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Understanding how older adults living in deprived neighbourhoods

Annemiek Bielderman, Gert Schout, Mathieu de Greef, Cees van der Schans

Annemiek Bielderman, Researcher, Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of

Applied Sciences, Groningen, the Netherlands; Gert Schout, Senior Researcher, Department of Metamedica, VU Medical Center,

Amsterdam, the Netherlands; Mathieu de Greef, Professor of Allied Health Care and Ageing, Institute of Human Movement

Sciences, University Medical Center Groningen, the Netherlands, and Professor, Research Group Healthy Ageing, Allied

Health Care and Nursing, Hanze University of Applied Sciences; Cees van der Schans, Professor of Health Care and Nursing,

Department of Rehabilitation Medicine, University Medical Center Groningen, and Professor, Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences

aintaining a good quality of life in advancing age is relevant in the ageing process and, subsequently, an overall goal for policymakers (Netuveli and Blane, 2008; Walker and Maltby, 2012). Nursing care has the potential to improve the health care of older adults and optimise their quality of life (Young, 2003; Williams and Kemper, 2010; Markle‐Reid et al, 2013). Maximising patients’ quality of life by managing health care throughout their lives

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is an aim in nursing (American Nurses Association, 2010). Optimising quality of life with nursing care merits primary attention, especially in frail older adults.

Owing to the rapidly increasing number of older people across the world, the importance of nursing care for community-dwelling older adults will continue to grow (Grady, 2011; Etman et al, 2012). Older adults with a lowsocioeconomic status and residing in socioeconomically deprived neighbourhoods are at risk of developing frailty and becoming care dependent (Lang et al, 2009; St John et al, 2013).

Living in a deprived neighbourhood is associated with a variety of adverse physical, cognitive, and psychosocial health prospects including a greater risk of mobility difficulties and chronic diseases, such as diabetes and cardiovascular disease, as well as increased feelings of loneliness and depression (Winkleby et al, 2007; Lang et al, 2008a; Mair et al, 2008; Yen et al, 2009; Stringhini et al, 2012; Jaffiol et al, 2013). In addition, the onset of multiple morbidities, including mental health disorders, occurs 10–15 years earlier in people living in the most socioeconomically deprived areas compared with those living in more affluent areas (Barnett et al, 2012). As a consequence, older adults living in deprived areas are at risk of developing frailty, experiencing a lower quality of life, and subsequently becoming care dependent and a target group for community nursing care (Lang et al, 2008b; 2009).

Health literacy refers to a set of cognitive and social skills that determine the motivation and ability of people to gain access, understand, and use information in order to enhance and maintain good health by modifying personal lifestyles and living conditions (Nutbeam, 1998). An inadequate health literacy is one of the suggested causes of less adequate health outcomes in older adults living in deprived areas (Howard et al, 2006; Cutler and Lleras-Muney, 2010; Pampel et al, 2010).

This deficiency is often associated with inadequate socioeconomic circumstances and, in older adults, is related to a less healthy overall status, frailty, and higher overall mortality rates (Nutbeam, 2008; Sørensen et al, 2012; Berkman et al, 2011; Lassetter et al, 2015).

Considering that nursing encompasses specific responsibilities for the detection of vulnerable populations such as older adults with inadequate health literacy, the challenges in health promotion require an awareness of obvious conflicting opinions (Hilton, 1997). Community nurses providing health care at home encounter community-dwelling older patients in deprived neighbourhoods. Therefore, older adults’ perspectives on ageing may serve as a guide for the nurse to provide appropriate care. Since there is a lack of information regarding these older adults’ perceptions, the perspectives on ageing and frailty among this group of older adults needs to be explored. The aim of this qualitative study is to explore how community-dwelling, older Dutch adults living in deprived neighbourhoods address ageing issues.

The research can be characterised as a qualitative descriptive and exploratory study using in-depth interviews with 20 participants. The interviews were performed using a qualitative case study design (Stake, 1995). This method is used to explore and obtain depth of understanding on how older adults living in a deprived neighbourhood address ageing issues. This design is chosen to capture the multitude of perspectives in dealing with ageing. In this method, ensuring diversity of perceptions is crucial.

Included participants were community-dwelling, aged 65 years and older, not dependent on care, and living in a socioeconomically deprived urban neighbourhood in the northern part of the Netherlands. The participants reside in a deprived neighbourhood of a mid-sized city in the Netherlands. According to data from the Netherlands Institute for Social Research (Knol et al, 2012), this neighbourhood has a low-socioeconomic-status score based on the area’s education, income, and occupation levels. Compared with other areas in the Netherlands, this neighbourhood belongs to the 10% of areas with the lowest area socioeconomic status score in the country.

