Older Adults’ Experiences of Using Strategies to Maintain and Foster Social Participation: A Systematic Review with Metasynthesis of Qualitative Studies

Social participation is positively associated with older adults’ health. Health-care services, therefore, need to empower older adults to adapt to the social changes that accompany aging. Tis systematic review, with a metasynthesis of qualitative studies, aimed to describe and develop an understanding of home-dwelling older adults’ (65 yrs+) experiences of using strategies to maintain and foster their social participation. Te main search was performed in March 2022 using the PubMed, CINAHL, PsycINFO, and AMED databases and included peer-reviewed articles published between 2012 and 2022. A total of 35 full-text articles from 15 diferent countries were included and assessed for quality by the assessment tool for qualitative studies provided by the Critical Appraisal Skills Programme (CASP). Te metasynthesis resulted in the main theme: strategically creating routines that foster social participation and two main categories: inward-looking strategies for social participation and outward-looking strategies for social participation. Each main category contained three subcategories. Te fndings suggest that for perceiving social participation, it is important for older adults to create routines with patterns of activities and to be able to engage in these activities. Te fndings further refect that older adults use earlier experiences of social participation to facilitate the making of routines. Tis indicates that health-care interventions supporting older adults’ social participation must be applied early and with a health-promotive focus. Conclusively, researchers need to develop interventions that support older adults in healthy activity patterns by raising awareness of how to use inward-looking and outward-looking strategies to create routines for social participation. Te fndings further suggest that older adults’ possibilities for social participation could be supported by designing accessible venues that facilitate spontaneous meetings and encourage older adults’ own choices and initiatives for social participation.


Introduction
Te aging population poses medical and social challenges worldwide [1].Tese demographic challenges have increased health-care costs and damaged economic growth in developed countries [2].It is stated in the third of the United Nation's global goals for sustainable development in Agenda 2030 that there is a global need to create sustainable solutions to promote human health and reduce health risks [3].Terefore, health-care systems must address and respond to the demographic trend of an aging population and manage the increasing health-care demands of older adults who are living longer and often with disabilities [4].
Te World Health Organization (WHO) defnes healthy aging as the process of developing and maintaining the physical, mental, and social abilities that enable well-being in older age [5].Accordingly, during the last two decades, a shift has occurred among policymakers, from traditional age care services focusing on long-term service provision and residential care to implementing more sustainable models for aged care.Tese models aim to improve abilities that decrease reliance on supportive services [6][7][8][9][10].However, current interventions and research are mainly aimed toward maintaining physical abilities.Terefore, practitioners and researchers need to develop interventions with a focus on social participation for older adults [8,11,12].Social participation is known to be related to older adults' health.For example, involvement in social activities and contact with others are associated with improved health outcomes [13].Conversely, social frailty, i.e., a decline in social activities and a restricted social network, is a risk factor for the development of physical frailty [14].According to Levasseur et al. [15], social participation can be defned as a person's involvement in activities providing interactions with others in community life and in important shared spaces, evolving according to available time and resources, based on the societal context, what individuals want, and what is meaningful to them.Social participation can further be described at diferent levels of engagement, e.g., being with others, interacting with others, preparing for activities in the vicinity of others without interacting, doing activities with others, and contributing to others and society [15].
Aging, however, often leads to social changes such as losing a spouse, or friends, or having to relocate, which might threaten social participation and represent a risk factor for loneliness [16].Tis is a growing public health concern in the aging population globally [17,18].Te physical and social environment, such as access to community centers, can act as a catalyst in stimulating new or other forms of social participation for those whose opportunities to social participation have changed due to aging [19].When adapting to social changes in the life situation, diferent strategies can be used in planning, gathering information, making decisions to solve problems, reducing stress, and achieving goals [20][21][22].Commonly, strategies can be explained as self-initiated and manifested in various response actions [22].Tese can be seen as active meaningmaking in moment-by-moment transactions in various activities and situations in everyday life [23].Tey can also be used deliberately, consciously, and with planning as well as spontaneously [23].
Research has been conducted regarding how older adults experience loneliness [18,24] and how older adults use strategies to manage experiences of loneliness [25].However, in accordance with the WHO's approach to healthy aging [1] and research [26], there is a knowledge gap and a need for health-care services to provide and coproduce early health-promoting interventions targeting the maintenance and continuance of social participation rather than the management of loneliness.
Within the current transition to person-centered and integrated care,WHO states that future health-care services need to empower older adults to adapt to and shape the challenges they face due to the social changes accompanying aging.In person-centered care, it is important that health-care interventions are cocreated and proceed from an understanding of older adult's own experiences [27].Tus, it is valuable to build knowledge of older adult's selfinitiated strategies rather than externally generated ones.Terefore, the aim of this study is to synthesize research and develop an understanding of older adults' experiences of using strategies that maintain and foster social participation.

