Abstract
As global population ages, “Aging in Place” is prioritized as the top aging strategy for many of the older adults worldwide. India, being a nation that is expected to hold the maximum share of the older adult population in the near future, has a huge responsibility vested in it to take care of the needs of older adults. The social structure of the nation has emphasized the importance of older adults to age in place, experiencing all the independence and autonomy at their own dwelling places for as long as possible. This study aims to provide a profound understanding of the meaning, attitude, and perceptions of older adults toward aging in place. Using a qualitative research design, in-depth interviews were conducted among 15 community-dwelling older adults who chose aging in place in Kerala, India. Following the interviews, thematic network analysis was done, inspired by Jennifer Attride-Stirling. Three global themes were derived, which include the older adults’ perspectives on (1) determinants of aging in place, (2) challenges of aging in place, and (3) strategies for successful aging in place. The study evokes in-depth exploration of the experiences of older adults aging in place, which inform future evidence-based practices and policy-level implications.
Keywords
Introduction
Aging is a natural and inevitable process associated with the time-based deterioration of physiological functioning and capacities. It is also a transitional period for many people, as it entails retirement, seclusion, bereavement connected to the loss of loved ones, and declining health and wellbeing. Although aging is experienced at an individual level, it is intrinsically connected to societal attributes like the healthcare system, intergenerational support services, investments by countries etc. (MacGuire, 2020). Advancements in healthcare, increased educational qualifications, and higher workforce participation by women have substantially contributed to the decrease in fertility rates and increase in the number of baby boomer generations. The pace and prevalence of the aging population are extensively changing worldwide. World Health Organization studies show that by 2050, the global population of people above 60 years old will approximately double from 12% to 22% (World Health Organization, 2022). Most high-income countries (HICs) have a large older adult population, while low- and middle-income countries (LMICs) are still young. But when viewed through a prospective lens, the LMICs, especially nations like China and India, are expected to hold 80% of the world’s total population who are above the age of 60 by the year 2050 (United Nations Department of Economic and Social Affairs, Population Division, 2022). According to the United Nations Populations Fund India Ageing Report of 2023, the population of people above 60 will double from 10.5% to 20.8% by 2050 (UNFPA India, 2023). It reveals the nation’s necessity to ensure the care and support older adults need to lead a healthy and fulfilling life with dignity.
One major concern related to rapid aging is the proper institutionalization of older adults in India. Institutionalization is often associated with higher economic costs and a lower quality of life (de Medeiros et al., 2020). Aging in place emerges as an alternative to institutionalization, where older adults have been provided with the opportunities to age successfully at their own dwelling places. Aging in place can involve living in one’s own home, another building where older adults maintain complete autonomy, or sharing living spaces with friends or families, as seen in cohousing. According to Rogers et al. (2020), aging in place is defined as “one’s journey to maintain independence in one’s place of residence and to participate in one’s community.” The concept of aging in place is deeply rooted in the bioecological systems theory of Urie Bronfenbrenner and Lawton’s ecological model of aging (Greenfield, 2012). Both theories conceptualize the dynamic and explicit relationship between individuals and their environment. The bioecological systems theory focuses on understanding the relationship between proximal and distal environments (physical or social) and the development of older adults throughout the life course. Thoughts and perceptions about aging in place can be influenced by the changes occurring in the diverse layers (micro-meso-macro-chrono-exo) of the environment (Bronfenbrenner & Morris, 2006). Analogous to Bronfenbrenner’s theory, Lawton’s ecological model of aging, drawing principles from Kurt Lewin’s Person-Environment Fit theory, explains the “fit” between older adults and their environment. Biological, psychological, and social changes happening in the environment can influence the functionalities of older adults (Lawton & Nahemow, 1973). These theories provide a foundation to strengthen supportive factors and reduce barriers to catalyze the development of more initiatives to enable people to age in place.
Aging in place is a preference for most older adults, whether in India or any other country (Ratnayake et al., 2022). In India, care for older adults has traditionally been vested in family members or relatives. Institutionalization, or foster care, is equivocal for many people in India. The thrust of Indian society lies in the family system, considering caring for older adults as a cultural obligation. However, the demographic and cultural changes have impacted the prevailing Indian family system, with joint kinships changing to nuclear families and the responsibility of older adults transitioning from family care to institutional care. Older adult care has been encapsulated in the three-layered system, which includes family, institutions, and society (Andruske & O’Connor, 2020). As social structure changes, society and institutions share the responsibility of caring for older adults.
