|Year : 2022 | Volume
| Issue : 1 | Page : 34-42
Changing social dynamics and older population: A qualitative analysis of the quality of life among older adults in Kerala
Julie Abraham1, Sibasis Hense2, Elezebeth Mathews1
1 Department of Public Health, Community Medicine, Central University of Kerala, Kasaragod, Kerala, India
2 Department of Community Medicine and Public Health, Central University of Kerala, Kasaragod, Kerala, India
|Date of Submission||03-May-2022|
|Date of Decision||11-Jun-2022|
|Date of Acceptance||02-Jul-2022|
|Date of Web Publication||03-Aug-2022|
Dr. Elezebeth Mathews
Department of Public Health and Community Medicine, Central University of Kerala, Periya, Kasaragod, Kerala
Source of Support: None, Conflict of Interest: None
Background: The concomitant availability of services and care with the rise in the older population in India does not commensurate with their health care needs, thus affecting their well-being and quality of life (QoL). The Indian State of Kerala, epidemiologically and demographically advanced and often compared with developed countries, has the highest number of older persons. It also ranks top in the human development index in the country. This study seeks to explore the factors influencing QoL among older persons in Kerala, a state located within a low middle-income country. Materials and Methods: Qualitative methods using exploratory design were employed. Ten focus group discussions and ten face-to-face in-depth interviews were conducted in two districts of Kerala. The data were thematically analyzed using a framework approach. Results: The study explored a multitude of factors influencing QoL among older people in Kerala. The themes that emerged from the study were, “Financial securities and insecurities,” “psychological well-being,” “lifestyle,” “health-care utilization,” and “social engagement.” Conclusion: The current study findings have explored the changing importance or value of the factors attributed to older persons' QoL in an advanced population within a low middle-income country such as India.
Keywords: Exploratory design, framework approach, lifestyle, older people, psychological well-being, qualitative methods, quality of life, social engagement
|How to cite this article:|
Abraham J, Hense S, Mathews E. Changing social dynamics and older population: A qualitative analysis of the quality of life among older adults in Kerala. J Geriatr Ment Health 2022;9:34-42
|How to cite this URL:|
Abraham J, Hense S, Mathews E. Changing social dynamics and older population: A qualitative analysis of the quality of life among older adults in Kerala. J Geriatr Ment Health [serial online] 2022 [cited 2022 Dec 2];9:34-42. Available from: https://www.jgmh.org/text.asp?2022/9/1/34/353163
| Introduction|| |
More than half of the global population of older adults live in the Asian region. In India, while the national average of older people is 10.1%, it is 16.5% in the state of Kerala. The rise in older people in Kerala is attributed to its social development and decreased fertility and mortality. This proportion of older adults is likely to increase to 20% in 2050, suggesting intense aging of the Kerala's population. This context raises many critical questions among the researchers. Will population aging be accompanied by good health and better quality of life (QoL) for older people? Is there a change in the importance of the factors attributed to the QoL of older persons with the changing sociocultural dynamics within a low middle-income country such as India?
QoL, a subjective component of well-being, is defined as an individual's perception of their position in life within the context of culture and value systems inhabited by them and their goals, expectations, standards, and concerns. However in a developing, resource-constrained country like India, as the population ages, the available resources become limited, leading to politico-socio-economic, psychological, cultural, and health problems affecting the QoL of this group. Earlier studies suggested that the QoL of older people in India ranged from “poor to fair,” while in Kerala, it was “fair to good.”
In developed countries, factors such as sociodemographic, psychological (depression, memory problem, and loneliness), physical (activities of daily living difficulties), financial (insurance, employment, and income), health, social (social engagement, social support), and life satisfaction, have influenced QoL. Although similar factors were reported in developing countries, additional factors such as environment and social relations were more significant.
