Open access peer-reviewed chapter - ONLINE FIRST

Social Connectedness and Wellbeing of Ageing Populations in Small Islands

By Sheena Moosa

Submitted: December 7th 2018Reviewed: February 21st 2019Published: March 21st 2019

DOI: 10.5772/intechopen.85358

Downloaded: 102

Abstract

This chapter presents the findings relating to social connectedness and isolation from a sample survey of the 393 older people aged 65+ years in an island context, the Maldives, where families are often dispersed across many islands due to the nation’s particular geo-spatial features. Maldivian society while traditionally collectivist, is currently showing effects of modern development on its social structures and values. Against this background, the life domain of social connectedness and social isolation is conceptualized. Although operationalized to include the community, the findings stress the importance of family and friends, rather than the community, in providing social connectedness. There is an indication that family and friends provide experiences that differ emotionally and that varied composition of social networks provide different experiences for social connectedness. Factors within this life domain demonstrate specific aspects of social connectedness in the small island context in contrast to industrialized country contexts.

Keywords

  • social connectedness
  • isolation
  • social network
  • small islands
  • wellbeing

1. Introduction

Social connectedness has consistently shown a positive correlation with quality of life and wellbeing across different societies, especially among older populations [1, 2]. Correspondingly, social isolation and loneliness have been associated with poor wellbeing [3, 4]. As such both social isolation and social connectedness are conceptualized together. Social isolation is perceived not only by the number of contacts in a person’s social network but the sense of companionship and belonging one derives from the contact [5]. This view can be applied to social connectedness as even large social networks does not always lead to a high level of emotional fulfilment and rewarding, and may even be associated with emotionally negative experiences and loneliness [6]. It is thus contingent that if loneliness is “the situation experienced by the individual as one where there is an unpleasant or inadmissible lack of (quality of) certain relationships” [5], social connectedness is the other (more positive) side of the same coin. While some define social connectedness as the “presence or absence of social ties” [7], others suggest it is the “relationships people have with others” [8].

While social connectedness (or the lack of it) plays a critical role in wellbeing, it has been established that with age, the size of one’s social networks decline [9, 10]. The theoretical perspective on life course suggests that an individual forms a convoy of social relationships from childhood to old age. But relationships with colleagues, neighbours, friends and even family, changes and some terminate due to death, migration, divorce, retirement and health reasons [11, 12]. However, some have argued that even though loss of network contacts occur during the life course, some of these are compensated by gains through life events such as the birth of grandchildren, marriage, and even migration, leading to changes in the composition of social networks and their function [13]. It has been argued that even those older people who have many social contacts focus on maintaining a core social network that is emotionally supportive and rewarding [9, 13]. This observation is explained by the socio-emotional selectivity of older people who become more discriminatory in their social contacts; they often choose to maintain only those social contacts that are emotionally meaningful, rather than acquaintances and novel social contacts [14, 15]. Thus, in older years, social connectedness is maintained through a network of family and close friends that provide emotionally rewarding experiences, rather than colleagues or casual acquaintances [16].

Social connectedness is operationalized by focusing on different aspects of social relationships such as social ties, social networks, social support and social integration [17]. While these aspects are examined under the broad umbrella of social connectedness, in research, distinctions are made between these terms on the argument that these are different aspects of social relationships within the social network of an individual [7, 18]. In a more Durkheimian approach, the wider social and cultural context is taken into account, and a framework of a social network that includes both upstream social structural conditions and downstream behavioural, psychological and physiological pathways that impact on wellbeing has been put forth [17]. This conceptualization provides for a more comprehensive approach to identifying network characteristics that allow for social support, social engagement, person-to-person contacts and access to resources [17, 18]. Proponents of this conceptualization view social connectedness through the opportunities provided in the context of a social network [7]. The characteristics of social networks that shape social connectedness include the size and composition of the network, physical proximity of network members, and number of members with whom one has frequent contact [16]. For example, the English Longitudinal Study on Ageing, observed that the quality of life of older people significantly increases when they have many close relationships and more frequent contact with friends [19]. Social support, especially non-instrumental emotional support, has been shown to operate through social networks affecting the social connectedness of an individual [7, 20]. The focus of ageing research in small island countries in the Pacific and Caribbean has been on social support, in terms of the provision of care rather than on social connectedness itself, perhaps due to the extended family norm and cultural belief that children should provide care and support for their elderly parents [21, 22].

