Successful Aging from the Perspective of Hong Kong Elderly

ABSTRACT

Aim Successful ageing is a worldwide discussion topic, but its definition is diverse and controversial. This study aimed to explore the meaning of successful ageing from the perspective of elders in Hong Kong, and to compare their attributes with those identified in the literature.

Methods Qualitative in-depth interviews on the perspectives of elderly persons were held with 4 participants aged above 60, recruited from a community medical center.

Results All respondents rated themselves as ageing successful. Five themes were identified: Good health and ability of self-care, good family relationship and being cared for, feeling of contentment, economic security, and social activities. This reflected the multi-dimensional perspective in local elderly people.

Conclusions A life span perspective rather than assessment at certain point provide better insight to understand people's perception of success in old age. More research is needed to explore the needs and expectations of elderly in Hong Kong.

SUCCESSFUL AGEING FROM THE PERSPECTIVE

OF HONG KONG ELDERS

INTRODUCTION

The world population is ageing rapidly. This ageing trend, occurring in many developed countries as a consequence of falling mortality and birth rates, is a phenomenon of “demographic transition” in sociology. In 2006, the overall percentage of the world population aged 65 or over was 15%, as high as 19% in Germany and 21% in Japan (New Horizons, 2007). In Hong Kong, the proportion of those who aged 65 and over was 12.6% in 2008, which is expected to be gradual up to 16.2% in 2018 (Planning Department, 2009). It is projected that the proportion will rise markedly to 24% in 2031, which means that one in four people will be in the aged group. Demographic changes challenge policy makers to put greater than ever effort in dealing with the consequences of an ageing population. Changes in societal values and family structures will also cause profound effects on all segments of our societies. Ageing becomes the mainstream social transformation in Hong Kong.

LITERATURE REVIEW

Many concepts on ageing have been studied over the last half of the twentieth century. Cumming and Henry (1961) posed the disengagement theory at a time when life expectancy was shorter and mandatory retirement was in place. They posited that ageing is a natural and voluntary withdrawal by elderly people from society and simultaneous withdrawal by society from elderly people in order to fulfill the functional needs of the society. However in the past few decades, more gerontologists have taken a positive approach. With increase life expectancy and improved health condition of the aged group, there has been a shift in the focus of studies of ageing from emphasizing on disabilities and functional decline among the elders to factors facilitating the aged group to live a healthier and more satisfactory life.

For the past several decades, gerontologists have been developing conceptual frameworks or schema to describe ideal outcomes of the ageing process. The idea of ‘Productive Ageing’ emerged in the early 1980s challenges the historical view that old age is a period of frailty and dependence and appeals that currently majority of older adults can remain productive through contributions as workers, volunteers, care-givers and active citizens (Morrow-Howell, Hinterlong & Sherraden, 2001). ‘Active Ageing’ is a concept advocated by WHO (2002) as “the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age”. It encourages strategies for prevention of chronic disease, access to age-friendly primary health care and creation of age-friendly environments to foster the social engagement of older people.

‘Successful Ageing’ was first introduced by Robert Havighurst (1961), defined as "adding life to the years" and "getting satisfaction from life". Since then, various authors have given different definitions or models of “successful ageing”.

The existing models of successful ageing have been developed from the views of medical, psychological and social sciences. The theories evolved take a biomedical or psychosocial approach or combinations of both.

Biomedical Approaches

Biomedical theories define successful ageing in terms maximizing life expectancy and minimizing disability. They focus on absence of chronic diseases and their risk factors, and high levels of independent physical and cognitive functioning.

The MacArthur Studies in 1988 are the most widely published biomedical studies of successful ageing. It was the research basis for the frequently cited book ‘Successful Ageing’ by Rowe and Kahn (1998). Participants were followed for an average of seven years, monitoring their status as they aged. Rowe and Kahn suggest that within the category of normal ageing, a distinction can be made between usual ageing and successful ageing. They also confirm three components of successful ageing: (a) low risk of disease and disease-related disability; (b) high mental and physical function; and (c) active engagement with life. These three components are hierarchical since absence of disease or disability makes maintaining cognitive and physical function easier, and in turn maintenance of these enables active engagement with life.