Efforts have been made by the government since 1999 through the establishment of “National Policy on Older Persons” that focused on ensuring healthcare, financial security, food security, and other needs to enhance the quality of life of older adults (Ministry of Social Justice and Empowerment Government of India, 1999). Subsequently, several other initiatives by the government and voluntary organizations aim to enhance the welfare and development of the older adult population in the country. The “Maintenance and Welfare of Parents and Senior Citizens Act” of 2007 is a similar policy-level approach defining the responsibilities of families and the state in caring for older adults (Issac et al., 2021). Government programs like the Indira Gandhi National Old Age Pension Scheme (IGNOAPS) and the Pradhan Mantri Vaya Vandana Yojana (PNVVY) provide pensions and insurance for older adults, promoting self-sufficiency (PIB, 2022). India’s National Programme for Health Care of the Older Adults is another prominent scheme for healthcare for older adults (Vaishnav et al., 2022). All these policies and programs envision enhancing the wellbeing of older adults, promoting safe and standard living opportunities in the country, and prioritizing aging in place over institutionalization, thereby promoting the autonomy of the older adults.
In western countries, family care for older adults is limited as compared to India. However, aging in place is a widely popular concept preferred by older adults to live the rest of their lives. Considerable literature depicts the benefits and challenges associated with aging in place (Ratnayake et al., 2022), with most studies illustrating the phenomenon in a western context and a few focusing on a LMIC like India. For a country like India, which is aging rapidly and values the family-based system, there is a significant opportunity to contribute to the existing knowledge of “aging in place.” This qualitative study aims to shed light on the meaning, perceptions, and attitude of older adults toward aging in place and to understand the prospects and needs of “aging in place” in India. The study also tries to explore the practical challenges and hurdles in implementing “aging in place” in the country.
Methodology
A qualitative design was employed to study the prospects and challenges of aging in place among 15 community-dwelling older adults in Kerala, the southernmost state in India. It was ideal to use qualitative design because it enabled the researchers to get a thorough understanding of what older adults feel while aging in place and to explore their experiences deeply.
Study Setting and Participant Recruitment
Kerala, the southernmost state in India, holds the maximum share of older adults in the nation (Rajan et al., 2020). The state has a well-established and replicable healthcare system comparable to that of many developed nations (National Health Systems Resource Centre, 2013). This has contributed to better medical care facilities, especially for people aged 60 and above in Kerala. Given the diverse socioeconomic backgrounds of people in Kerala and their diverse perspectives on aging, selecting participants from this state was crucial to obtaining more comprehensive insights into the possibilities of aging in place in India.
The sampling strategy aimed to purposefully select a minimum of 15 older adults who chose to age in place from Kerala and to continue selecting more until data saturation was achieved. The study included participants from diverse socioeconomic backgrounds to understand differences in experiences while aging in place. Older adults were selected based on their living circumstances, specifically people above the age of 60 who (1) live with their spouse and children, (2) live with their spouse only, and (3) live alone for qualitative interviews. Participants were selected based on their general health, assessed using the General Health Questionnaire-28 (Goldberg, 1978). Only individuals with moderate to high mental and physical wellness were chosen for in-depth interviews. Older adults with serious physical and mental impairments were excluded, as their needs and priorities regarding aging in place were beyond the focus of this study. Recruitment of participants was ceased as codes generated became repetitive.
Data Collection
The study was led by a team of two researchers from July 2023 to September 2023. The research team prepared an interview guide collating information from various sources, including secondary data, previously available literature, and discussions with experts in the field. As a result, an interview guide was developed with domains and questions related to the study theme. The guide was translated into Malayalam (vernacular language of Kerala) under the supervision of a language expert, and the responses were recorded. The study protocol and guide were approved by the relevant institutional ethical committee.