Despite the countless ways of operationalizing social connectedness, it is important to note that different dimensions of social connectedness are themselves positively associated with wellbeing [2, 23]. The Survey of Health, Ageing and Retirement in Europe as well as studies in East Asia such as China have shown that while the degree of social interactions with family members and friends enhances the wellbeing of older people, it is the quality of the social contact that have a stronger association with wellbeing [24, 25, 26, 27]. Similarly, research in New Zealand has shown that satisfaction with social contacts positively influenced one’s wellbeing while the number of contacts did not do so [2]. These findings provide support for the theoretical perspective of socio-emotional selectivity related to the social network and social connectedness of older people. It has been proposed that the characteristics of the wider social context (cultural norms and values), social change (urbanization), economic factors (poverty) and public policies also influence network formation and subsequent social relationships [17]. For example, in Singapore, social relationships with children, parents and friends, and involvement in leisure and spiritual activities with others were found to be important dimensions that correlate with wellbeing [28]. A study in the Caribbean islands found that older people often engage in a number of informal social activities, but noted that the level of social engagement is influenced by their socio-economic situation [21].

Proximity has been identified as a factor closely related to the extent and quality of social interaction, either with family or friends [10, 29]. In the context of geo-spatially isolated populations like Maldives (very small island countries where the population is dispersed across the ocean), physical proximity to network members is of special interest when examining social connectedness [16]. The characteristics of small island contexts are different from industrialized country contexts as socio-cultural practices assert the central role of family in social networks, while the geo-spatial situation results in the separation of older people from their kin and other family relations. Thus, the characteristics of geo-spatially isolated island communities such as few occupational choices, limited health and social services, poor transport, sensitivity to traditional and religious values, and limited privacy have a greater potential to decrease the opportunities for different types of social contact with family and friends of older people [16]. Migration of adult children also causes a reduction in the opportunities for social contact, thereby undermining family interactions for older people [11, 21]. Furthermore, it was observed in the Pacific islands, older people in both rural and urban areas were found to be socially isolated, perceived as receiving a low level of respect and facing a more difficult financial situation than younger people [11]. The unique aspects of geo-spatially isolated small island communities thus characterize the ability to interact with family, friends and community, and to be socially integrated thereby constituting the important aspects of social connectedness that contribute to wellbeing [16].

2. Concept and methods

In the research in Maldives, data was collected from a sample of 393 older people 65 years and over covering 11 islands of Maldives. Ethics approval was obtained from the National health research committee of Maldives [30]. Wellbeing was regarded as the state of being; a sum of experiences in a range of life domains including social connectedness. Keeping with this definition, the measure used for this indicator is the self-reported satisfaction level to a single item question ‘How satisfied are you with your life as a whole?’ The responses reported on a Likert scale of 5-1, from ‘very satisfied’ to ‘very dissatisfied’. For the analysis, the data was compressed (4 to 5 = 3), (3 = 2) and (1 to 2 = 1) and recoded. The computed score for each respondent was used as the score for the level of satisfaction.

Given the collectivist nature of the societies and extended family norm in the small islands of Maldives, social connectedness was conceptualized to encompass structural and functional characteristics of social interactions. Social connectedness was defined as the ‘state of social integration of the individual through networks of family, friends and community through social contact, social engagement and social support’ [16]. As social connectedness is a multifaceted and comprise of interactions with family, friends, neighbours and the community, it was operationalized using the diverse dimensions of social relationships such as social network, social support and social engagement [17]. Specifically, given the collectivist nature of island communities and the effect of changing family structures from extended to nuclear families, older people’s social contact with family and friends is operationalized as separate factors [16, 21, 31].

Objective and subjective measures were used as indicators of social connectedness. The subjective indicator of social connectedness was measured with ‘satisfaction with overall social connectedness’. In addition, ‘satisfaction with social connectedness with family’, and ‘satisfaction with social connectedness with friends’ was also used to allow for a comparison of the contribution of these two dimensions of the social network to overall social connectedness and wellbeing [16]. Responses were recorded on a 5-item scale and compressed for analysis, similar to the measure of wellbeing as stated above.

