Review Paper - Journal of Aging and Geriatric Psychiatry (2017) Journal of Aging and Geriatric Psychiatry (Special Issue 3-2017)
Perspectives of social health for silver citizens: a conceptual analysisDivi Tara1, Dr. MamataMahapatra1, Dr. Santa Mishra2*
- *Corresponding Author:
- Dr. Santa Mishra
Department of Psychology
Sri Sathya Sai College for Women, Utkal University
Bhubaneswar, Odisha, India
Tel: +91 9437211371
E-mail: [email protected]
Accepted Date: May 24, 2017
Citation: Tara1 D, Mahapatra1 M, Mishra S. Perspectives of social health for silver citizens: a conceptual analysis. J Aging Geriatr Psychiatry. 2017;1(2):17-22
This paper is part of the PhD programme based on Gerontological issues and is placed here based on secondary data. The Indian tradition always sticks to the well- being of elderly in terms of physical, emotional, mental, economic, social, and spiritual contexts. But alarming physical and mental hassles of silver citizen in present day society now compel the psychologist and sociologists to think over the issue. The rapid socio-cultural changes in global level put in several problems to the population of ageing. Aligned to the above facts, the objective of the paper is to analyse the four components (physical health, mental health, economic health and social support) of the elderly population, in particular through the support of extensive literature search to enhance their ‘holistic’ health. The paper also aims to study the dimensions of social health for maintaining a healthy social life of the silver citizens in the society, adopted by the stakeholders, policy makers, administrative personnel and the general public, to help and enable the elderly to have a positive well- being within themselves and also in the society.
Social health, Gerontology, Elderly, Late-life mental health
The present paper is based on secondary data collected through reviewing research articles published in the field of gerontology. The articles reviewed help identify the various dimensions of social health with regard to the population in consideration, that of the senior citizens of India.
The advent of globalisation and modernisation has brought upon several changes in India and on a global scale. These changes in turn cause great turmoil in the society not only in economic terms but also in the various social structures and constructs. India has been predominantly a collectivist society and the root strength has been its social support structures, but with the rapid urbanisation even the social structures seem to be deteriorating as reported with the rising number of nuclear families . The evolution of nuclear families is also changing the support systems, leaving many elderly to take care of themselves during a period of their life which is already strenuous as it comes with significant physical changes, with most of the elderly population having chronic ailments. A commonly growing phenomenon observed globally is one that of population ageing. Released by the Central Statistics Office Ministry of Statistics and Programme Implementation Government of India (2016)  showed that 8.6% of the total population is of elderly persons in India, that is, any person aged 60 and above. One of the major reasons attributed to this shift can be the decreasing fertility and mortality rates in the present society.
The traditional Indian society has been able to safeguard its population through its support structures of joint families and community living, but the dwindling structures of the society are leaving its elderly in a vulnerable state in terms of physical, emotional, mental, economic and spiritual well- being. Lower death rates and increased life expectancy due to technological advancements in the field of medicine and advanced health facilities along with the growing economic market; the cost of living and maintaining health or even accessing a health facility are also increasing. Research studies have reported that in the population aged above 60 years, 10% of the elderly suffer from impaired physical mobility, 10% are hospitalised at any given time . An Indian Council of Medical Research study found in its investigation that Hypertension, chronic cough, skin diseases, diabetes, urinary problems etc. are a common and chronic occurrence for almost about 12% of the population. A similar study done in the urban areas of Chandigarh and Haryana found that 87.5% of 200 elderly patients suffered from physical disability. A study conducted in Delhi by the ICMR found that 34% of men and 40.3% of women suffer from obesity. These diseases directly affect the quality of life of any human being not just elderly persons. Ageing comes with several problems of its own starting from physical health deterioration, loss of certain abilities to social detachment following which isolation and depression are popularly growing concerns for the society .