Kerala with a population density of 859/km2, has the highest human development index (HDI) and best health indices in the country, offering the state a different sociocultural environment compared to other Indian states. Digitalization, infrastructural development, robust public health system, and cultural exchanges have facilitated social transitions within the state, posing both advantages and challenges for the aged population in adapting to the changing environment. Moreover, the State of Kerala is a forerunner in chronic disease management. It will play a crucial role in geriatric health as well. Therefore, it is important to understand the factors that facilitate and inhibit the adaptability to older people's changing context and QoL to promote healthy aging. The transition in the importance of each factor attributed to the QoL of older persons, with the changing sociocultural dynamics, is explored. Despite the need for a better understanding of QoL and associated factors among older people, there are very few studies on Kerala. Existing literature examining the QoL are primarily cross-sectional; therefore, the methodological viewpoint to understand the QoL among older people remains an important concern yet to be explored. In this context, this study tried to explore the inhibiting and facilitating factors influencing QoL among older adults in Kerala.
| Materials and Methods|| |
The study employed a qualitative approach using an exploratory design to explore the factors influencing the QoL of older adults. The exploratory research design refers to broad-ranging, intentional, systematic data collection designed to maximize the discovery of generalizations based on the description and direct understanding of an area of social or psychological life. It facilitates adjustments when participants, events or data present unanticipated information. Although our initial exploration was based on the known factors understood through a rigorous literature review, we anticipated newer angles and answers to our research questions using qualitative data collection techniques like in-depth interviews and focus group discussions (FGD).
Researcher characteristics and reflexivity
In this study, the researcher took a neutral position during the data collection phase by giving probes to guide the in-depth interviews and the FGDs. Participants' experiences and perspectives were given utmost importance. The participant's nonverbal cues and interaction in the FGDs were also observed, and field notes were taken. Transferability was ensured by selecting participants purposefully, and the factors of QoL identified are relatable in other parts of the country.
As the study aimed to explore the factors affecting QoL among diverse groups of individuals and for the findings to represent the population in the entire State of Kerala, the HDI was used to select the areas of study. Within the State, there exists a variation in HDI, ranging from 0.75 to 0.80. Therefore, to understand the sociodevelopmental factors influencing QoL among diverse older groups, we decided to study higher and lower HDI districts. Among the 14 districts in Kerala, Alappuzha, and Kasaragod districts were selected as high (0.79, 4th position) and low (0.76, 11th position) HDI districts, respectively.
The participants for this study included mentally stable older men and women aged 65 years and above. We did purposive sampling for both FGD and in-depth interviews to ensure that the individuals are critical cases for understanding the phenomena of interest.
For FGD, we maintained homogeneity of members to have synergistic discussions. As perspectives of older persons from diverse groups were required for a holistic understanding of the phenomenon, we categorized diverse characteristics among older persons in the general population into five quotas, namely, (1) older persons of lower socioeconomic status as identified by the monthly earnings of the older person or their family, (2) older persons living in the same locality, (3) older persons with noncommunicable diseases like type 2 diabetes mellitus and hypertension and under treatment, (4) older persons who are religious and visit temples, churches or mosques once in a week and do daily prayer for 10 min, and (5) older persons who receive senior citizen pension from government social welfare schemes.
We conducted FGD with participants specific to each quota to ensure homogeneity. Heterogeneity of the study population was ensured through multiple FGD, specific to each quota until saturation of the information. We employed a purposive maximum variation sample technique (heterogeneous sampling), to recruit older adults for the in-depth interviews. FGD of two each, with five diverse characteristics as mentioned above, were conducted (Ten FGDs in total; each group consisted of eight participants). Similarly, ten face-to-face in-depth interviews were conducted, and sampling continued until data saturation was attained as a result of information redundancy.