This approach, though the most widely used, is criticized to be unrealistic for older age people who are rarely disease-free. Later research found that fewer than a fifth elderly people who self-rated themselves as ageing successfully could be so categorized with this biomedical model (Strawbridge, Wallhagen & Cohen, 2002).

Psychosocial approaches

In contrast to biomedical model which stresses on absence of disease and maintenance of physical and mental functioning, psychosocial models emphasize life satisfaction, social participation and functioning, and psychological resources.

Baltes and Baltes (1990) suggested that “an inclusive definition of successful ageing requires a value based, systemic, and ecological perspective, considering both subjective and objective indicators within a cultural context”. Ageing is a lifelong adaptive process, an ongoing dynamic of selection, optimization and compensation (SOC). As physical and cognitive limitations imposed increasing restrictions, individuals will ‘select’ or specialize their efforts into areas of high priority. They continue to engage in behaviors that enrich and augment their physical and mental reserves that they may ‘maximize’ their chosen life courses. They also devise psychological and technological strategies to ‘compensate’ losses in specific functions. Successful ageing is seen as positive adaptation to the decrements of ageing, making the best of one’s remaining capacities and compensating for losses and limitations.

Ryff (1982) defined successful ageing as positive or ideal functioning related to developmental work over the life course. She proposed an integrative model of successful ageing based on six dimensions of positive functioning: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Besides, resilience, defined as the maintenance or recovery of health and well-being in the face of cumulative adversity, is also an important factor for successful ageing. (Ryff, Singer, Love, & Essex, 1998).

Lay Perspectives

Recent studies have shown that the way older people themselves define successful ageing are different way that of the researchers. In 2004, a survey was conducted on American older adults, including a cohort of Japanese Americans, to compare their perceptions of successful ageing with definitions of successful ageing taken from the published literature (Phelan, Anderson, Lacroix & Larson, 2004). Of the 13 items rated as important to successful ageing by 75% or more, two items related to physical health, one item to functioning, eight to psychological (or mental) health, involving perceptions of autonomy, control, and coping, and two to social health. The study discovered that older adults may emphasis on functional aspects but take satisfaction and adjustment more important. Their views of successful ageing are multidimensional and more complex than the viewpoint of earlier studies.

Bowling and Dieppe (2005) also conducted a survey of perceptions of successful ageing in Britain. 75% respondents rated themselves as ageing successfully. In response to open ended questioning, they mentioned definition of successful ageing falling into categories in order of health, psychological issues, social roles and activities, finances, social relationships and neighbourhood. Having good health and functioning was the most mentioned definition but these were rarely mentioned in isolation. It is found that lay model has the strongest predictor of self-rated quality of life.

Local Studies

Chou and Chi (2002) conducted a study comparing successful ageing among the young-old, old-old and oldest-old Chinese in Hong Kong. Successful ageing was found to be highest among the young-old. The best predictors, all with modest associations, were higher life satisfaction, being male, more education, no financial strain, self-rated health, adequate hearing and contact with friends.

In 2008, a symposium on “successful ageing” was held in Hong Kong which addressed the Hong Kong Chinese perspective and well-being indicators comparing with other countries (CADENZA, 2008). Successful ageing was defined as a socially and culturally determined construction. Understanding of the diversity and commonality of the ageing experience across cultures is emphasized, including the influences of Chinese cultural beliefs like protecting the family’s face, maintaining harmony and being thankful. Key factors of successful ageing among Chinese elders are identified, to be harmonious family relation, independence in daily functioning and self-care within one’s physical ability, positive orientation to life in general and old age in particular, adequate social contact and sufficient financial resources.

The application of the concept of successful ageing is, however, still unclear. Firstly, there is there is no agreed standard or operational definitions for assessment. Secondly, most of the findings are based on western populations. The word "success" is a distinctly American construct which is better acknowledged in the context of Western culture. The concept may not appear to translate easily into our local cultural contexts. Thirdly, the perceptions of elders on successful ageing should be taken into account so that policies and actions are designed most relevantly to their needs and expectations. It is unclear what ageing successfully means to Hong Kong elderly specifically. Thus, a research aiming to define successful ageing in the perspectives of local elders would be useful.