According to a report submitted by the WHO, elderly persons who suffer from depression have a four times higher death rate than those without, mostly due to heart disease or stroke . The Chennai Urban Rural Epidemiology Study (CURES) showed in primary care settings the prevalence of depressive disorders amongst elderly with chronic co-morbid diseases to be 10% to 25%. Atul Gawande in his book called ‘Being Mortal’ has rightly stated the fact that ―scientific advances have turned the process of ageing and dying into medical experiences, matters to be managed by healthcare professionals .
India is not the only country facing this problem. Much like India, China is leading in the rise of their elderly population which is reported at present to be at a 128 million and is expected to rise to nearly 400 million by 2050. Similar to India, the Chinese culture has also witnessed changing of societal values and changing family dynamics . On a similar page, about 25.6% of the population of Japan is estimated to be the grey population by 2025. Although ageing in Japan has also witnessed an increase in population that is employed being aged above 60 years and a decrease in young adults being employed .
These statistics raise an alarm about various aspects of this phenomenon wherein the holistic health of this stratum of the society needs to be looked upon. Holistic health as defined by the American Holistic Health Association is ‘an approach to life’. This ancient method of healing lays its focus on the whole person and his/ her interaction with his environment instead of only viewing illness or any specificity of a disease. It emphasizes the connection of mind, body, and spirit. “The goal is to achieve maximum well-being, where everything is functioning to the very best that is possible” .
Review of Related Literature
In light of the preceding introduction, review of literature has highlighted the challenges and problems faced by the elderly population in India.
The Central Statistics Office Ministry of Statistics and Programme Implementation Government of India, 2016 reported that 8.6% of the total population is of elderly persons in India, that is, any person aged 60 and above. The old age dependency ratio has increased with about 12.4% of the urban elderly population being dependent on their off springs and/or others while in the rural area about 15.1% are dependent. The statistics are ironical, as the total rural elderly population being employed or engaged in some form of work/labour is 47.1% whereas in the urban areas it is almost half, which is about 28.5%.
Economic burden is not the only problem faced by the elderly in India. A 10-city survey by Help Age India done with young working adults (25-45) with at least one elderly parent was done. The study suggested that 85% of the youth in Delhi admit that elder abuse exists yet 92% of them would not act to prevent it. 42% of the population across India feels that elder abuse is a problem faced in developing societies. In most cases of Elder abuse the daughter in law was found to be the topmost perpetrator (61%) followed by the son (59%). The youth of India feels that abuse begins at an early age and the abuser is mostly aged between 18-34 years .
On similar lines another study conducted in the city of Goa, India that focussed on the status of older people and the concept of late- life mental health conditions, particularly focussing on dementia and depression. The qualitative study was carried out through focus group discussions with older people and their key informants. The results of the study revealed that while depression was a common occurrence with the primary physician, it often went undiagnosed. The causes of depression were attributed to abuse, neglect and often lack of love from the children towards the parent .
The breakdown of families into nuclear families and deterioration of cultural values and changing societal norms often leave the elderly feeling caught in the rut. While the pension schemes in the country mostly cater to the population that has worked in the organised sector, a large portion of the elderly have no such access being in the informal sector. A research based on reviews from the NSSO and Census to uncover the economic problems faced by the urban and rural elderly. Most elderly in the rural sector were found to be employed in informal sector and manual labour jobs while the urban elderly were more involved in services. There was noticed a deliberate withdrawal from work participation in labour jobs .
A research study was study carried out in the urban areas of Uttar Pradesh, Varanasi, on the quality of life of the elderly people. This quantitative study gathered a sample of 166 elderly persons collected from four colonies of the city. The results suggested that a majority of the population that had a mean age of 63.95 ± 6.08 years, had an average quality of life while there were still some percentage of the elderly that reflected a poor quality of life. The study suggests immediate social protection steps that may be taken by the government and policy makers to be that of assuring old age pension to all while also encouraging life insurance policies to be modified in compatibility with the needs of this population .
A descriptive study was carried out in the Department of Community Medicine, Karnataka, South India; by interviewing the patients who accessed the outreach clinics. A sample of 213 persons was taken all aged 60 and above. The results showed that nearly half of the respondents were illiterate. Around 48% felt they were not happy in life. A majority of them had health problems such as hypertension followed by arthritis, diabetes, asthma, cataract, and anaemia. About 68% of the patients said that the attitude of people towards the elderly was that of neglect. One of the recommendations of the study highlighted the immediate need for geriatric counselling centres .