Data collection procedures
The study protocol was reviewed and approved by the Institutional Human Ethics Committee of the Central University of Kerala. Participants were briefed about the research and recruited after obtaining written consent. FGDs were conducted in the vernacular language (Malayalam) using a semi-structured FGD guide [Table 1]. The questions were uniform for all focus groups irrespective of their characteristics to ensure multiple perspectives on the phenomenon of interest from diverse groups. The FGD participants were selected by door-to-door canvassing. The participants were briefed about the FGD, and informed consent was taken from the participants who were interested in participating in the study. Each group consisted of eight members. Eight members were selected in a group because a focus group should consist minimum of 6 to a maximum of 12 members. The relevant characteristics of the group were prefixed and described under the study participant section of the paper. Five groups from each district were selected for discussion. The group discussions were held in a panchayath hall near the group member's house, considering the participant's comfort, accessibility, and low level of distraction by the sound of vehicles. The moderator was the first author; she is a registered nurse with a postgraduate degree in public health. She was trained in public health research techniques, including qualitative data collection techniques. The areas explored in the group discussion are detailed in [Table 1]. The observer documented the nonverbal cues and impact of the group dynamics and general content of the group discussion. The researcher has no past association with the participants and took a neutral role which helped her understand the participant's perspective without the interviewer's bias. Each FGD lasted 60–90 min and was audio recorded. Intermittent break time was given in between the session. The transcribed responses of the participants were translated into English and back-translated for quality and accuracy. Rigor and trustworthiness were ensured using the audit trail and peer debriefing of methodology and results in a public seminar. The data analysis was performed using a framework approach, and coding was done using NVivo-12.4.0 software.
|Table 1: Focus group discussion guide to explore factors influencing the quality of life among older adults in Kerala|
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Face-to-face in-depth interviews were performed using a semi-structured guide, developed from an extensive review of the literature examining the factors affecting the QoL of older people, which underwent both face and content validity checks. The in-depth interview guide is given in [Table 2]. The maximum variation purposive sampling technique was used to select the participants for in-depth interviews. Five participants from each district were selected till a clear pattern, and no new information was obtained (data saturation). The participants were briefed about the purpose of the in-depth interview, and informed consent was obtained. Sensitive topics were questioned in an in-depth interview hence a convenient place selected by the participant was used for the interview, which provided privacy to the participants, and which helps participants to answer more openly about their thoughts and perspectives. The first author conducted the interview. The areas explored in the in-depth interview are detailed in [Table 2]. Each in-depth interview lasted 45–60 min and was audio recorded. The transcribed responses of the participants were translated into English and back-translated for quality and accuracy. Rigor and trustworthiness were ensured using the member checking, audit trail and peer debriefing of methodology and results in a public seminar. The data analysis was performed using a framework approach, and coding was done using NVivo-12.4.0 software.
|Table 2: In-depth interview guide to explore the factors influencing the quality of life among older adults in Kerala|
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Rigor and trustworthiness
The response of the FGD and in-depth interview with the members were audio-recorded, and field notes were taken in English. The FGDs were conducted to explore the general perspectives of the older people about the factors influencing their QoL. It also helped obtain richer data as the group members were opened to interacting with each other. The in-depth interviews were conducted to explore sensitive information such as abuse and neglect on older adults affecting the QoL of the older person. The first author conducted all FGDs and in-depth interviews. Fieldwork was extended over 3 months, between December 2018 and February 2019. Rigor and trustworthiness were ensured using the member check technique for the in-depth interview, and FGD participants, peer debriefing of methodology and results in a public seminar, and audit trail techniques were also employed.
FGD's and in-depth interviews were analyzed separately using framework analysis, which could adapt with many qualitative designs aiming to generate themes. Both descriptive and in vivo coding were done using NVivo-12.4.0 software. The analysis procedure used seven steps to compress/condense the data to generate themes. The first step included the verbatim transcription of the audio-recorded interview and FGDs. After familiarizing with the data through repeated re-reading and listening to the transcripts, coding was done for both descriptive and in vivo codes. An analytic framework was formed where all codes can be grouped into categories based on similar patterns (using a tree diagram). Indexing of the transcript was done as per codes and categories. Finally, five themes influencing the QoL among older people were generated from patterns as the output of the whole dataset. Data triangulation from both techniques was done to make inferences.
| Results|| |
We conducted ten FGD and in-depth interviews each. All participants were aged 65 years and above, with a mean age of 72.60 years (6.8). [Table 3] describes the sociodemographic profile of the participants. The majority (54.44%) of the participants were female. About 17.75% were widows/widowers, and more than half of the respondents (57.78%) studied up to the 10th standard. Most participants were from lower socioeconomic status families (62.22%) and were doing unskilled work (42.22%). About 70.00% of the participants live with their families (with children and grandchildren).