The objective level of social connectedness was operationalized with the view that social connectedness occurs through a network of contacts with the family members, friends and community. Such contacts are created through social support and casual or formal social engagement that older person perceives as emotionally rewarding or unsatisfactory. The social network characteristics such as composition, frequency, mode of contact and place where social contact occurs are used for measure network factors. Social support and personal activities outside the household, participation in group activities with family and friends, and participation in religious and community activities were also recognized as constituting different opportunities for social interaction. See in Moosa [16] for a detail account of the social connectedness measure.

3. Findings: the impact of social connectedness on wellbeing

The findings demonstrate that social connectedness is an important determinant of wellbeing (Table 1). Specifically, social connectedness has a significantly large impact on the wellbeing of older people in Maldives (overall social connectedness having a 29% shared contribution with wellbeing).

Wellbeing (overall satisfaction with life)Satisfaction with overall social connectednessSatisfaction with social connectedness with familySatisfaction with social connectedness with friends
Pearson correlation0.538**0.506**0.417**
r20.2890.2560.174

Table 1.

Pearson’s correlationa statistics for wellbeing and measures of social connectedness.

Correlation is significant at the 0.01 level (2-tailed).


Listwise N = 389.


Reproduced from Ref. [16].

The results also show that the contribution of social connectedness with family to the wellbeing of older people in Maldives is larger than that of social connectedness with friends. The correlation statistics (Table 1) show that ‘satisfaction with social connectedness with family’ has a significantly larger positive correlation with wellbeing (26%), compared with that of the ‘satisfaction with social connectedness with friends’ and wellbeing (18%).

The Pearson’s correlation statistics (Table 2) show that a number of factors that significantly (p < 0.01) contribute to ‘satisfaction with overall social connectedness’ also have a significant correlation (p < 0.01) with wellbeing. The only exception is the type of contact (p = 0.604). However, the r2 statistics indicate that the size of the contribution by each variable to the ‘satisfaction with overall social connectedness’ and wellbeing is different.

VariableStatistical measureSatisfaction with overall social connectednessWellbeing (Overall satisfaction with life)
Social support familyPearson0.191**0.195**
Sig. (2-tailed)00
r20.0360.038
Family contacts numberPearson0.317**0.240**
Sig. (2-tailed)00
r20.10.058
Friends contacts numberPearson0.266**0.296**
Sig. (2-tailed)00
r20.0710.088
Family contact frequencyPearson0.363**0.377**
Sig. (2-tailed)00
r20.1320.142
Friends contact frequencyPearson0.321**0.299**
Sig. (2-tailed)00
r20.1030.089
Family contact typePearson0.175**0.026
Sig. (2-tailed)0.0010.604
r20.0310.001
Friend contact typePearson0.209**0.102*
Sig. (2-tailed)00.045
r20.0440.01
Religious social activityPearson0.195**0.279**
Sig. (2-tailed)00
r20.0380.078
Informal personal activityPearson0.179**0.285**
Sig. (2-tailed)00
r20.0320.081
Social activity with friendsPearson0.324**0.371**
Sig. (2-tailed)00
r20.1050.138
Social activity in the communityPearson0.160**0.164**
Sig. (2-tailed)0.0020.001
r20.0260.027
Social activity with familyPearson0.315**0.312**
Sig. (2-tailed)00
r20.0990.097

Table 2.

Pearson’s correlationa statistics for variables that determine satisfaction with overall social connectedness and wellbeing.

Correlation is significant at the 0.01 level (2-tailed).


Correlation is significant at the 0.05 level (2-tailed).


Listwise N = 387.


Reproduced from Ref. [16].

The variables that make the largest contribution to ‘satisfaction with overall social connectedness’ is the ‘family contact frequency’, accounting for 13% of the contribution (see Table 2). Other variables that show significant correlation with the ‘satisfaction with overall social connectedness’ and have an effect size of 10% or more are ‘social activity with friends’ (r2 = 0.105), ‘friends contact frequency’ (r2 = 0.103), ‘family contacts number’ (r2 = 0.100) and ‘social activity with family’ (r2 = 0.099). The contribution of the ‘type of contact’, ‘social support family’, ‘social activity in the community’, ‘informal personal activity’ and ‘religious social activity’ to ‘satisfaction with overall social connectedness’ are each small, accounting for 3–4%. The cumulative contributions from variables on ‘family network’ account for 40% of the shared variance with ‘satisfaction with overall social connectedness’, while variables on ‘friends network’ account for 31%, and ‘community and personal social engagement’ accounts for 10%. These results thus confirm that, in the Maldives context, family network makes a larger contribution to the individual’s overall social connectedness than friends.