DESIGN OF THE STUDY

This is a qualitative and descriptive study aiming to document the ageing experience of elderly Chinese and gain insight into the meaning of successful ageing to them. It was conducted among Hong Kong older adults during January 2010.

Objectives:

1. To examine the lives and experience of older adults in Hong Kong

2. To identify the perceptions of successful ageing among older adults in Hong Kong and to compare with those identified in earlier studies.

Method:

The study is qualitative in nature, relying on information gained from in-depth interviews. Voluntary participants aged 60 and above were recruited by random from a community medical centre located in Kwai Tsing District. A guided semi-structured approach was adopted to provide flexibility. The central research questions focused on the experience of and being old and the perception of the concept of successful ageing. After collection of demographic data, three exploratory questions were asked:

1. How is your life and experience of being old? 2. Are you ageing successfully so far? 3. What do you think are the things associate with successful ageing?

For respondents who were hesitant with the word “successful”, ‘ageing well’ or ‘satisfactory ageing’ is used instead.

RESULTS

A total of four respondents were recruited. The age range was 62-87. All respondents had lived in Hong Kong for over 50 years. Three lived with their spouses. All lived together with at least one child. All respondents were independent in their daily living activities. Their demographic characteristics were tabularized as follows:

|Sex |Age |Education |Career before Retirement |Marital Status |Residence |Living together with |
| | | | | |In HK | |
|M |82 |Primary |Factory Worker |Married |60+ years |wife, son & daughter-in-law |
|M |62 |Secondary |Shopkeeper |Married |Since birth |wife, son and daughter |
|F |78 |Illiterate |Housewife |Widowed |50+ years |daughter, son-in law & 2 |
| | | | | | |grandsons |
|F |65 |Secondary |Self-employed |Married |Since birth |husband and son |

Life and Experience of Being Old

All respondent described themselves as content with their lives and successfully aged. They had a common agreement that ‘ageing was an unavoidable process of life’, and viewed it in a rather positive way. They accepted the fact of their ageing and tried to adapt the changes associated with it.

One of the respondents (M/62) had just retired for three months when all his children had a stable job. He enjoyed his retirement life quite a lot because for the past 30 years he had worked over 10 hours a day as a shopkeeper. He was glad that he had time to learn computer and use internet to know more about the world. He also started doing morning exercise in the park, joining Luktungkuen (六通拳) class. This did not only offer a way of keeping fit, but also the chance of knowing new friends and neighbours. Another respondent (M/82) had been doing morning exercise for the past ten years. He jogged in an open stadium regularly with other old people. He said they became like brothers and enjoyed chatting together after exercise. Both respondents demonstrated that they were more conscious of their health since getting old. The companionship of other older adults added motivation and fun to this health enhancing behaviour.

Two respondents (M/82, F/78) were solely supported by their children in finance. The other two were spending their own savings. One of them (F/65) was helping in a canteen to supplement her income. Though the job was quite labor-intensive, she still preferred to earn a bit more instead of relying on her children. She disclosed that she had chronic diseases including hypertension and osteoporosis, and her husband had diabetes with eye complications and was home-bounded. They were spending more than a thousand dollars per month for medical treatment. She did not turn to government medical services because of less confidence. Another respondent (F/78) also had hypertension and gouty arthritis receiving private treatment suggested by her daughter. Her son-in-law was the only bread-winner while her daughter took care of two little kids. She looked after the young one at home while her daughter took the older to school and for activities. She was relieved that she did not trouble her daughter because of old age and could even help in some way. Both respondents did not experience much limitation as a result of their chronic diseases.

Two of the respondents went to Chinese restaurant for morning tea (yam cha) routinely. They did it as an enjoyment and social gathering with friends. They also enjoyed walking around in malls and watching television. These leisure activities were convenient and free of charge. One respondent (M/62) was interested in joining courses held by community center, while another (F/65) joined a private social dance club with regular practices and gatherings. She would wear a wig and beautiful costume when danced. Dancing helped her feel young and energetic, and alleviated her stress in taking care of her disabled husband.