|Table 3: Sociodemographic characteristics of the study participants in the focus group discussion and in-depth interview (n=90*)|
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Perspectives on the factors influencing older persons' QoL were captured and analyzed thematically. [Figure 1] describes the themes that emerged from the study. The themes that emerged were “Financial securities and insecurities,” “Psychological well-being,” “Lifestyle,” “Health-care utilization,” and “Social engagement.” The themes that emerged from the study had a profound influence on the QoL of older adults.
|Figure 1: Thematic representation of factors influencing the quality of life among older persons in Kerala, India|
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Financial securities and insecurities
We explored the role of financial status in the QoL among older persons by interviewing a diverse group comprised those financially secure in terms of having their own house, savings, a liveable pension, and those without any source of income.
Most participants who had health insurance from Panchayat (village council), personal savings, own house and pension, and provision for geriatric consultations and facilities at all primary contact points of the public health-care system reported reduce the financial burden. They claimed that it contributedto their overall well-being. Inthis regard, one of the older adults said that:
“I have saved money for my health care expenses. I don't have to ask anybody for financial help. It helps me to feel secure.” (FGD-1, P5)
Similarly, a few cited financial insecurities related to lack of savings, increasing out-of-pocket medical expenditure, the need to support the family financially, and the financial dependence on children as factors affecting their well-being. In addition, the liabilities incurred from family responsibilities were one of the main reasons for anxiety and stress. In this regard, one of the older persons said that:
“Even now, I work whichever job I get to pay back the loan I took for my daughters' marriage.” (FGD-8, P6)
Poor financial status has a detrimental effect on the overall QoL of the elderly.
Psychological well-being emerged as a very significant theme that influences the QoL of older adults. Stress and loneliness emerged as a common theme in both FGD's and in-depth interviews. Low self-esteem, feeling oneself as a burden to others, helplessness toward life and its events, worrying about one's existence and others' well-being, lack of people to converse, anxiety, reduced interaction with family members and neighbors, sadness, grief, feeling of invisibility within the family, neglect, and feeling of uselessness in the society were the significant concerns that emerged. Reduced feelings of significance in the family and inability to decide for themselves were experienced by the majority of the participants.
One of them opined that: “They [children] don't ask my opinion for anything. I don't have a say in making my own life decisions. Even they don't have time to talk with me, anyway they are all grownups now, and they don't need me.” (FGD-5, P1)
The physical and emotional needs of an older person were different from others. Many older adults cite that they experienced emotional loneliness as they mostly stay at home and their friends are either at their homes, bedridden, or have passed away. At home, they are primarily alone and do not have people to discuss their fears or anxieties. Due to physical frailty, they have to depend on younger ones and adjust to their convenience even for traveling to the city center.
One older person expressing her emotions said, “All are busy at home; I have to adjust with their schedule and their convenience. I had a fall two months back, and nowadays, I spend most of my time in my courtyard. All are busy in their lives (sighs).” (FGD-9, P4)
Most of the older persons were emotionally or physically dependent on others. Physical dependence was overtly visible, while emotional dependence was expressed subtly. It was observed that many of the older adults and their family members ignore/neglect the mental health needs of the older adults. For example, many older adults expressed difficulty in sleeping because of anxious thoughts. Some even said that they were accustomed to and sad about the neglect of the family members. In addition, most older adults have memory problems and forgetfulness. They normalized these psychological distresses, which triggered many health problems, in their aging process. They were not aware of their mental health needs or the necessity for early screening for their psychological distress and treatment.
Emotional abuse and neglect are yet another phenomenon experienced by older persons. For example, one of the older adults said that “In my home, we are invisible most of the time. Even though he (son) tramples on my dignity and pride, we can't throw him out, it will be too humiliating to the whole family, and it undermines my upbringing of him. So, we are enduring it till we can; after all, he is our blood.” (ID-P1)
Older adults are more vulnerable to physical and emotional abuse. These abuses affect their dignity of living.