In a similar way, these factors show direct correlation with wellbeing, with the ‘frequency of contact with family’ having 14% shared contribution (r2 = 0.142) with wellbeing (Table 2). The contribution by the ‘number of family contacts’ to wellbeing is lower (6%), compared with its contribution to ‘satisfaction with overall social connectedness’ (10%). However, the contribution by the ‘number of friends contacts’ to wellbeing is higher than that for ‘satisfaction with overall social connectedness’, 9% for the former as compared with 7% for the latter. ‘Engagement in social activity with friends’ accounts for 14% of shared contribution with wellbeing and ‘engagement with social activity with family accounts’ for 10% of shared contribution. The shared contribution of ‘engagement in religious social activities’ (8%), and ‘informal personal activities’ (8%) are higher with wellbeing than with ‘satisfaction with overall social connectedness’ (4% for religious social activities and 3% to informal activities). The cumulative contributions from variables on family account for 34% of the shared variance with wellbeing, while variables on ‘friends’ account for 33%, and ‘community and personal social engagement’ accounts for 19%.

3.1 Placing social connectedness in the context of small islands

As in many small island countries, Maldivian society is collectivist, but given the geo-spatial characteristics many families are dispersed across different islands. Against this background, the findings established the important contribution of social connectedness to the wellbeing of older people. This was expected, given the collectivist social arrangements where interdependence, rather than independence, is the societal norm. The findings confirm that the prevalent socio-cultural norms and practices in small island countries such as Maldives provide the context that facilitates social connectedness despite its geo-spatial challenges.

It may be that the role of social connectedness in wellbeing has been recognized in previous research, but the conceptualization of social connectedness in the context of small islands of Maldives is different, given the collectivist social context with the central role of extended family. This makes comparison with other findings difficult, but the observations in this study generally align with those found in other research into social networks, social engagement and social support and wellbeing [2, 7, 18, 32].

The important aspects of social connectedness that have an impact on wellbeing relates to the conditions made available for the individual to interact with others and the social values and norms inherent to the collectivist social institutions to support such interactions. Of the various factors that was operationalized to measure social connectedness in this study, the items that make 10% or more contributions to satisfaction with overall social connectedness are ‘family contact frequency, ‘friends contact frequency’, ‘family contacts number’, ‘social activity with family’, ‘social activity with friends’, and ‘social support family’.

In the islands of Maldives, many older people are separated from several family members due to the specific geo-spatial characteristics of small dispersed islands with limited access to transport and technology as well as opportunities for economic and social activity. This situation inherently creates conditions to limit social connectedness and increase social isolation. However, the findings indicate that older people are able to adapt to the changing circumstances of a dispersed family in the isolated islands, perhaps as a result of repeated experiences of such instances during their lifetime. In addition, the historically large family size and the collectivist social values and norms appear to be conducive to social connectedness in these circumstances. The findings show that older people in the Maldives islands typically have a large network structure (with five or more family members and one to four friends, results not reported here) reflecting the kinship or friendship relations with many households in the community, as is reported as the case in other island countries [21, 33]. This finding supports the convoy theory that losses in the social network of family is compensated for by formation of new social contacts and friendships from the island community. Furthermore, this observation fits with the broader perspectives on formation of networks in collectivist cultures where it is postulated that when faced with institutional changes, people from collectivist cultures tend to rely on groups that share similar cultural values and beliefs, in this case from the same island community [34]. In the small islands, the common social values and norms along with the friendship linkages among households in the community allow for establishing new social relationships. The high satisfaction with social connectedness ‘with family’ as well as ‘with friends’ supports the premise that older people are able to maintain emotionally rewarding social relationships with family and friends as well as form new relationships with members from the community that share cultural beliefs.