After obtaining ethical clearance from the responsible body, in-depth interviews were conducted and recorded by one of the members of the research team. The interviews were conducted at the participants’ residences. Participants were asked questions about their demographics (age, marital status, income, occupational status, living arrangements, primary carers, etc.), health status, perspectives on an ideal place to age, limitations to aging in India, and aspirations related to successful aging in place. Additionally, guiding questions facilitated the participants in discussing their views on existing living conditions for older adults. Participants were given information regarding the purpose of the study before the interviews, and informed consent was obtained. In addition to the interview recordings, field notes were made by the researcher during the data collection process.
Data Analysis
The recorded interviews were manually transcribed and translated into English by another member of the research team. The translations were approved and authorized by a language expert. The analysis was done as inspired by the thematic network analysis proposed by Attride-Stirling (2001). Thematic Network Analysis facilitated the understanding of various themes at different levels and demonstrated it in the most effective way possible. Verbatim transcriptions were analyzed word by word, and codes were generated from the text. Themes were generated from groups of coded segments from the transcriptions. These basic themes were organized to form organized themes and later collated to form global themes. The themes thus generated are illustrated as networks based on their hierarchy.
Results
A total of 15 older adults participated in the in-depth interview. The demographic and health profile of the participants are provided in Table 1.
Demographic and Health Profile of Participants (n = 15).
Comorbid conditions are prevalent among most older adults. The top ternary comorbidity combination includes diabetes, hypertension, and high cholesterol. Additionally, the top binary comorbid combination comprises diabetes and musculoskeletal conditions.
Thematic Network Analysis systemized the emergence of three global themes based on the experiences and perceptions of older adults who are aging in place. These global themes include older adults’ perspectives on the (1) determinants of aging in place, (2) challenges of aging in place, and (3) strategies for successful aging in place. These global themes emerged through the extraction of basic and organizing themes from the narratives of older adults on aging in place.
Global Theme 1: Determinants of Ageing in Place
Most older adults prefer to age in place rather than in an institutional care facility. Several factors motivate older adults to age in place, including individual, social, and spiritual motives, which are depicted as organizing themes in Figure 1. Individual motives are based on the personal experiences of older adults when aging in place. The majority of older adults commented that aging in place is often associated with a feeling of freedom and independence, whereas other living options may cause dependence, which is rarely preferred. Participants can feel themselves and have a sense of belonging while aging in place. The majority of them choose to age in a place where they spent most of their lifetime. This provides them opportunities to cherish old memories and connect with past relationships. Most of the older adults expressed that they have complete freedom living in their own homes, which brings them peace. Some mentioned that depending on others for their needs is very difficult.
Determinants of aging in place.
“I and wife love to live here at our home. We have all the freedom to do whatever we like. We have everything at our home.” (Male, 66–70 years, P 09) “Nothing can replace the happiness and satisfaction we have living at our homes. . .every morning I roam and sit calmly around my house and surroundings. . .I can talk with my neighbors without any restrictions. . .” (Male, 71–75 years, P 01) “I do not even prefer my wife to take me a glass of water. I do not like depending on others to do my pity day to day activities” (Male, 66–70 years, P 05).
Social factors play a crucial role in motivating older adults to continue living in their own homes as they age. Among these factors, the critical determinant is the opportunity for older adults to engage socially. This encompasses the freedom to connect with neighbors, relatives, and various community resources without hindrances or restrictions. The ability to maintain social independence and establish a distinct identity within society serves as a significant facilitator for aging in place.
For some older adults, aging in place fulfils societal expectations regarding children’s obligation to care for their aged parents at home. In India, sending older parents to institutional facilities is considered a stereotype, and looking after aged parents is seen as obligatory.
“I feel it is not the right way for children to send us or any aged parents to some old age homes or similar facilities. This is the worst thing that any children can do to parents who spent the lion share of their precious life for children and family” (Male, 60–65 years, P 12). Spirituality also facilitates older adults to age in place. Spirituality and religiosity are critical as people age. All the participants are spiritual, and most of them find spiritual peace while ageing in place. Participants expressed that living in their own homes allows them complete independence to follow their beliefs and participate in spiritual activities. For some participants, home is a place to find solace in the absence of other family members. “I want to live the rest of life as God allows in my house. . .I can sing hymns and read the Bible as I wish in my house.” (Female, 60–65 years, P 14)
Older adults can freely participate in daily chanting, prayers, reading holy books, etc. leading to a sense of peace, solace, and the attainment of spiritual wisdom. Aging in place encourages older adults to share their spiritual values and beliefs during daily family prayers, eventually fostering good intergenerational relationships. All these determinants of aging in place are the interplay of individual, social, and spiritual factors for most older adults.