Method
A qualitative metasynthesis was conducted to analyze and synthesize data from primary qualitative studies [28] to develop an understanding of strategies older adults use for maintaining and fostering social participation.Te methodological approach described by the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU [29]) was applied to plan and conduct the review.Furthermore, when reporting the metasynthesis, the guidelines presented in Enhancing Transparence in Reporting the Synthesis of Qualitative Research (ENTREQ [30]) were used as a checklist to enhance the transparency.
2.1.Search Strategy.Initial preliminary searches were performed to explore and refne search terms.Relevant search terms were explored among the authors, by examining titles, abstracts, and keywords in articles relevant to the study's aim.
Te SPICE model [31] was used to prepare the main search, and the following search terms were used: Setting (S); independent, living, community health services, home care services, preventive health services, aging in place and community living.Perspective (P); aging, aged, aged 80 and over, retirement, widowhood, frail elderly, elderly, widowed, care giver and older.Interest (I); social participation, togetherness, social activities, loneliness, and social isolation.Comparison (C); was considered irrelevant in this study.Evaluation (E); adapt, strategies, coping and occupation.Te search terms used for S were not used in the main search due to the risk of excluding relevant articles since the setting was not always clearly described in the titles and search terms.Abstracts and articles were, therefore, manually included or excluded with guidance of the search terms used for the S criteria.

Inclusion Criteria.
Inclusion criteria include the following: English language articles, published between 2012 and 2022 that were peer-reviewed, qualitative studies or contained qualitative results in mixed method studies, articles focused on older adults living in ordinary homes with a mean age of 65 years or older and covering older adults' perspectives on, and descriptions of, strategies for maintaining and fostering social participation.

Exclusion Criteria.
Exclusion criteria include the following: quantitative studies and reviews, older adults living in a nursing home or in transition to a nursing home, homelessness, those with a mean age younger than 65 years or workers, studies with a focus on a specifc diagnosis or the perspectives of carers, relatives, or health-care professionals.
Te PubMed, CINAHL, PsycINFO, and AMED databases were searched, and the search terms were altered according to the subject terms used in the diferent databases.In the Cochrane databases, the flter "peer-reviewed" was chosen.Tis flter was not available in PubMed, and the results from PubMed were, therefore, manually checked for peer-review.

2
Health & Social Care in the Community MeSH terms were used to identify key concepts for each search term, and synonyms and antonyms were used when relevant.Search blocks were built upon the search terms for each area in the SPICE model [31] by combining the search terms with the Boolean operator OR.Tereafter, each search block was combined with the Boolean operator AND.See Appendix 1 for the full search strategies.

Selection Process.
Te databases PubMed, CINAHL, AMED, and PsychINFO were used in the fnal search, and the results were imported into the screening tool Rayyan [32].Duplicates detected by Rayyan were excluded after being confrmed as duplicates manually by LK.In the frst screening, titles and abstracts were assessed for relevance by LK.Te second screening started with all authors assessing ten abstracts independently to reach an agreement on the subsequent process.Diferences were then discussed among all authors to reach a consensus regarding the interpretation of the inclusion and exclusion criteria.In the continuing process of the second screening, the remaining abstracts were distributed among the authors in pairs (LK and EL/AN and GI) and divided consciously to prevent authors form assessing their own abstracts.Te second screening was performed independently and blinded, and diferences were discussed by the pairs to reach a consensus.If diferences remained after the discussion in pairs, consensus was reached by discussion among all authors.
During the full-text reading, a blinded assessment was performed where LK assessed all the full-text articles, and the other authors divided them among each other.Ten, discussions were held to reach a consensus regarding inclusion or exclusion.Te remaining full texts were included for the quality assessment.

Quality Appraisal.
Te quality assessment of included full texts was performed by LK using the assessment tool for qualitative studies provided by the Critical Appraisal Skills Programme (CASP [33]).Ten percent of the articles were also assessed by two other authors (EL and AN), to confrm inclusion.Te CASP [33] provides ten questions to guide the assessment of qualitative papers.A scoring system where one point per question was given if the criteria were met is used as an indicator of quality and enables comparison across the studies.No major methodological faults were found in any of the articles.Due to the diversity in the qualitative methods, the judgment of quality may be biased [28].An inclusive approach was, therefore, adopted, and no study was excluded due to the quality assessment.Te quality appraisal was, however, useful to familiarize the authors with the articles and their context [28] before they extracted data.