However, social engagement with the wider island community, though significant, was low. This is in contrast to the findings in developed country contexts where engagement in the community is an important contributor to wellbeing [2]. Low social engagement with the wider community can be attributed to the cultural beliefs in the collectivist societies that tend to prioritize family goals and interactions over time is a requisite to develop close relationships [36, 38]. Moreover, it is proposed that in collectivist cultures interactions are often segregated and are preferred through established social institutions [34]. While such cultural beliefs tend to maintain older people’s social networks within family and close friends, the geo-spatial isolation of the islands limit opportunities for wider social engagement. As such, structured community-based social activities for older people are irregular and occasional in the islands of Maldives, as in other small island countries [22]. Moreover, formal voluntary associations working with older people are non-existent in the islands of Maldives (except in the capital island), hence limiting the opportunities for social interaction with the wider community. In addition, there is a tendency not to include older people in some of the community-based activities as it may appear to be disrespectful, as aged persons maintain a high social status is such small island communities [16, 22]. Despite the low social engagement with the wider community compared to that of family and friends, the statistically significant association indicates that different types of social engagement generates experiences of social connectedness that positively affect wellbeing. While the findings reinforce the view that social connectedness of older people is established largely within the extended family and with close friends in the small islands of Maldives, it also points to the importance of establishing new social contacts outside the family networks, in the face of changing social institutions in Maldives.

The findings thus support the premise that social contact and interactions with friends and family is facilitated by collectivist social arrangements despite the geo-spatial isolation of the islands of Maldives. The collectivist social institutions and cultural beliefs together with the kinship and friendship relationships that exist in the small communities thus provide a conducive social environment for social connectedness of older people.

3.2 The role of the extended family in social connectedness in small islands

The lives of older people in Maldives are anchored within the extended family [16]. The collectivist cultural beliefs maintain an expectation for social interaction and social support from the family, as is the case for other island countries [21, 22]. The central role of family is supported by the finding that ‘satisfaction with social connectedness with family’ makes a significantly larger contribution to wellbeing (26%), compared with that of ‘satisfaction with social connectedness with friends’ (17%). However, Maldivian society is undergoing social change as demonstrated by the shift from extended family arrangements to a nuclear family structure, as is the case in a number of small island countries [16, 37]. This has the potential to weaken the social connectedness of older people, exacerbated with the migration of adult children and friends to other islands for education, work and other services. Despite this, the findings show that the majority of older people in Maldives continue to live in extended family households [16]. This opportunity is created from the historically very large family sizes and enables older people to live in an extended family environment, though with fewer kin. Such living arrangement provides for a large social network of family members and facilitates a high degree of social connectedness and in turn wellbeing.

The findings show that the structural characteristics of the network (such as network size) make a smaller contribution to wellbeing than the frequency and degree of social interactions that occur with the family members. This aligns with the view that existence of contacts is not adequate to form interpersonal relationships, but repeated interactions over time are essential [36]. In fact, of the factors that constitute social connectedness, ‘family contact frequency’ was the most important contributor to wellbeing, followed closely by the ‘social activities with family’ (providing more than 10% contribution). In Maldives, given the collectivist cultural beliefs and expectation of interdependence, the family relationships form the core of the social interactions. The extended family environment provides opportunities for a wide range of interactions with the family network that provide for both emotional and instrumental support [16]. As such, within the extended family environment, the interactions with children, grandchildren and other relatives that provide varied experiences of social connectedness that may be rewarding or dissatisfying. As the findings indicate a high level of ‘satisfaction with social connectedness with family’, it can be concluded that, at present, the experiences from social connectedness in the extended family is rewarding for older people in Maldives.

The social support from the family was found to be an important contributor to social connectedness (more than 10%) of older people in Maldives islands. This is consistent with the cultural practice and attitudes towards ageing and care of older people in collectivist societies and aligns with previous research on approaches to care of older people affecting social connectedness [16, 35]. The findings indicate that social support from family provides for opportunities for social connectedness of older people with their family network. The importance of the opportunities for social interactions with extended family through social support is supported by the significant contribution of social support from family to social connectedness and wellbeing.

Social support from family also made a significant contribution to wellbeing (4%). This is in contrast to findings from industrialized societies where social support from family was found to be negatively associated with wellbeing [20]. This may be a reflection of the expectation of social support from kin that is also linked with emotional interactions such as bonding and family affiliation [26, 33]. Furthermore, this is a reflection of the cultural beliefs around collectivism and individualism in these different contexts [34, 36]. These conflicting findings can be attributed to the different societal attitudes toward dependence, where receiving support from family is an expectation in small island societies, but regarded as a threat to independence in industrialized societies [39]. In the Maldivian society, there is an expectation that the family will care for and provide support to older people and this collective societal attitude towards dependence, explain the findings. The familial responsibility of caring for older family members (even when they are bed-ridden), therefore, provides for social integration within the family, and allows for interaction with family members, as has been observed in other island countries [22, 33].