Global Theme 2: Challenges of Ageing in Place
While there are several factors that motivate aging in place, challenges are also associated with it. These challenges are physical, psychosocial, and environmental (Figure 2).
Challenges of aging in place.
Aging in place, especially in an Indian setting, is associated with a high risk of falls and frailty (Devassy & Scaria, 2023). The lack of adequate age-friendly facilities in houses impacts the physical health of older adults. If older adults or their carers are not educated enough regarding health care management, it can significantly impact their physical health. Deprivation of proper care can lead to more serious problems.
“I love to live the rest of my life here, but what if I have some illnesses? Who will take care of me?.” (Female, 66–70 years, P 13) “We see in newspapers about the conditions of people living all alone. If they have any health issues or even if they die, people will not be aware of that till the smell comes out.” (Male, 66–70 years, P 02)
Participants express concerns about current and future psychosocial challenges while aging in place. Psychosocial challenges are prominent among participants who are living alone. The lack of proper social support systems, like neighbors and relatives living nearby, can cause loneliness and isolated feelings. Some participants also express anxiety related to their or their spouse’s physical health and its proper care.
Aging in place when living alone soon after the death of the spouse is challenging. It encompasses the loneliness associated with the grief of losing a husband or wife.
“Me and my husband have 2 daughters. After their marriage we have been living in this house all alone for the past 16 years. They often visit us and spend time with us. We were happy with our life. But after my husband’s demise, I sometimes dislike being at this house alone.” (Female, 71–75 years, P 08)
Aging in place can lead to higher “empty nest” and “retirement” blues for those who are living alone.
“I always miss my deceased wife and children who are in America . . .I was occupied for most of the time when my wife was alive. But now I am free and feel bored many times. . .If somebody was here, I could’ve talked and spent time with them. . ..” (Male, 71–75 years, P 04)
Safety issues arise while aging in place if not taken care of properly. Like the increased chances of falls and frailty, older adults are exposed to external threats too. Most participants who choose to age in place have comparatively good economic conditions, but many live with the fear of being coerced into their personal security by outsiders.
“I live very near to the roadside. . .I always live with the fear of somebody intruding into my compound and house without any permission.” (Female, 60–65 years, PI 10)
To have a better experience while aging in place, the living system and surroundings need to be made age-friendly. Proper care must be ensured, causing constraints in the financial ability of some of the participants.
“Once people like us are unable to do things by themselves and are not financially well, living in their own homes can affect them negatively. They will find it hard to make their end meet with limited resources and health.” (Male, 66–70 years, P 06) “I have to pay for my electricity, water, and food all alone. Above this I need to meet my healthcare requirements also. But I have no other options other than doing all these things at this age.” (Male, 66–70 years, P 07)
Older adults face multifaceted challenges while aging in place, with physical health and psychological distress being challenges for some.
Global Theme 3: Strategies for Successful Ageing in Place
Older adults view aging in place as the most desirable option for living the rest of their lives. They can adapt certain strategies to foster better conditions for successful aging in place (Figure 3).
Strategies for successful aging in place.
Social support is crucial for older adults to age in place, both formal and informal. What older adults need the most is support from their families and neighbors. They cherish the warmth and care of their children and grandchildren, enjoying sharing their rich experiences with others.
“I cannot stay with my children in USA all the time because it is hard for me to cope with the climate there. But I want them to come here with their children. When they are at home, we together visit the houses of our relatives and churchmates.” (Female, 60–75 years, P 15)
Older adults also prefer services from formal settings.
“I always think of people from the local government or our residential associations or any similar groups to visit our homes and have a regular check on people like me and my wife.” (Male, 60–65 years, P 12) “Just like how you came here and talked with me, I wish somebody from the panchayat or neighborhood would come and have their regular checks on aged like me.” (Female, 60-–65 years, P 14)
Intergenerational support, both formal and informal, is a crucial strategy for fostering successful aging in place.