One of the interesting themes that emerged from the broader category of physical well-being is lifestyle. Therefore, we tried to understand the lifestyle in the context of healthy behaviors. As a result, we found that most participants perceived that good eating habits, regular exercise, yoga, good sleep, dental hygiene, knowledge, motivation for a healthy lifestyle, and taking medicines at the right time improved their well-being. In contrast to this chronic pain, sedentary lifestyle, fear of falls, comorbid conditions, poor memory, dental problems, eating at the odd time, food restriction due to medication, improper medication, poor knowledge about healthy lifestyle, poor sleep habits or quality of sleep, smoking and excessive alcohol consumption inhibited QoL.
One of them said that “We don't know whom we have to consult to understand what we should follow for a healthy lifestyle. We eat what is prepared at home if we don't feel like eating, we don't, and nobody is bothered whether we eat or not.” (FGD-10, P3)
Following a healthy lifestyle will help to improve the overall health and well-being of older adults.
The need to utilize healthcare facilities increases during old age due to the declining bodily functions and health. Beyond the willingness of the family members to support the older persons, the accessibility, availability, and affordability of health-care services play an essential role. In our study, we understood that online appointments facilitated the accessibility of the services to older persons as they need not wait for long hours. However, lack of human resources in specialized geriatric care and limited understanding of modern-day technology compromised their ability to seek and access health care.
One of them said, “The hospital is in the town, and the doctor in the health care centre near home always refers us to the town hospital. So nowadays when my spouse or I get sick, my son or daughter-in-law takes us to town hospital which is more than Rs. 100/- for one side travel itself, and if a prior booking is not made, we have to wait a long time too.” (FGD-7, P7)
Furthermore, enabling the health system to assist older persons in self-management and supervised care is required with the changing social dynamics.
The participants in both FGD and interviews cited those social networks and engagements are much needed to adapt well to the increasingly digitalized surroundings. They felt good education, social interaction, a right friends circle, meeting friends regularly, good family and neighborhood relationships, and participation in social activities facilitated their well-being. In contrast, poor communication with family and neighborhood, lack of social interaction, social stress, and the burden of taking care of grandkids increased loneliness and social isolation.
One of them said that “My son and daughter-in-law are busy, and they don't have even half-an-hour to talk with me; but they needed me to help them at home, I don't get time to gossip with my neighbours. They don't allow me to stay away from home too. Even with all my health problems, I still take care of my grandkid, and many think it's our duty.” (FGD-5, P2)
Many participants mentioned that political stability plays a role in their well-being. Good governance, legal support, and congenial social and welfare policies such as Pradhan Mantri Vaya Vandana Yojana, National Programme of Health Care for Elderly in India, Sayamprabha, Senior Citizen Cell, Thanalekiyavarkku Thanal enhanced the QoL of older adults. As the population is aging, the political factor also plays a significant role in the total welfare of older people. Some opined that the progressive thought of the ruling government and welfare policies and social security helped improve older people's QoL over the decade.
In short, the themes generated from in-depth interviews are similar to the FGD themes. However, older adult abuse was a unique factor that emerged from the in-depth interviews.
| Discussion|| |
This study explored the facilitating and inhibiting factors that influenced older persons' QoL in Kerala. The themes that emerged from the analyses of the FGDs, and the in-depth interviews were financial securities and insecurities, psychological well-being and lifestyle, health-care utilization, and social engagement.
Having a secured financial status, such as health insurance, senior citizen pension, and personal savings improved the QoL of the older persons in this study too. We also noted that out-of-pocket medical expenditure, financial dependence on children, and financial debt negatively influenced the QoL, similar to studies in India and the U.S., In addition, we noted a “reverse dependency” between older adults and their families; where the older person financially supported the family members and taking care of the grandkids and becomes exhausted, thus compromising their health and well-being. Unlike high-income countries, we found that older people were concerned and stressed regarding the well-being of children who were unemployed. These differences could be due to the collectivistic culture in India. Financial insecurities led to stress and anxiety, resulting in older adults' poverty and suicides.
