as cooking and cleaning.^{33Living for Help is usually coordinated by universities, often in collaboration with local governments and other organizations. For example, the programme in Cologne is a partnership between the University of Cologne, the city's housing office and elderly representative group. See AARP (2017).} First piloted in the 1990s, this programme has gained traction and is now expanded to over 30 municipalities.^{34Ibid and see Legislative Council Secretariat (2021).} New York operates a similar home-sharing programme, with an additional feature of conducting background checks on hosts and guests, and helping them arrange match meetings and signing of a written agreement to give a sense of security and confidence in home-sharing arrangements.^{35Adults aged 18 or older are eligible to apply for the matching service, but at least one of the match-mates must be aged 60 or older. See New York City Department for the Aging (2022) and New York Foundation for Senior Citizens (2022).} This programme secured a US$1.4 million (HK$10.9 million) government funding boost in 2019 to extend its reach to 4 000 elderly people in the next five years, apart from receiving private contributions.^{36See Official Website of the City of New York (2018) and New York City Department for the Aging (2019).} It is useful to note that some elderly and young people in Hong Kong have revealed interest in such schemes according to a local survey, but the idea of home-sharing has yet to gain traction due partly to space constraint for most local households.^{37See 明匯智庫及大舜基金(2017).}
  • (c)
    Integrating elderly services with child and youth care: Some places have launched intergenerational programmes at the community level to foster "non-familial intergenerational interactions". For instance, Singapore rolled out in 2016 an initiative to co-locate eldercare and childcare facilities in 10 new HBD housing projects, as part of its S$3 billion (HK$17.1 billion) Action Plan for Successful Ageing.^{38The action plan covers more than 70 initiatives in 12 areas to help the elderly age healthily and actively. See Ministry of Health (2016).} Kampung Admiralty is the first of these housing projects under the Plan, completed in 2017 by HDB in collaboration with the Ministry of Health and Early Childhood Development Agency to re-create more opportunities for intergenerational bonding. The 11-storey housing complex integrates elderly housing with healthcare, social and communal facilities, as well as a childcare centre, which organizes regular activities such as storytelling and craft workshops for both generations to join together.^{39The project was sold as HDB's Build-to-Order flats in 2014. See Centre for Liveable Cities Singapore (2020).} Early assessments showed that elderly residents have reported enjoying interactions with the younger generation.^{40See Chan (2021).}

    Likewise, Germany's Federal Ministry for Family Affairs, Senior Citizens, Women and Youth has managed to synergize services that used to operate in silos, such as elderly services, child and youth care, through its multi-generational houses ("MGHs") ("Mehrgenerationenhäuser") programme. Featured by the United Nations as a best practice example in promoting social integration of the elderly^{41See United Nations Economic Commission for Europe (2009).}, MGHs are essentially community centres where multiple generations can offer support to one another under the notion of "younger people helping older people and vice versa". While the elderly can volunteer to read books to children and run a "rent-a-granny" service to provide relief for working parents, teenagers can share their technology know-how with the elderly such as how to use mobile phones. Currently, there are some 540 MGHs in Germany, and they are found across nearly all urban municipalities. An evaluation report noted that 70% of the surveyed municipalities agreed that MGHs had facilitated intergenerational exchanges that would not otherwise take place.^{42See Bundesministerium für Familie, Senioren, Frauen und Jugend (2021).}

• Social distancing under the COVID-19 pandemic has caused a disruption of elderly services in some places. Home to an ageing population and recognized by WHO as an age-friendly place, New York has identified elderly isolation as a priority issue to be addressed amid the public health crisis. Among the measures introduced was handing out 3 500 robotic pets to the isolated elderly through partner organizations. Though relatively low in cost (US$110-US$130, or HK$858-HK$1,014), each robotic cat/dog has built-in sensors that respond to human voices and touching, and a simulated heartbeat to make it look more lifelike.^{43See Hudson et al. (2020).} While this move has drawn debates on whether virtual interaction can replace human contact, a government study showed that 70% of participants previously on a pilot programme reported a reduced level of feeling isolated after adopting robotic pets.^{44See New York State Office for the Aging (2021) and National Academies of Sciences, Engineering, and Medicine (2020).}
• In response to the closure of elderly centres, the New York City Department for the Aging ("DFTA")^{45Established in 1975, the New York City Department for the Aging is a dedicated government department tasked with supporting the elderly and their caregivers, and combating ageism.} has coordinated with its network of providers to swiftly transition some of the centre-based services to online services accessible from home. A notable example was providing eligible elderly with 10 000 free Wi-Fi equipped mobile tablets, alongside technological support and training.^{46These tablets are distributed through local elderly centres, with priority given to those who live alone, lack access to digital devices and are active participants interested in attending virtual programmes. See New York City Department for the Aging (2021).} These tablets were pre-loaded with essential communication tools (e.g. Zoom and email) and an app offering free virtual interest classes and fitness programmes. Furthermore, DFTA has mobilized centre staff to make regular wellness check-in calls to the elderly to provide home care monitoring services, and recruited 1 000 volunteers to connect with homebound elderly via weekly phone calls or video chats.^{47Since October 2020, New York City Department for the Aging has introduced a programme called Friendly VOICES, which trains and matches volunteers to connect remotely with the elderly who are socially isolated during COVID-19. Elderly participants also have the option to be matched with a peer close to their age or join a small virtual group. See New York City Department for the Aging (2020a, 2020b).}

• Social isolation among the elderly, aggravated by COVID-19, is a public health threat that has garnered growing attention from policymakers in Hong Kong and other places. In some developed places with an ageing population, a broad array of strategies have been pursued to tackle this complex issue. On top of bridging the digital divide with programmes for training and providing subsidized smartphones for the needy elderly, Singapore offers a tailor-made electronic solution for vulnerable elderly by introducing an alternative mechanism for contact tracing under the pandemic. Also, efforts to create living environments conducive to intergenerational connectedness are observed in Singapore and Germany, ranging from facilitating intergenerational home-sharing to integrating eldercare and childcare services. Meanwhile, New York has experimented with digital innovations from robotic pets to tablet classes to ensure the continuity of some elderly services. All these initiatives enable new perspectives and offer potential for solutions to boosting the mental health of the aged population in Hong Kong.