Along with a proper social support system, older adults prefer to have a better environment for aging in place. In India, the aging process is happening rapidly, but the system to care for the aged is not completely ready. Many of the older adults expressed their views on modifying the existing conditions of the environment and making it more age-friendly.
The modification has to start with the infrastructure. Safe spaces beyond one’s own home are essential for older adults to age successfully. Green spaces with safe pavements and pedestrian walkways are part of this. This not only helps them in entertainment but also in asserting their autonomy to participate in and engage in social activities.
“When I was working abroad, we had places to go and enjoy our leisure time like parks. I wish to have a similar space exclusively for older adults with all facilities for the people to spent time, engage with other people. . .” (Male, 70–75 years, P 04)
Healthcare facilities in India, especially in Kerala, are conducive for older adults to age gracefully. Older adults view hospitals and health centers as inclusive of people over the age of 60.
“I have seen our ASHA (Accredited Social Health Activist) worker from the community coming home and meeting palliative needs of my ill mother. They provide diapers, waterbeds, and equipment to support sitting and standing and I am quite satisfied with the services.” (Male, 60–65 years, P 11)
Though some people believe that the health system needs some more change.
“I go for a checkup once a month. I have to climb this hill from my house to reach the main road. It would be good if somebody could take medicine for people like me who find it difficult to walk.” (Female, 60–65 years, P 15)
Another major finding is the need for age-friendly transportation facilities.
“I have to take an auto or bus to go somewhere. Getting on a bus is really hard for me and I don’t always have money to take an auto. Again, I find it convenient to walk under these situations. How long will I be able to walk like this?” (Female, 60–65 years, P 14)
A safe and secure living environment is crucial for successful and active aging in place. From the perspective of older adults, aging in place not only happens in one’s own house but rather extends beyond the concrete walls of the houses and spreads to the whole community.
Discussion
The study has uncovered the perceptions and experiences of older adults regarding aging in place, contributing to the development of tailor-made practices for creating age-friendly communities in line with their preferences. Given the high number of older adult populations, effective and sustainable interventions are crucial for the state to care for and protect older adults.
The first global theme reveals the older adult perspectives on the determinants of aging in place, with three organizing themes: individual motives, social motives, and spiritual motives. It is obvious from the western literature and this study that most older adults prefer aging in place. Common determinants include freedom, autonomy, and social connectedness (Ratnayake et al., 2022). Aging in place is associated with a sense of identity, attachment, social connection, familiarity, and security (Cho & Kwon, 2023; Wiles et al., 2012) corroborated in this study. A social motive that is explicitly found in this study is the societal expectation of children to take care of their parents in old age, which is uncommon in western countries and has been less reported in studies. Spirituality, which is articulated through religion, has become a prime determinant of aging in place. The study has explored the way in which the spiritual needs of older adults are satisfied through aging in place. Spiritual gatherings are more often possible for adults who are independent and autonomous, which is possible through aging in place. The results also show that older adults connect everything that happens in their lives spiritually and with the past. Aging in place provides a perfect platform for most of them to cherish memories and live in reminiscence, which ultimately gives them a sense of happiness and contentment. It also gives them a place to be at peace with themselves, others, and God. Some of the older adults perceive their dwelling place as a space for self-reflection and to grow in spiritual wisdom. Aging in place provides the freedom for people to nurture these attributes. Those older adults who are close to their end of life find solace and gratification in the spiritual world, where that individual connects
with a higher, universal power or God in the absence of intergenerational support (Andrews et al., 2023). Spirituality is depicted as a source of peace and comfort, which is truly reflected in this study in the purview of aging in place (Malone & Dadswell, 2018). Participants in the study also felt a sense of social connectedness and belongingness through spiritual gatherings, as Malone and Dadswell (2018) quoted. There are studies that connect the quality of life of people who choose to age in place (Arias-Merino et al., 2019), which is unexplored in the study. But there is scientific evidence that connects an individual’s autonomy to make decisions and live with their quality of life (Rondón García & Ramírez Navarrro, 2018).