Data Extraction and Metasynthesis.
All full texts were downloaded and saved in digital format.A study attributes table was developed to visualize the methodological aspects, sample types, size, and assessed quality (see Table 1).Next, LK read the fndings and discussion sections carefully, noting memos in the margin of each full text, and highlighted qualitative fndings related to the research question.Te highlighted text extracts from each study were, in accordance with the data analysis framework [28], copied and pasted into a separate document with their related instudy notes, resulting in preliminary codes and categories.AN and EL read twenty-fve percent of the articles for comparison and refective discussions with LK.Te results and discussion sections of all articles were read by LK until the text extraction was considered saturated.Refective cross-study notes and memos were developed during the review process to identify commonalities, diferences, and relationships between the studies [28].Due to the large volume of data, LK created a mind map to obtain an overview and a visualization of these commonalities, differences, and relationships.Te cross-study memos and notes were used to synthesize the fndings and further describe and develop codes and categories throughout the fndings in a back-and-forth manner where the original text extracts were reread to ensure the original meaning was maintained.Five articles were excluded in this step of the analysis process (see Figure 1).Te extracts from these articles were, due to their specifc context, isolated islands in the mind map and did not form relationships with the other areas.Tus, they did not ft into any of the emerging categories.Data from one emerging category could not be clearly separated from any of the categories and eventually developed into an overarching main theme.Te extracted data were compared and contrasted with the emerging categories and the main theme in a back-and-forth manner.Gradually, six categories emerged from the data.When developing these categories, it became clear that due to similarities and diferences among them, they could be grouped into two constellations.Tis process resulted in the development of two main categories for which similarities and diferences were described and clarifed.Each main category contained three subcategories.An illustration of the main theme, categories, and subcategories was developed by LK to visualize and describe the emerging results (see Figure 2).

Study Selection.
Te fnal search was performed on 2022-03-16 and yielded 4559 abstracts.Of these, 989 were marked as duplicates by Rayyan [32] and excluded after a manual control to confrm them as duplicates.In the frst screening, a total of 2378 articles were excluded.Abstracts were excluded for the following reasons: quantitative studies (n � 1942); studies written in languages other than English (French: n � 1 and Spanish: n � 2); wrong population (young age: n � 413 or animal: n � 20).For the second screening, 1192 abstracts remained.Te second screening resulted in 252 articles eligible for full-text reading.After the screening of the full texts, 40 articles remained for the quality assessment.No article was excluded due to the quality assessment, and 40 full texts were, therefore, included in the metasynthesis.In the metasynthesis process, fve full texts were excluded.A fowchart of the full study selection process is presented in Figure 1.
Health & Social Care in the Community

Strategically Creating Routines Tat Foster Social
Participation.Te main theme refects that older adults strategically created routines for maintaining and fostering social participation.Central to continuously creating and upholding these routines and experiencing them as fostering social participation was the sense of control and choice.When the routines were created strategically by the older adults themselves, they deliberately chose routines that fostered patterns of activities and interests that had been important to them throughout life.Tis facilitated them in upholding a positive mindset and relationships.Having routines set by or controlled by others created a sense of loss of control and resulted in a reduced perceived social participation.
Routines for everyday activities provided the older adults with a personalized activity pattern that gave a sense of familiarity and safety which was important for perceiving social participation.Having set routines for maintaining and fostering one's social participation made it easier for older adults to handle and persist through challenges brought about by aging.When challenges arose, it was described as important to persist in maintaining one's routines and strategically alter, plan, and create new routines.Such challenges for social participation could include relocating, retiring from work, losing a spouse, or experiencing ill-health.Tus, it was described as both a choice and a struggle to strategically create and uphold routines that foster social participation.
Te routines were created through various strategies to reach various aspects, or levels, of social participation.As this routine-making was described as a choice, the strategies were consciously and deliberately used to reach social participation as a goal.Earlier experiences of social participation in relationships, activities, and interests facilitated this routinemaking.Te strategies used to create routines were complexly intertwined and infuenced each other reciprocally.
Te result synthesizes the strategies used for achieving various aspects of social participation.To reach a simplifed comprehension of their relation to perceived social participation, they are illustrated as two main categories: (1) inward-looking strategies for social participation with the subcategories: keep moving forward using a positive mindset, creating continuity in relationships related to one's identity and using activities to preserve one's social role and (2) outward-looking strategies for social participation with the subcategories: using activities to create connections to others, joining groups in the community, and giving and receiving support.Tis is illustrated in Figure 2.