Another study in Chennai, South India, based on the Resources, Stressors and Psychological distress among older adults was conducted. The resources taken into consideration in the study were social support, religiosity, and mastery whereas the stressors comprised of life events, abuse, and health problems. The findings showed that there was a negative indirect relationship between resources and psychological distress while there was a positive direct relationship between stressors and psychological distress. This can be interpreted as, if resources are managed well and are adequate to cater to the needs of the older population; there is minimal psychological distress but if the resources become inadequate and unusable, there is psychological distress. While the relationship between stressors and psychological distress signifies that more the number of significant/ traumatising life events or abuse or health problems exist, more psychological distress is faced by the elderly. In such a context the study also recommends that the resources of the elderly need to be identified and strengthened  .
Engagement and productivity plays a significant role in old age and coping with the process of ageing. Supporting this theory a study was conducted on 838 elderly persons analysing their social engagement and cognitive function in old age. The findings reported that higher level social engagement is associated with better cognitive functioning but the associations vary across different domains of social engagement .
In another study the relationship between social engagement and cognitive functioning was examined among older persons. Social engagement was measured under three dimensions: social network size, frequency of participation of social activities and perceived social support. The results of the study indicated that higher levels of social engagement was positively co-related to cognitive functioning but the results vary across the domains of social engagement .
A study aimed at finding out the Social Adjustment among Old People of Bengal was conducted gathering a total of 50 elderly respondents. The findings of the study revealed that the old people in Bengal had a poor social adjustment and very high social adjustment problems. While the men in Bengal were at a slightly better position than women were more affected and had even more social adjustment issues .
Another research on similar lines was conducted aimed at understanding the social determinants of quality of elderly life in a rural setting of India. The study used Who Quality of Life Brief Questionnaire to conduct the survey and Focus group discussions to describe their perspectives on the various issues related to their quality of life. The results of the study indicted the determinants of perceived physical health as currently working status, not being neglected by the family, and involvement in social activities. The determinants for psychological support were health insurance, and their current working status. The determinants for social relations were membership in social group and their present working status. The determinants for perceived environment were membership in social groups and relationship with the family members. In qualitative research, factors such as active life, social activity, spirituality, health care, involvement in decision making, and welfare schemes by the Government were found to contribute to better quality of elderly life . Problems or conflicts in family environment, lack of shelter and financial security, over tapped resources, and gender bias add to negative feelings in old age life .
The rationale of the paper stems from the alarming rise in the elderly population that poses a number of problems, to combat which, Indian systems, inclusive of the Government and the related stakeholder and policy makers ought to be prepared. This paper helps identify the various dimensions that affect the social health and quality of life of the elderly while suggesting some steps that may be taken in order to safe guard the population from enduring distress and provide an atmosphere that promotes positive mental and holistic health. Based on the preceding review of literature the following objectives have been derived.
The objective of the paper is:
1) To analyse the social health aspects of the elderly population through the support of extensive literature search which emphasizes on the ‘holistic’ health.
2) To study the dimensions of social health for maintaining a healthy life of the silver citizens in the society.
3) To suggests some preventive and positive steps that may be adopted by the stakeholders, policy makers and the general population, to help enable the elderly to maintain a good general well- being.
Dimensions of Social Health
The process of ageing brings with it several life adjustments such as developing and struggling illnesses that are predisposed to increasing age such as impairments in audiovisual functioning and motor and structural weakening in terms of bone density and muscular decline, weakening of the immune systems and thus being unable to fight off infections. Dealing with chronic illnesses such as hypertension, obesity, urinary problems, diabetes, and disability have become highly prevalent as corroborated by the Indian Council of Medical Research Report. It has been estimated that by 2030, 45.4% of health burden would be borne by the elderly population of India especially with the increased prevalence of non- communicable diseases .