The challenges of aging in place constituted the second global theme. Challenges align with those found in western literature, including inadequate infrastructure facilities while aging in place. Improper housing is one of them (Fausset et al., 2011). Another challenge in common is the financial constraints or cost of living that are associated with aging in place. Security and safety breaches are another challenge. Older adults who age in place are highly prone to falls and physiological injuries. Especially in the absence of carers, older adults in India invest less time and energy into self-care management, and this can be a huge threat to older adults aging in place. The prevalence of chronic conditions is high during the later years of life, and high adherence to treatment protocols is essential. In the absence of external care support, this is a threat for people who age in place (Bosch-Farré et al., 2020). Western studies reveal the support-seeking behavior of older adults in possible caregiving systems. But people in India find it difficult to do so, and they are highly dependent on family members, especially their children, for care and support. Extra-family care is stigmatized in India. Inadequate intergenerational support leads to improper health management and the psychosocial challenges of loneliness, seclusion, abuse, and many more (Rajan et al., 2020). Grief caused by the spousal loss or death of people of similar ages can also have a high impact on older adults, especially those who are aging in place because of a lack of social support (Das, 2013).
The third global theme is the older adult perspective on strategies for successful aging in place. Strategies are multifaceted, and proper provision of network and support systems, as well as environment modification, can facilitate successful aging in place. One sub-strategy that can be used to enhance the network system is the facilitation of an intergenerational support system for older adults (Ratnayake et al., 2022). It is common for older adults from all parts of the world that they want to be loved and heard. Support from their own family is important for older adults in India, which differs from other countries. Several programs implemented successfully in European and American countries enable younger generations to spend time with older adults who live alone. The government can take the initiative to monitor and care for older adults regularly. More initiatives can be introduced to generate education and awareness among older adults and carers to enable aging in place (Greenfield, 2012).
Another major strategy is to modify the existing environment and make it age-friendly. WHO has already developed and published a comprehensive framework to build age-friendly communities (World Health Organization, 2007). The Age-Friendly Sarasota program implemented in Florida is a sustainable model for many countries to replicate. This program was developed and implemented based on the age-friendly community’s framework proposed by WHO (Owusu et al., 2023) which can be replicated considering India’s geopolitical and cultural context. Most older adults have commented on improving transportation and other infrastructure facilities in the country, which is also reflected in other studies. Age-friendly transportation facilities, including vehicles, traffic systems, and pedestrian walkways, need to be implemented. Respect and social inclusion for older adults are other key strategies. Communities need to be educated about inclusive practices. When these practices are integrated with existing policies and programs for older adults, aging in place in India will be successful.
Kerala holds the credit of being one of the first to establish state-level policy for the protection and welfare of older adults in congruence with the National Policy for Older Persons, 1999. The Social Justice Department, Government of Kerala, is the nodal agency for implementing social welfare programs for older adults in the state. Sayamprabha Home is a multi-service daycare facility for community-dwelling older adults across the state. More healthcare and similar services are being provided through these centers (Social Justice Department, 2019). In India, voluntary organizations are involved in various efforts, including organizing exclusive employment exchanges, creating recreation spaces and sensitization programs for multiple stakeholders, health care initiatives, elder helplines, livelihood support, digital literacy programs, lifelong learning programs, research and consultancy initiatives, etc., which all contribute to age-friendly environments (Agewell Foundation, n.d.; Help Age India, 2020) which could be scaled up. All these initiatives are finding ways to reduce institutionalization and enhance the option of aging in place.
The study is limited to a specific population in India, and the findings are also limited. The study can be reproduced in other parts of India to increase its generalizability. There is scope for conducting more cross-sectional and longitudinal studies incorporating quantitative methods of data collection and analysis to bring more empirical insights into the determinants and risk factors of aging in place.
Conclusion
The insights from the study suggest the creation of more sustainable and effective practices that can make aging in place a healthy living strategy for older adults. Although the study aims to explore the perceptions of older adults about aging in place, it is essential to gain a better understanding of the subject from a more diverse population. Though Kerala is a state with remarkable experience in imparting care services to older adults, selecting the state as the study location may have skewed the research findings. Further research could be conducted among the carers of older adults, particularly family carers, to comprehend their perspective on aging in place in an Indian context. Moreover, future research could focus on bringing more technology-driven practices, such as the use of social media, digital health applications, electronic media in daily activities, and time bank facilities for informal geriatric care, to promote aging in place and establish it as a sustainable solution for government and voluntary organizations in creating safe spaces for the booming aging population in India.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