Inward-Looking Strategies for Social Participation.
Tis main category describes the active doing of older adults to consciously use inner dialogues as a strategy to motivate themselves and to create opportunities for maintaining and fostering social participation.Te category further describes how older adults strive for a continuity in relationships and activities that through the relation to the past and present are linked to their identity.As such, these relationships and activities create social participation and a sense of belonging because the continuity preserves the older adult's identity and their view of themselves in relation to others throughout life, supported by others' view of them.Terefore, older adults consciously use various strategies driven by the motivation to continue relationships and activities linked to their past.Tese strategies are considered inward-looking due to their focus on the self and one's values, which demands cognitive and emotional processes that are not observable from an outside perspective.Additionally, the category further develops how the individual's inner experience of meaningfulness in relationships and activities linked to their past and present is necessary for perceiving meaningful social participation in the relationship or activity.
Te inner drive to maintain active and social participation was described as a conscious choice [35-38, 40, 41, 44-47, 49, 50] motivated and fueled by a positive outlook [34,[36][37][38][39][40][41][42].However, in several studies, it was also recognized that to uphold a positive outlook, one needed to accept one's situation and come to terms with declining abilities to be able to make use of realistic opportunities [34,38,43,44,47].Tis process was not always easy or linear, meaning that the older adults had also developed strategies for consciously choosing to foster social participation [36, 38, 40, 41, 44-47, 49, 50] by regulating their emotions to reach acceptance [40,49] and to remain positive [38,39,41,43,46].Tis regulation could mean that the older adults from time to time needed to have delimited outlets of negative emotions.Tese outlets could occur either in private [36,44] or by sharing negative feelings with someone close to them or with a support group [53].After such an outlet, it was important that one consciously tried to leave the negative emotions behind, showing a positive front [36,53].Humor [44] or religious activities such as praying [36,37,44] were described as delimited outlets of negative feelings [36,37,44,53].Tis was also a strategy for briefy Health & Social Care in the Community acknowledging the negative aspects of one's situation and then consciously moving on with reaching acceptance and fnding positivity in challenging situations [36,37,44,53].
Te regulation of feelings for reaching acceptance and fnding positivity helped the older adults form a mindset, described as not giving up in challenging situations but pulling together, taking risks, moving on, and persisting in remain active together with others and becoming part of diferent contexts [26,34,36,45].Tis was both described as an ongoing struggle and as a way of being an active agent in creating opportunities to maintain and foster social participation [34,36,45,46].Older adults mentioned that opportunities for social participation created by this mindset helped them to remain curios and motivated to learn new things [26,38,39,45,49,51,[53][54][55][56][57][58].However, reaching out to others was sometimes a challenge due to the risk of being rejected or when there was a lack of reciprocity [43].Additionally, planning activities, keeping up with current affairs, getting ready, and transporting oneself were sometimes demanding and consumed energy [47,50].In these challenging situations, a routine of regulating one's feelings was important to overcome the challenge and maintaining a positive outlook where, among the strategies mentioned above, it was also useful to picture oneself participating in future activities or looking forward to the positive aspects of participating [36,59].

Creating Continuity in Relationships Related to One's
Identity.Maintaining and upholding relationships with family members, siblings, or old friends who have known the older adult's past selves created a continuity that provided a meaningful perceived social participation [36,39,41,44,47,49,60,61]. Te motivation to maintain and uphold these relationships was derived from the connection to one's identity and sense of self, where the bond to past, present, and future social roles within the relationships and throughout the lifespan was important [36,39,41,44,47,49,60,61].
Maintaining one's role in relationships with family members mainly involved creating routines for keeping up with what was happening in relatives' lives [44,45,61,62], providing advice, emotional support, and upholding traditions [41,50,61].Tis could be conducted through routine phone calls, social media, or gatherings with family members or old friends [36,39,41,44,49,60,61].Te use of social media, such as Facebook and Instagram, was highlighted as a way for the older adults to control when to update themselves about the life events of their younger family members at a self-determined suitable time where they could comment or respond at their own pace [46,57].
Older adults could experience social participation by upholding their role as independent and able to care for themselves in relation to their children, not wanting to burden them with their worries and problems [36].For these older adults, fostering social participation by sharing a mutual understanding of struggles with equals was important [44,53,63].Other older adults described the opposite: a transition in roles [44].For them, a continuous bond from social participation was present when they depended on and were willing to receive help and support from family members.Tese older adults felt a natural transition in their role from being the supporter to being the receiver of support [44].
Fostering social participation with old friends or siblings was centered around sharing memories or telling stories about or refecting upon past examples of participation together and the routines consisted of, for instance, weekly phone calls or visits [38,39,41,46,49].Tis was also a strategy used for maintaining connections to a spouse with dementia; by scheduling regular visits for sharing mutual memories and events from the past, a sense of connection and social participation could be reached even if the couple was separated due to the spouse being enrolled in a nursing home [35,61].When the spouse's verbal and cognitive abilities declined, the maintenance and continuity of the relationship were still highly valued, and social participation could be fostered through sharing common impressions connected to their past social participation such as listening to music or smelling fowers together [61].