A research paper based to review the prevalence of depression among the elderly in India found that community based researches indicated 62.16% incidences depression while the prevalence in the clinic based studies ranged from 42% to 72%. The study also indicated depression to be more common an occurrence among females as compared to the male elderly population . A study corroborating with the same was conducted to estimate the prevalence of depression and its association with socio- demographic factors in the Indian rural community. The results of the study revealed that 42.7% of the total sample of 103% had mild to severe depression . Depression is one among a long list of mental health problems that strangle this population. Dementia is another highly prevalent disorder and often goes undiagnosed diagnosed with statistics revealing 3.36% of a population studied in a South Indian community of elderly had depression while in North India it has been observed to be growing . In such a scenario proper measures and a diligent strategy must be adopted to enhance the quality of life of the elderly.
Technological advancements have although increased the life expectancy of the elderly, but these advances come at a cost, which many a times are not affordable, even with pension schemes. The insurance policies are also not accommodating enough to support the elderly or do not help provide any subsidised rates. While the Government of India has put in place some measures to support those elderly who are economically vulnerable in the form of National Old age Pension scheme and Maintenance and Welfare of Parents and Senior Citizens Act, the policies fall short of what is required .
The changing societal structures have again placed a great demand on the elderly. The transition of joint families to nuclear families is happening at a rapid rate leaving many elderly to support themselves. A commonly growing problem faced with the changing societal values is that of elderly neglect and abuse. As reported by Helpage India study 42% of the elderly population in India is subject to abuse and Neglect. Based on these increasing incidences of abuse, Helpage India along with the City Police of Chennai, Tamil Nadu, opened a Helpline assistance number in the year 2004. More than 2500 elderly have used the helpline and gained help from the officials in matters of abuse and violence .The new familial structures are paving the way for more elderly care homes and institutes to be developed. These are now often adopted by the elderly who have been shunned and abandoned by their families or are frustrated of enduring abuse and violence from their families, they opt to stay at old age homes that have been built to cater to their day to day needs .
The research articles reviewed shed light upon some of the many issues faced by the elderly in India. The changing socio- cultural norms have placed much burden on the elderly and left them feeling caught in a flux. Though the process of globalisation has opened up many avenues and opportunities for the youth to explore, thus further enhancing international migrations, at the same time it has been a major factor contributing to the rising number of nuclear families and decreasing joint families. This process leaves the elderly parents with little choice if their children go far away from home in lieu of work ,the elderly are left with no choice and ‘have’ to stay alone despite their vulnerabilities and inabilities. For those who can afford the expense of hired help get help, but even then the well- being of the elderly person cannot be guaranteed. Many cases of criminal violence have also been reported in India wherein an elderly person’s hired help has taken advantage of their vulnerability and committed acts of violence. Help age India studies also reflect on how children abuse their parents in their old age with the son being a major perpetrator in acts of physical and verbal abuse. If abuse is not enough a burden, the elderly who are either self- employed or engaged in the informal sector jobs such as being a street vendor or a rickshaw puller, which is a highly cumbersome task, especially in the scorching heat waves during the summers and the extreme cold of the winters in India, physical ailments seem merely like a problem. While the literacy levels in India are low, the available number of job opportunities and outlets for elderly persons is even lower. The elderly in urban India hardly have any social outlets and means of engagement other than their laughter clubs, the prayers and the temples while the rural elderly struggle just for survival.
Hence in conclusion it can be understood that social health, quality of life, physical health and other aspects that comprise of holistic health are all inter linked. In other words it is an interplay of the mind, body and spirit that encompasses holistic health. The elderly in India undergo and endure various issues ranging from financial insecurity, physical disability, informal working conditions and manual labour, to abuse from children and family, neglect and lack of social support system. In such a crisis, the elderly have become a vulnerable stratum of the population. Despite various reforms, policies, organisations and pension schemes being in place, the elderly in India do not live a good quality life. A majority of the elderly suffer from depression and/ or have other psychiatric morbidities. And while the problem already exists, to top it there is a gender disparity as well where, as observed, women are more susceptible to depression and having a lower quality of life. Socio-demographic factors have also been observed to affect the overall health of the elderly along with literacy levels. Thus, with the preceding suggestions, if the quality of social life is made better for the elderly citizens of India, all other related dimensions of holistic health would follow.