Things Associated with Successful Ageing:

After analyzing the data, several themes emerged associated with successful ageing identified. It was coded under five main themes:

1. Good health and ability of self-care 2. Good family relationship and being cared for 3. Feeling of contentment 4. Economic Security 5. Social activities

1. Good health and ability of self-care

In this study, good health was the most important factor associated with ageing well in perception of the respondents. However, they did not regard their health as a ‘success’ but said that they had been fortunate or blessed (托賴). At this age, good health is emphasized as ‘the maintenance of basic functions (such as vision, hearing, power, memory)’ and ‘the absence of painful or disabling conditions (such as arthritis, chest pain, toothache, tremor)’, rather than being completely free of diseases. The key issue is being ‘independent’ and ‘mobile’, so that they can take care of themselves and travel around as they wish.

Physiological decline is a natural and inevitable process. Decline is not necessary a problem and most elderly can adapt to these changes. For instance, one of the respondents had impaired vision for the past twenty years. This was only partly corrected by spectacles, so he would avoid going to unfamiliar places by himself. Another respondent had arthritis of knee and she would bring along her walking-aid when it ached. Despite these, they were able to adapt quite well and function independently in their daily activities. Acceptance and adaptation seemed essential in maintaining a feeling of well-being. However, they also foresaw that their health condition would deteriorate as they aged, and more limitations and dependence would happen sooner or later. To optimize their years of functioning and to avoid being a burden to their family, they may engage in health behaviours, such as doing physical exercise, observing diet, avoiding dangerous action and using appropriate devices.

2. Good family relationship and being cared for

All respondents said that it was very important to have family members around for the elderly. They expressed that they were not too worried of growing old if they had relatives, especially children, who cared for them. All four participants were living with at least one child. Two of them had children staying in their parents’ house even after getting married because they could not afford the rent in private market. Though the living environment became more crowded, the parents still welcomed their decision of staying together. Besides the economic support, integrity of the family gives considerable comfort and sense of fulfillment to the elderly, and frees them from the fear of isolation.

One respondent (M/82) expressed that he was very fortunate to have a responsible wife. They complement each other in the household tasks. He was also pleased that all his children showed filial piety to their parents. He said, “It is my greatest success in life to have a harmonious family, a good wife and considerate children. I often mention them before my friends and relatives. They admire me a lot. ” He concluded that having his family around, he was not worried even to face that day. He pitied those older people who had to live alone or institutionalized. In his view, family care was the first choice to the elderly in Chinese tradition.

3. Feeling of contentment

Another theme found to be associated with successful ageing was the feeling of contentment. Ageing well was described by respondents as ‘feeling satisfied’, ‘being free of worries’, ‘having a peaceful mind’, and ‘following my own heart’. For some older adults, psychological well-being is related to one’s personality and attitudes towards life. Just as a respondent (M/62) quoted ‘happy is he who is content’ (知足常樂) to be his life philosophy, “It depends on how you to look at things. It is impossible to have all your wants meet. Just be content with what you have. Keep an optimistic mind and don’t worry too much.” He also found satisfaction in learning new stuffs. Another respondent said, “The key to have a good old age life is to open your mind, do what you want and adjust to changes.” She had her hair dyed and wore a wig sometimes since her hair became thin and turned gray. This made her feel confident before people.

Some respondents also attributed psychological well-being to extrinsic factors such as absence of diseases, financial security and family care. One respondent wished that she could stay healthy and did not become a burden to her child. She would feel good about herself if she could continue to help in some housework. This reflects that old people need a sense of worth.

4. Economic security

All respondents mentioned financial security as an important element of satisfactory ageing because this ensured their basic needs are met. Their expenses relied mainly on their children’s supply and earlier savings. Only one respondent had a part-time job with earnings sufficient for her medical expenses. Though they were not ashamed to receive from their children, they understood their children’s difficulty in supporting their own families and did not want to burden them too much.

Economic strains cause anxiety to elderly people because they lack working ability and opportunities. In the Chinese culture, it is the moral obligation of children to care for parents when they grow old. Although majority of Hong Kong elderly people still live with their children, they tend to received less economic support. This may be related to the decrease number of children born to a family to share the responsible of care, and the economic downturn, re-structuring and high unemployment rate in recent years. Research has shown that poverty in old age is associated with increase health risk. It may deprive them of access to and quality of health care and basic needs such as good nutrition and safe environments. This is also associated with also high levels of stress, depression and isolation (House, Lantz & Herd, 2005).