Using activities to Preserve One's Social Role.
Activities performed earlier in life and throughout the lifespan had a special value that created a perceived social participation due to their connection to the older adult's identity [36,39,40,44,45,49,53,54,59,64].For instance, religious and political values [37] and the value of being kind to others [35] or being physically active [58] could be considered parts of older adults' identities, and these values could be shared with others and represented in various activities performed throughout the lifespan [36].Tese activities also included those performed in their childhood with their parents and as thus now performed with a special meaning connected to past experiences of social participation [54].For experiencing value in the activities and perceiving social participation when performing them, the older adults needed to feel in control of the activities performed.Also, they needed to be able to choose the activity, the location, the time, andwhom to perform the activity with [34,41,52,57,59].
When interests or hobbies with special value were shared with others in the present, it provided a new dimension to current social participation and a link to past social participation where these activities were shared with others [43,47,59].It was, however, important for older adults to have the ability to adapt and change the performance of these valued activities to suit their present situation but with preserved value [35,43,47,60,61].For example, instead of performing the interest and hobby of gardening, a physically demanding activity, one could share their knowledge about gardening, discuss gardening with others, visit gardens, or simply look out the window and into the garden while remembering [47].In this way, the value of the activity could be preserved in the present and, through memories, connect to the older adult's identity and past experiences of social participation and the social role of a gardener.

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Health & Social Care in the Community

Outward-Looking Strategies for Social Participation.
Tis main category describes how older adults use routines to connect to others and create new relations.Te focus of these outward-looking strategies is directed toward other individuals and at becoming a part of a community or a larger world.Te main category further describes that the performance of activities can create social participation through the sense of belonging they provide, regardless of whether the activities are performed with others or in solitude.Additionally, this category highlights that older adults strive for and use strategies of acting in a conscious way to become part of diferent groups in the community and that by helping others or receiving help from others, meaningful social participation can be developed and/or maintained.
Tese strategies are considered outward-looking due to the focus on using activities to connect with others.Tese strategies, therefore, demand the individual's performance of activities and/or interaction with others.Te activities manifested from the outward-looking strategies are thus observable from an outer perspective.

Using Activities to Create Connections to Others.
Accessing a larger world through activities that updated the older adults on current events and world news, such as watching TV, listening to the radio, reading newspapers and books, or using the Internet, permitted social participation through the connection to the outside world and a collective social identity within a community [41,44,47,57,60,65].
Studies have revealed the importance of continuously keeping up with developments and current events as conscious social fuel, providing topics to talk about with others or to keep up in conversations [38,39,42,44,45,49,[54][55][56][57][58]65].For instance, watching football on TV or reading the latest novel by a certain author provided a sense of belonging to a wider community of likeminded others even if performed alone [60,65].Tese valued activities could also develop from being performed and enjoyed alone into conversations about football with others in diferent situations or lead to a visit to the library to discuss the book with others [60].Interests pursued alone could also foster social participation when resulting in products that could be given or sought after by others, such as baking for visitors or gatherings or knitting for grandchildren living abroad [36,37,65].Te activity performed when producing the product, the act of giving, and the perceived appreciation of receiving fostered social participation [65].
It was important to have routines for getting out of the house and being around other people routinely to foster social participation and create a sense of belonging to people and places [39,48,64].Having access to and the possibility of going out into the neighborhood seemed to be an important aspect of maintaining social participation [39,48,64].By creating routines for leaving the house and being aware of the local area, opportunities to meet others were consciously created in diferent ways.Informal contact was described as important for feeling a sense of belonging to the community and could comprise spontaneous meetings when being out, such as just saying hi to someone in the streets [48,64].Older adults had strategies for facilitating these informal meetings by following routine activity patterns and routine routes visiting the same places at regular times when performing errands, walking in nature, grocery shopping, visiting the library, or visiting informal meeting places [44,48,64].One informal meeting place was the post boxes, where older adults could stay and await others when retrieving the newspaper as a strategy to meet and chat with neighbors [44].Following routine activities when getting out of the house created a sense of familiarity and belonging where the older adults recognized and were recognized by others, facilitating interaction [44,48,49,55,64].Tese routine activities could be performed alone, with a spouse, or, for instance, as a weekly gathering of friends meeting for cofee or lunch [35,36,39].Routinely going out for meals could also be a means for avoiding feelings of loneliness after losing a spouse since mealtimes were previously shared with the spouse [51].