Suggestions and Recommendations
The following steps have been suggested based on the research review to enable a holistic and healthy life for the elderly:
1) To establish centres at community level for enabling social gathering and engagement amongst the elderly. This step may inculcate the various dimensions of engagement such as physical engagement, spiritual engagement, occupational engagement and civic engagement. This type of engagement may involve activities such as yoga for community, religious/ spiritual gatherings at the temples, finding work or volunteering in organisations (schools, colleges, hospitals, MNC’s), volunteering or working towards the development of the community by making councils functioning towards beautification of the society, cleanliness, security etc. Any means of engagement that may be meaningful to the elderly can help alleviate their distress and lead them to live a wellbalanced engaged life. Post- retirement the daily life routine of an individual is drastically affected leaving him/ her with lesser outlets to engage. Many a times the illness takes over control of the body in such a way that it leaves many elderly bed- ridden thus eliminating activities that they may have once been able to perform such as simple activities of performing household chores. In such cases community must organise activities based on the needs of the elderly and this could only be done by doing a need assessment research within the community which is then aimed at fulfilling their needs. Research studies indicate that active engagement tasks and activities are associated with a higher quality of life among retirees.
2) To establish centres at community level that promotes and provides counselling services especially for the elderly, especially for the women and disabled. Counselling has become a need of the hour in the globalised world where almost every individual requires a professional to talk to, someone who would be accepting, understanding, empathic, genuine and non- judgmental. The elderly should be provided with the option of having a counsellor available at community level with subsidised fees or as a part of their voluntary work.
3) Stakeholders must take into account the existing services and number of primary health care centres and aim to establish more number of such care centres. Access to healthcare systems in India pose a major challenge for a majority of the rural elderly with their nearest health care centres being located in far off districts. The stakeholders must gather all information on the already existing systems and increase the number of centres as the demand for health care centres is very high but the accessibility to them is insufficient.
4) Stakeholders must also take into consideration the feasibility of “access to” and “prices of” healthcare services. Government hospitals and primary health care centres provide treatment at subsidised rates to all those who access them, but the disparity is in the demand and supply. The population seeking help at such centres is extensive while the number of such centres are limited and placed in far off locations, hence making it difficult for all to access. Those suffering from disabilities find it even more challenging to access these centres due to lack of infrastructures of the PHC’s, excessive travel time to reach destinations etc. Thus leaving no choice for the people but to access a private health care set up which is in turn highly expensive and unaffordable not just to the rural elderly but also to the urban elderly who do not have a stable economic support income or rely solely on their pensions to get through the month. The prices of medications are also not given at subsidised rates for the elderly making them crunch even more financially and thus distressing them further. The stakeholders must become more sensitive to the problems faced by the elderly in India and bring about reforms.
5) Awareness must be spread on the issue of elderly abuse through promotion in universities, schools, value education and campaigns. Helpage India studies have shown that elderly abuse exists in India and while it cannot be denied, it can be ignored which is done by the youth of India. Most common perpetrators of elderly abuse are often found to be sons and daughter in laws. Value education along with sensitivity training should be provided in schools and colleges to make the life of the elderly more comfortable and secure. Many elderly often chose to live in old age homes or care centres for the very reason of being insecure or feeling unsafe at home, either due to abuse or they are afraid that someone may exploit them .
6) Stakeholders and policy makers must ensure policies of economic security for the elderly and bring about changes in the existing laws with respect to elderly safety and security. Even though the Parents maintenance and welfare act provides the ruling that parents cannot be removed from their own property, still many disturbing cases come to light almost on a daily basis where feuds have evolved over matters of property and the elderly face shabby treatment from their family members. A research conducted by Age well foundation in its study found that of 5000 elderly persons interviewed in Jaipur itself, 2829 of them face abuse in the form of verbal and physical violence, harassment etc. The stakeholders should provide for more strict rules and laws and must oversee their proper reinforcement.
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