5. Social activities

Three out of four respondents perceived social activities as essential for successful ageing. These included chatting with friends and neighbours, having morning tea and doing exercise together and joining interest clubs. They responded that social activities helped them to stay involved with the people around and entertained their excessive leisure time. Instead of a necessary duty, voluntary participation provided them more satisfaction and pleasure.

Research shows that remaining engaged in social activities is a key to staying physically and mentally healthy for older adults. Volunteering work, in particular, can lead to greater functional ability, and strengthen one’s resilience when dealing with health problems, reduces despair and depression, help offset the loss of purpose felt by many older adults, and lead to an overall improved quality of life (Grimm, Spring, & Dietz, 2007).

Participation in social activities improves the elder's well-being in multiple ways. Besides avoidance of isolation and expansion of their social network, social interaction increases the motivation and persistence of the elder to engage in various activities. For instance, physical activities like jogging and dancing improve their physical well-being, activities such as learning class, playing chess or computer and help maintaining the cognitive function, activities such as chatting, going to restaurants, singing provides the elders the chance to ventilate their emotions and relieve their anxiety. It also increases their self-esteem and adaptability.

DISCUSSION

While biomedical model emphasizes on absence of disease, maintenance of physical and cognitive functioning, and active engagement with life in defining successful ageing, our findings seem to match more with that of the psychosocial model which emphasizes life satisfaction, social functioning and psychological resources. Successful ageing is not an objectively measurable functional state. It is a process of successful adaptation to limitation, a perceived sense of satisfaction.

From the perspective of participants, five themes associated with successful ageing were identified, which included the ability to remain independent, being cared for by family members, positive attitude towards life, economic security and social activities. One special feature among Chinese elders is that they emphasize family care as one of the most important condition for successful ageing. This factor is essential because in it finds the provision of physical care, psychological support and economic security.

However, this traditional Chinese practices is under challenge in Hong Kong. A recent news report revealed that in 2009, 6.8% of Hong Kong elderly people live in institutions. The rate is considerably higher than that of Mainland China (3%) and Japan (3%) (Mingpao, 2010). The phenomenon is attributed to smaller size of family and reluctance of children to live with their aged parents. Besides, over 10% of elderly live alone and many more reside only with their ageing spouses. In view of the changing attitudes of children to care for their parents, community-based care for local elderly is the current trend. Better development in co-ordination and quality is urgently needed.

Elderly poverty is a also growing problem in Hong Kong. The Hong Kong Council of Social Services reported that 315 out of 1000 elders (31.5%) lived in low-income households in 2005. Two-third of Comprehensive Social Security Assistance (CSSA) applicants are elderly people. Old Age Allowance (OAA) is another source of income accessible to citizens aged 70 and above to those aged 65 and above. The growing economic burden on social security has pushed the local government to lunch the Mandatory Provident Fund (MPF) Scheme as a long-term strategy. However, the problem of elderly poverty remains largely unsolved at present.

Chinese elderly are more prone to have low self-image and sense of helplessness. The incidence of elderly suicides is higher among Chinese compared to Western population (Chi, Yip & Yu, 1997). It is estimated that twenty percent of the elderly population had symptoms of depression. This may be attributed to the impact of social changes to the tradition values of Chinese family. The prestige of being the elders in the family has changed. Loss of esteem, isolation, loneliness, poverty and lack of social assistance lead to growing psychological problems among Chinese elderly.

CONCLUSIONS

Because of limitation in time and resources, only four participants were interviewed. Two belonged to the group of young-old and the other two old-old. All of them had relatively good physical and cognitive function. No participant was recruited from the group of oldest old. Therefore the findings might not be representative of this group which is known to be associated with more declines in physical and cognitive function. Their lower socio-economic background did not reflect the perspective of those in the higher social stratum.

However, the study still provides a concrete picture of local ageing experience as the respondents made reference to their personal life history and social environment in various themes. Ageing is a continuous process. A life span perspective rather than assessment at certain point provide better insight to understand people's perception of success in old age. The vivid description on their lives of growing old and perception of ‘successful’ or ‘good’ ageing had shed some light on the genuine needs and expectations of elderly in Hong Kong. More research is encouraged to explore the local perspective of successful ageing and to guide policy goals with more relevance for the elderly themselves.

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