Joining Groups in the Community
. Some studies described the strategy of fnding places and scheduled community-based activities to attend where one could meet new individuals and develop new friendships [39,58].It was considered important to rethink one's life situation after retirement or after life-changing events such as the loss of a spouse, developing new routines, and joining new community-based activities [38,40,49,52,63].Earlier developed routines of participating in community-based activities facilitated the continuance of community participation [39,42,58].Activities and competencies, sometimes work-related, could be used as a foundation for joining new groups [39,42,58].When fnding community-based activities, older adults strived to fnd the right group to join, using their interests, values, and experiences to be around likeminded people where they could be themselves, feel accepted, and have common topics to discuss [38,39,41,42,63,66].Long-term involvement in the community could lead to friendships as close as family bonds [40,51].Belonging to a minority group or sharing an extraordinary past, such as the experiences of refugee immigrants, could also lead to strong friendships due to the experiences and often similar values and beliefs shared within the community, and where the activities performed often were often related to the common background [63,66].
One aspect of motivating the maintenance of community participation was that it could provide a sense of safety and support where the older adults, through their routines, were expected to be somewhere, and others noticed if one was missing [49].Tis was described in the studies as a reciprocal process where older adults looked out for each other [41].For instance, it was important to feel invited and encouraged by others to start participating in communitybased activities [41,43,49], and if participating in community activities, it was considered as important, or even as one's duty or obligation, to also include and invite others [34-36, 41, 42, 47, 49, 54, 55, 59], and online contexts were useful for this purpose [57].
Health & Social Care in the Community 4.3.3.Giving and Receiving Support.Supporting others meant being a social contributor [42] and nurtured feelings of being needed, appreciated, useful, and having a purpose through one's role in other people's lives [34,41,42,49,54,55,59,67] instead of being a passive receiver of support [44].In this way, helping and supporting others was described as an important aspect of social participation [49].Strategies for fostering social participation through feeling useful and helping others were manifested in diferent ways: inviting others [49], driving others to appointments or events [36,41], baking or cooking for others, walking the neighbor's dog, and being involved in congregations [41].Older adults also felt useful and needed by sewing, knitting, and altering clothes for others or charities, by being a mentor for children, checking in on others, creating neighborhood projects [36,37], or looking after grandchildren [66].Being a caregiver [35,61,65,67], visiting, advocating for [35,61], monitoring the care of a spouse in a care home [65], or ofering support to other caregivers [67] also harbored social participation by inducing a feeling that one was needed.Volunteer work was also a strategy for cultivating meaningful social participation by using one's interests [39], knowledge and abilities to feel useful to others [38,55,63], giving back to society [63], or just having someone to talk to [35].It was also described as a reciprocal process where, by helping others, one was better able to accept help themselves when necessary [34,55].
Asking for and receiving help from others were also strategies for maintaining social participation.By opting out and receiving help with demanding activities with low value, older adults could continue with more valued activities and routines that fostered social participation [43,44,62,67].Help from others that involved social participation included receiving support, encouragement or advice from family, friends, neighbors, home care personnel, support groups, or community members [41,43,51,53,62,67].Older adults also embraced practical help as a strategy to foster social participation such as technical support that enabled engagement in online activities that connected them with other individuals and the digital community [45].Practical support with household chores and/or transportation was likewise highlighted in the studies as a facilitator of social participation [43,51,65,68].Sometimes older adults' main social participation with others was through home care services [41,65] and relationships with home care helpers that were well-established, and long-standing could even have the closeness of friendships [65].One study further described how older adults used strategies to increase their time spent for socializing with the helper during or after chores, such as consciously leaving things undone or asking for extra help [43].

