Ageing is a global phenomenon and the pace of population ageing is faster in developing countries compared to the developed world. People over 60 years of age are projected to reach one billion by 2020 and almost 2 billion by 2050 representing 22 percent of the world’s population.
The number of Bhutanese older adults (aged 60 years and above) is estimated to increase from 4.7 percent in 2005 to 11.2 percent in 2045, at the population growth rate of 1.8 percent. Improved health, economic growth, and increased access to education are said to have led to low fertility rates and longer life expectancy in every region of the world.
While population ageing in one sense represents a human success story, reflecting the benefits preventable causes of premature death, however, its steady growth presents many challenges to families, communities, and societies, particularly for sustainability of healthcare, pension and social benefits, and the preservation of quality of life and wellbeing.
An ageing population is the biggest driver of a considerable rise in the prevalence of chronic conditions such as non-communicable diseases (NCDs) which are the major causes of deaths and disabilities among older adults. In 2012, approximately 56 million of global deaths were attributed to NCDs and in Southeast Asia NCDs were responsible for 60 percent of deaths.
Older adults have traditionally been held in high esteem because of their vast experience in life, role as head of the family and often as an effective mediator in conflict resolutions. However, trends such as urbanisation and economic modernisation tend to change the family structure, affecting care and support of older adults in the family. More people are observed to be moving to urban areas in search for better economic futures. The mobility of population brings certain disintegration in the family and community, cohesion and cooperation; most notably affecting the much cherished and revered extended family system.
Already findings from the Gross National Happiness (GNH) survey 2015 confirmed a decline in the sense of belonging to communities (especially in the urban areas), family relationships and perception of safety from crime and violence, clearly indicating the decrease in the contribution of community to the overall wellbeing of the people in Bhutan.
Over the last 30 years of research into what influences happiness globally, a great deal has been learned. Every experience of the individual is influenced by their genetic make-up. However, the kind of person we become depends on the interactions between genes and the environment we encounter. In other words, interactions between personal internal and external factors determine wellbeing.
As population ageing increases worldwide, knowledge about quality of life, wellbeing and its influencing factors in old age has become more critical. Till date, there are limited studies on older adults in Bhutan. Studies both in the west and in Bhutan reported decreases in quality of life (QOL) and happiness with age, respectively. Numerous possible reasons such as the younger generations attaining better social status, or seemingly declining care in the families were cited. It could also be because of deteriorating health conditions with the natural ageing processes.
There is evidence of a correlation of adverse life experiences such as stressful life events (SLEs) and adverse childhood experiences (ACEs) with poor physical and mental health conditions in adults, although some argue the impact of SLEs on health may depend on the individual’s perception of such events as threat or as challenge.
People with higher cumulative ACEs tend to have higher probabilities of engaging in risky lifestyle behaviour and consequently suffer from poor health and wellbeing.
A lot of age related health problems are rooted in early life experiences and living conditions. In order to explore ACEs, SLEs, spirituality, and social connectedness and their associations with health, quality of life and wellbeing in the context of Bhutan, a study with sequential mixed-method design was carried out in four major commercial towns of Bhutan.
Data was collected through in-depth face-to-face interviews and focus group discussions. Findings from both qualitative and quantitative studies supported that perception on QOL and wellbeing among older adults in Bhutan to be good.
However, mixed feelings and apprehensions were also expressed. For instance, economic development and infrastructure have helped increase living standards particularly in rural parts of Bhutan. However, participants have also expressed such progress and development compromises social bonds and trust.
Quantitatively, an analysis on self-reports of overall QOL and wellbeing revealed social relationships domain of QOL with highest mean score contrasting with findings from other countries such as India and Malaysia. This was consistent with findings from the 2010 Gross National Happiness (GNH) survey. Men, enjoying better relationships with children, and having some form of formal schooling significantly reported better QOL and wellbeing. The significance of education was strongly indicated from participants in the qualitative interviews. Education was seen to be fundamental for the overall development of a person and is believed to broaden a person’s thinking capacity and was felt to improve survival in the modern world.
Very few studies have examined the influence of language proficiency on QOL and wellbeing. This study demonstrated a positive relationship with multiple language proficiency and QOL. One of the positive influences could be that a person speak diverse language, better their communication with health professionals or other service providers.
Formal employment is a significant determinant of QOL as having a job improves financial status, enables greater autonomy, and improves access to more types of social and health services. Although higher income cannot buy happiness, increase income was associated with higher wellbeing in particular for poor people.
Health problems such as frequent back pain (67 percent), memory decline (61 percent), visual impairment (57 percent), disease of the joints (60 percent), fatigue (51 percent), depression (46 percent), insomnia (42 percent), high blood pressure (53 percent), and diseases of the lungs (37 percent) were commonly reported and were higher among the female gender.
The current study supported that these disease conditions were significantly linked with lower QOL and wellbeing. Poor health literacy was evident among older adults as many of the health-related terms were unfamiliar and can be possible as most of the participants had no formal education (85 percent) which may have compromised accurate self-report of their health conditions.
The study supported that higher number of ACEs and SLEs reduces overall QOL and wellbeing. Likewise, higher total health problems were related with higher ACEs and SLEs. The cumulative influence of ACEs on health conditions clearly pointed out the need for rigorous ACE prevention. Adults’ health condition could be improved by reducing children’s modifiable bio-psycho-social risk factors as promoting healthy experiences for children promotes QOL across the life course. This in turn would help mitigate the economic burden related with ACEs.
A vast majority of the participants in the qualitative interview indicated the significance of spirituality on their QOL and wellbeing. Mental satisfaction, feeling of happiness, reduced worries and sadness, and obtaining peace of mind are some of the benefits believed to derive from spiritual engagements.
Likewise, a strong correlation was found between social connectedness and QOL and wellbeing. In particular, the sense of belonging to the community was highly reported. Participants in the qualitative research pointed out that children and grandchildren are their main sources of happiness and enjoyment and also immediate people to rely on in times of need.
Their ability to support their children and family in early adult life was the main reason for their life satisfaction, wellbeing, and happiness in old age. Studies suggested that greater satisfaction with social networks (especially family relationships) benefit emotional and psychological wellbeing and have positive effect on QOL for older people. Physical, psychological, social and spiritual needs of older adults are said to be met when they live with their family members.
However, feelings of grave concern were raised during qualitative interviews, in particular fears about not sustaining harmonious relationships between parent-children-grandchildren, threats to the culture of filial piety, respect and reverence for older adults passed down for generations and the appearance of dwindling in the midst of modernisation.
A strong concern about changes in the family dynamics and social values fundamental to older adults were also raised. The seemingly declining trend of veneration for older adults makes them feel lonely, disconnected, disappointed, and depressed.
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One of the important implications from this study was the close link between childhood adversities and multiple health complaints. This strongly suggests that there will be greater demand for healthcare services among those exposed to greater adversities in childhood. It therefore reinforces the need for strenuous efforts by society to prevent violence and other adverse childhood experiences.
The indirect benefit is to reduce the financial burden on the individual, family, and to the healthcare system of the country. Thus, a greater investment by government toward preventing childhood adversity would consequently help in building stronger children and adults to contribute more productivity to society.
Dr. Nidup Dorji (PhD)
Faculty of Nursing and Public Health
Khesar Gyalpo University of Medical Sciences of Bhutan