Psychological well-being played a significant role in QoL among older adults in the study. The factors that influenced were self-esteem, respect and dignity received from the family and society, peaceful and relaxed atmosphere, and ability to make decisions for self and people to converse. The importance of relaxation, good self-esteem, and people to converse and its positive impact on QoL has been described in previous studies too. Consistent with previous studies, fear and anxiety, low self-esteem, grief, loneliness, stress, and lack of people to communicate,, were very often reported as the reason for stress by older adults. These factors negatively influenced their QoL. Communication gap and loneliness could be due to the lack of time and patience among the family members and the increased immigration of the younger generation. Another factor noticed was the biased perception of old age by the family members, resulting in the restriction of their mobility, both physically and socially. A World Values Survey, with respondents from 57 countries, reported that over 60% across all age groups did not respect older persons, and the lowest levels of respect were in high-income countries. The cultural milieu in India has been collectivistic in nature, where the presence of the old members gave more relevance to the lives of the younger generation in the joint families. However, with the emergence of nuclear families, their relevance in the lives of the younger members in the household diminished, leading to a gradual change in the attitude toward the older persons. Ageism leads to emotional loneliness, helplessness, low self-esteem, anxiety, and depression among older adults. In the current study, psychological well-being emerged as the prominent domain which has a greater impact on the QoL of older people. This points toward the need for further in-depth screenings to identify mental disorders among the older population and suggest appropriate interventions. Consistent with the previous studies, unhealthy behaviors and lifestyles were reported to have inhibited the QoL in the current study. Suffering from chronic pain and diseases like diabetes and hypertension would significantly inhibit the QoL., However, most older adults in this study understood chronic diseases as a part of aging. Therefore, many of the male participants considered moderate consumption of alcohol acceptable but perceived smoking and excessive drinking as detrimental to their well-being. The sociocultural attitude of Kerala toward alcohol consumption could have influenced this understanding of the participants. Such a persistent unhealthy lifestyle will lead to multi-morbidity, which affects financial, social, and psychological aspects.
The accessibility, affordability, and utilization of health-care services facilitated QoL of the older adults., The study identified the willingness of family members to take older adults to health-care centers as a factor that helped to increase their QoL. Furthermore, the data showed that cognitive impairment and lack of old age-friendly technology hindered the older adults, even those willing to learn, from accessing advanced healthcare technology, which hampered their QoL. Although the government has introduced geriatric wards in every district hospital majority are yet to be functional. Most older adults depended on primary health centers, which were not equipped with geriatric nurses or doctors for their immediate care and medicine. Nonetheless, the accessibility, availability, and affordability of health-care services in Kerala are better than in other states in India.
Similar to the previous studies,, the older adults stated that good friends circle, social networks, senior citizen groups, education, good family relationships, and participation in social activities had a positive influence on their QoL. In this study, it was also noted that good social welfare policies such as Sayamprabha and Pradhanamanthri Vaya Vandana yojana positively influenced their QoL. However, like the previous studies, poor social interaction and social mobility, lack of awareness of legal support, social stress, and ageism negatively influenced their QoL. The lack of awareness among older adults regarding government welfare schemes was due to the minimal social interaction and mobility. As suggested by previous studies, poor social support, social isolation, and lack of communication will increase the chances of dementia among older adults.
The in-depth interviews emphasized that most older adults were vulnerable to physical and emotional abuse and neglect from their family members and society. These abuses indirectly pushed them into depression, loneliness, and low self-esteem.
This study gave insights into the unhealthy behavior, perception of old age by the older adults and the younger generation, vulnerability to emotional abuse, need for psychological distress screening, social welfare policies, and financial support for older adults, which will help in taking an unbiased approach toward improving the QoL of older adults.
The main limitations of the study were the opinions expressed by older people may not be generalized. The native culture, belief system, and social cohesion may influence the interaction.
| Conclusion|| |
This study strongly affirms that the factors influencing QoL such as financial security, psychological well-being, older person-friendly infrastructure, need for more geriatric care, active life, social support, good governance, and healthy lifestyle facilitate older persons' QoL in Kerala. On the other hand, poor perception of old age, financial insecurities, stress and loneliness, emotional and physical dependence, and unhealthy lifestyle inhibit the QoL of older people. Furthermore, knowledge about technology, social behavior, attitude, and maladaptation to social changes also influence older people's QoL.
Identifying both facilitating and inhibiting factors of QoL will help strategize interventions to improve older people's life in Kerala. Already existing policies and programs should be implemented in due diligence, and the government agencies should minimize the gap between the expectation and actual service delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]