Discussion
Te aim was to synthesize research and develop an understanding of older adults' experiences of using strategies to maintain and foster social participation.Te fndings show that older adults strategically created routines for maintaining and fostering social participation that positively afected perceived health.In this creation of routines, various inward-looking and outward-looking strategies were used, motivated by various aspects of social participation.Tis is in line with theory [69] proposing that individuals structure their days with patterns of activities and that the balance, or imbalance, of these activities afects perceived health.Te fndings further show that being in control and acting according to one's own choice is central to the older adult's routine-making and perceived social participation.Tis emphasizes, from a person-centered approach for older adults [70], that health-care providers should form a dynamic and collaborative relationship with older adults and involve them in all decision-making about their health to the extent that they themselves wish.In addition, the fndings suggest that for perceiving social participation, it is important for older adults to create routines or patterns of activities of their own choice to be able to engage in these activities satisfactorily.Previous research has shown that it is important for perceiving health and social participation to have the ability to make and act upon own choices [71].
In accordance with research by Dahlberg et al. [16], the fndings refect that age-related challenges such as retiring from work, losing a spouse or friend, or having to relocate constitute a threat to social participation.Tese challenges cause a changed activity pattern which could lead to an imbalance in activities and ill health [72].Te fndings show that older adults handle these challenges by maintaining their ordinary routines and strategically altering, planning, and creating new routines.Tis was not described as a process supported by health-care providers.Tus, these challenges of aging need to be given more attention in health care since it is essential to provide the right support at the right time for each individual [73].Terefore, these fndings suggest a need for health-care providers to develop individualized support mechanisms for older adults to build healthy activity patterns.Te fndings further refect that older adults use earlier experiences of social participation to facilitate the strategic routine-making, which was described as both a choice and a struggle.Tis fnding suggests that when supporting older adults in handling challenges that could potentially lead to reduced social participation and decreased perceived health, health-care interventions need to be provided early and with a health-promoting focus.Within this health-promoting approach, the fndings imply that older adults' own experiences could be used as a resource when supporting older adults in creating healthy activity patterns that foster social participation.Tis is consistent with the WHO's [74] framework that highlights the importance of health-care providers consciously adopting the perspectives of individuals and coproducing care that meets people's needs through a continuum of health promotion interventions.
Te fndings further show that older adults use a variety of inward-looking and outward-looking strategies within routine-making.Tis variation in strategies is used to achieve various aspects of social participation, supporting the idea of social participation as occurring on diferent levels of engagement [15].Te fndings suggest that older adults' experienced that values and roles afect the level of engagement and, thus, perceived social participation in performed activities.Previous research indicates that it becomes possible to negotiate a social identity through shared experiences [75].Te fndings further show that older adults actively and consciously use strategies for aiming their thoughts, feelings, and motivation toward facilitating social participation.Tis extends the current defnition of social participation as a person's involvement in activities providing interactions with others [76] since the fndings show that older adults also use noninteractive and nonobservable strategies and activities for maintaining and fostering social participation.
Te value people experience when performing daily activities is related to an overall experience of meaning and subjective health where meaning is operationalized through diferent values in daily activities [77].Te fndings refect that inward-looking strategies contain the upholding of personal values related to one's identity and social roles through experiences of former social participation in certain relationships or activities.It has been previously described that roles infuence the manner, content, routines, and repertoire of doing [72].However, the doing manifested from the inward-looking strategies is closely related to the concept of being.Being is described as the sense of one's self and includes identity, personal abilities, roles, creativity, and consciousness [78].Being is closely related to symbolic values which are characterized by what an activity signifes for a person, for example, strengthening his or her identity, role, or bonds with a certain group or culture [77].Tis reasoning also complements Levasseur's [76] conclusion that what individuals want, and experience afects perceived social participation in daily activities.
Inward-looking strategies are not observable; thus, they must be identifed by person-centered communication where older adults' narratives of perceived value in activities that relate to one's identity, roles, and social participation throughout life are highlighted.Tis further supports the person-centered care approach, where knowledge of an individual's everyday preferences is a cornerstone [79].Within the person-centered care approach, health-care providers should elicit an individual's values, and these should guide all aspects of older adults' health care, supporting their realistic health and life goals [70].Knowledge of older adults' strategies for maintaining and fostering social participation provided by this metasynthesis can be useful in this approach.Te fndings indicate that through a person-centered approach, health-and home-care providers could promote activities that, through their value, strengthen older adults' identity, roles, and perceived social participation.Furthermore, supporting older adults to be aware of strategies for fostering social participation could strengthen their own abilities to make informed healthrelated choices [70].Tis could facilitate the cocreating of health-promoting plans and goals for handling and positively adapting to challenges brought upon aging [74].Conclusively, researchers need to develop interventions that raise awareness about and support older adults in healthy activity patterns [72] by using inward-looking and outwardlooking strategies to create routines for social participation.
Outward-looking strategies comprise activities, performed alone or with others, to create connections to others.Tus, observable outward-looking strategies are contextdependent, and as such, the doing manifested from them was closely related to the sense of belonging [78], which is largely created through diferent places: homes, neighborhoods, or meeting places in society [75].Routines created through outward-looking strategies revolved similarly around belonging to a community, which is an important factor for perceived health for older adults [80].Te fndings show that the cultivation of a sense of being a part of something bigger than oneself could be achieved through activities either performed in solitude or in organized community activities.Te fndings show that routines built on outward-looking strategies could facilitate spontaneous contact and recognition by others, creating a sense of familiarity in the neighborhood.Tis is in line with previous research which shows that this kind of interdependence can become a source of ordinariness and safety in everyday life [75].Te sense of being needed and useful to others in various ways was also an important outcome of outwardlooking strategies.Te fndings align with research [79,80] that indicates a need to develop age-friendly cities and communities that support older adults' own choices of activities and social participation.Te fndings further suggest that older adults' own choices could be supported by designing accessible digital and physical venues that facilitate spontaneous meetings and encourage older adults' own initiatives for social participation.Te fndings imply that this approach may have health-promoting potential that complements access to varied organized community activities and targeted health-care interventions.