However, in the extended family environment, the older person has less choice in family contacts and some of these contacts may not be as rewarding as others and may have negative effects on wellbeing, as they are not always supportive [20]. In such environment the older person does not have the opportunity to be selective in their social contacts and interactions. Furthermore, if such contacts and interaction does not meet the cultural expectations, it is likely to reduce the satisfaction derived from the contact. This is reflected in the smaller contribution of ‘family contacts number’ to wellbeing than ‘friends contact number’, implying that having a large family network, does not necessarily provide emotionally rewarding experiences. In contrast, older people have the opportunity to be selective in friendship contacts and interactions that are emotionally rewarding [15]. This proposition is further supported by the finding that ‘social activity with friends’ has a similar contribution as ‘social activity with family’ to the satisfaction with overall social connectedness. However, social connectedness with friends is challenging in island countries, as older people are often faced loss of friends that migrate to other islands for better health care and social support from family. At the same time, the limited amenities and services in the small islands in the small islands limit the opportunities for older people to interact and engage in social activities with friends, as observed in the Caribbean island countries [33]. Nonetheless, as discussed earlier, the smallness of the communities with shared cultural beliefs in the more isolated islands means there are kinship and friendship relationships in close proximity facilitating social contact. The findings, thus, establish that although family is the basis of social connectedness, friends also play an important role by providing different opportunities and experiences to those provided by the family.

Thus, it is established that the collectivist cultural beliefs and predominant extended family living arrangements in Maldives, couples with the expectation of social interaction and the care of the older people by the family results in a social network that is anchored within the family. In this context, older people achieve a sense of social connectedness not only through social support, but also through frequent contact and interactions with family members within the extended family household that generate emotionally rewarding experiences [16]. This is a marked difference to the situation in industrialized contexts and, therefore, distinctive to the island country context. The small size of the community with shared cultural beliefs in the small islands is also conducive for older people to compensate for loss of friends through the life course. Furthermore, they are able to exercise selectivity in their contacts with friends resulting in a smaller number of friends, but achieve different emotional experiences from that of family. It is proposed that when composition of the social network that includes Both family members and friends, there is a higher satisfaction with social connectedness and wellbeing. However, there is limited opportunity for older people for social engagement within the wider community, that if improved is likely to further improve social connectedness of older people in the small islands. Thus, the findings underscore the importance of family, yet indicates that social connectedness through a combination of family and friends can be more favourable for wellbeing.

4. Conclusion

It is established that social connectedness is one of the most important aspects of life that impact wellbeing of older people where social network, social support and social engagement make significant contributions. The findings from this research in Maldives stress the importance of family and close friends, rather than the wider community in providing social connectedness. This is attributed to the socio-cultural context of small islands where collectivist cultural beliefs and extended family arrangements prevail that compensate for geo-spatial isolation of the island communities. In the small island communities where older people often lose contact with their friends, the smallness of the island communities with shared culture is conducive to the formation of new kinship and friendship relationships. It appears that a social network that includes both family and friends provides different emotional experiences that enhance social connectedness and wellbeing of older people in these small islands. Nevertheless, there is clear evidence that the family occupies the central role in the social network, social engagement and provision of social support than friends, influenced by the collectivist beliefs of interdependence.

The collectivist social values and social arrangements of small island communities enable a high level of social connectedness, despite the geo-spatial challenges. It also highlights the importance of promoting social connectedness in small islands with a focus on the collectivist social arrangements, including both family and friends, rather than on the wider community and formal programmes.

Acknowledgments

The author would like to acknowledge and thank Emeritus Professor Peggy Koopman-Boyden, University of Waikato, for her for her guidance and support during the original research in Maldives, part of which is presented in this chapter.

Conflict of interest

The author has no conflict of interest.

Notes/Thanks/Other declarations

The data and analysis presented here is drawn from the original research conducted for a PhD thesis by the author.

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Sheena Moosa (March 21st 2019). Social Connectedness and Wellbeing of Ageing Populations in Small Islands [Online First], IntechOpen, DOI: 10.5772/intechopen.85358. Available from:

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