Limitations and Strengths.
A systematic metasynthesis was performed, and a transparent description of the selection process for the included articles, using the ENTREQ checklist [30], was presented, strengthening the study's credibility [29].However, a complete overview is not attainable, despite our approaches.Developing keywords to identify relevant articles for the study's purpose was challenging since social participation and strategies can be described with many synonyms, yielding an unmanageable number of articles including irrelevant results.Te process of identifying relevant keywords, and databases and planning the search strategy was performed with the guidance of an information specialist at the university library, which strengthened the validity of the literature search in accordance with SBU's [29] guidelines.Te sample size and richness of the data complicated the coding structure since it required several separate fles and worksheets.A mind map was developed to address this dilemma and obtain an overview of the overall results, which is a deviation from analysis theory [28].In the analysis process, and visible in the mind map, it became evident that some raw data fell outside of the scope of the study and did not ft in the current theory-generating metasynthesis; as such, these articles did not meet the criterion of ft and were excluded, strengthening the validity of the emerged result [28].Since the Health & Social Care in the Community authors involved in this study are occupational therapists, this perspective infuenced the understanding and interpretation of the raw data.However, the back-and-forth process with the analysis process of constant comparison and the continued reevaluation of the results [28] ensures that the fndings were grounded in the data.

Conclusions
Te fndings refect that older adults meet challenges that arise with aging that are handled not only by persisting in the maintenance of their routines but also by strategically altering, planning, and creating new routines.Older adults use their earlier experiences to facilitate strategic routinemaking.In this process, a variety of inward-looking and outward-looking strategies are used to achieve various aspects of social participation.Te fndings suggest that for perceiving social participation, it is important for older adults to create routines or patterns of activities of their own choice and to be able to perform these activities satisfactorily.Tus, there is a need for health-care professionals to develop support for older adults in building healthy patterns of activities.Te fndings further refect that older adults use earlier experiences of social participation to facilitate strategic routine-making, which was described as both a choice and a challenge.Tis fnding suggests that when supporting older adults in handling challenges that lead to reduced social participation and decreased perceived health, healthcare interventions must be provided early and with a healthpromoting focus.Conclusively, researchers need to develop interventions that raise awareness about healthy activity patterns in older adults and support them using inwardlooking and outward-looking strategies to create routines for social participation.Te fndings further suggest that older adults' autonomy could be supported by designing accessible digital and physical venues that facilitate spontaneous meetings and encourage older adults' initiatives to engage in social participation.Te fndings imply that this approach may have health-promoting potential that complements access to varied organized community activities and targeted health-care interventions.

Table 1 :
Presentation of studies included.
Tanakwang, K.; Mongkolpraoset, J. (2012) Tailand To provide an in-depth understanding of the views of healthy aging among elderly Tai adults and to explore the factors that contribute to healthy aging In total (n): 155 Female/male (n): 95/65 Ages (mean): 60-88 (68.2) Takashimaid, R.; Onishi, R.; Saeki, K. et al. (2020) Japan To explore support in the community using social activities more suitable for older men: What are the values of social activities, and what are the meanings for retired older men living in an urban area of Japan?In total (n): 15 Female/male (n): 0/15 Ages (mean): 68-88 (68.2) Sugarhood, P.; Eakin, P.; Summerfeld-Mann, L. (2017) UK To gain a rich understanding of the concept, in particular from those who had not been represented in previous research, those from diverse ethnic and cultural backgrounds, in a variety of home living arrangements and in the older age range of those over 80 In total (n): 11 Female/male (n): 5/6 Ages (mean): 81-96 (87.
Russo-Netzer, P.; Littman-Ovadia, H. (2019) Israel To complement previous knowledge in the feld through a "bottom-up," open-ended exploration of Israeli older adults' own perspectives regarding the experience and potential resources at this life stage In total (n): 31 Female/male (n): 14/17 Ages (mean): 60-83 (70.8)Papageorgio, N.; Marquis, R.; Dare, J. (2016) Australia Te research questions this study aimed to answer were: 1.What factors do older people identify as enabling their participation in community-based activities? 2. What factors do older people identify as barriers to their participation in community-based activities?In total (n): 10 Female/male (n): 9/1 Ojembe, B.U.; Ebe Kalu, M. (2018) Nigeria To describe the existence of loneliness among older adults in Nigeria, recognize its factors in order to attempt to identify context-dependent solutions to loneliness within this population In total (n): 12 Female/male (n): 7/5 Ages (mean): 62-88 (73.3)Ojembe, B.U.; Ebe Kalu, M. (2019) Nigeria To explore in detail the experiences of older adults using television, radio, and telephone in reducing loneliness In total (n): 15 Female/male (n): 9/6 Ages (mean): 60-88 (79.9)

Table 1 :
Continued.Figure2: Illustration of main theme, categories, and subcategories.Te studies were conducted in various countries worldwide, and the continents of Africa, Europe, North America, Oceania, and Asia were represented.For further details, see Table1.
Health & Social Care in the Community3.2.Description of Included Studies.Te included studies in this qualitative metasynthesis were generated from authors of various disciplines including nursing, education, social gerontology, social science, physiotherapy, occupational therapy, public health, psychology, sociology, and social work.Te qualitative studies were guided by various methodological frameworks such as grounded theory, interpretive and descriptive phenomenology, case study, mixed method, constructivist epistemology, narrative, descriptive hermeneutic, and structural ethnographic