Participants were recruited from a community-based lifestyle programme for physically inactive older adults from this area (n=120). A purposive sampling strategy was used to recruit older adults in order to obtain a study sample comprising a wide array of personal characteristics, such as age, sex, health status, and living status, that are an accurate reflection of the population at large (Palinkas et al, 2013). In this qualitative study, 20 older adults were personally invited to participate. The older adults were informed about the intent of this study by information leaflets and were asked to provide their written informed consent.

In-depth interviews were conducted in March, April, and May 2013, by six trained interviewers. Participants could choose to be interviewed at the community centre or at their own home. In the interviews, a biographical method was used to collect a detailed account of a participant’s life. The interviewer began by asking the respondent to describe his/her own family history, including the birthplace, living environment, and family. The interviewer asked subsequent probing questions in order to gather more relevant information if a respondent mentioned a life event that was important or related to the ageing process or frailty. All interviews were audio-recorded and transcribed verbatim. We continued collecting data until saturation occurred, that is, until no new themes, factors, attributes, or suggestions for categories emerged (Morse and Field, 1995).

Transcribed interviews were analysed with the help of ATLAS.ti (version 6.0.15). Following the constant comparative method of Boeije (2002), codes were allocated to meaningful sentences or fragments (open coding). These codes were ordered and grouped into categories (axial coding). Finally, data were integrated by connecting categories (selective coding). In order to obtain investigator triangulation, two independent researchers individually coded the transcribed data. A third researcher was consulted to discuss differences in coding. Collectively, the three researchers decided on and concurred with the final categorisation. To present our results, verbatim quotes were selected to illustrate the findings.

The university ethics review board granted exemption from ethical review considering the minimal burden for the participants. All participants gave their written informed consent to participate in the study. The research was performed in compliance with the Declaration of Helsinki.

In-depth interviews of 1–3 hour duration were conducted with 20 older adults. Table 1 shows the characteristics of the participants. The age of the participants ranged from 65 to 86 years with a mean (SD) age of 72.5 years (6.2). Majority of the participants were female (65%) and were residing with a partner (65%). Half the number of participants had low educational attainment, while the other half had moderate education attainment. One participant was highly educated (high school). All participants were of Dutch nationality.

In order to illustrate the participants’ background, the participants were asked to narrate their childhood memories and young adulthood experiences.

Half the number of participants were born during the period of the Second World War; the other half were born shortly thereafter. Only the oldest participants (75+ years) reported unfavourable memories of the War period—a vast majority of them mentioned that they had lived in poverty during that time, with a scarcity of food. Almost all participants grew up in large families in small working-class cottages in rural areas. In the time when they were young, it was unusual to continue one’s education following primary school, as financial means were insufficient. For the participants, it was customary to help parents with daily activities, such as assisting in housework or working on the farm and performing agricultural work. Participants reported that, in those days, it was unusual to discuss personal problems or feelings. Despite the scarcity of food, participants reported that there was always enough, and any available food was shared. Income was also shared at all stages of life. Most participants began working at the age of 16 years. Participants reported that, at that time, women worked until they were married, and it was common for women to be wed because they became pregnant. The participants usually married between the ages of 20–23 years. The male participants were the primary source of income for their families and mainly worked in shipping, (heavy) industries, or factories. Consequently, participants relocated from the rural countryside to urban villages to be near their work facilities.

The first finding focuses on the participants’ evaluation of health and the (lack of) knowledge about health and ageing. Subsequently, attitudes regarding health are discussed.

Individual health and the health of one’s partner were described as: ‘the most important thing of people’s life’ or ‘the greatest wealth that exists’. A female participant, aged 68 years, explained why health is so vital to her:

As a consequence of ageing, most participants have experienced diminished health, which they described as ‘part of life’, ‘that’s simply the way it is’, ‘it just happens to you’, or ‘we have no influence over it’. Another female participant, aged 68 years, and with progressive knee problems, explained it as follows:

‘It became increasingly worse, but you adjust to the situation. It causes annoyance, but you are getting used to it. At a certain point, they operated on my knees and, now, I can walk again, and that is worth a lot. I am getting older, and I have to accept that.’

The same was valid for participants with a limited social network. Participants who reported having only a small circle of friends stated that it is a primary consequence of ageing.

Participants varied in their level of awareness of the effects of lifestyle on their individual health. Several participants stated that they attempt to lead healthy lives by being aware of what they eat and performing physical exercise. In addition, they considered ‘just continuing with your activities’ to be a component of a healthy lifestyle. In spite of age-related health problems or functional disabilities, continuing life (‘just move on’) was important to them. Other participants did not mention the effects of lifestyle in relation to health.

Several participants described the consequences and causes of health problems or disorders. In these responses, the consequences of disorders were often underestimated. For example, a male participant, aged 77 years and diagnosed with diabetes, explained that the main consequence of being diagnosed with diabetes is ‘It’s no great matter, I just need some pills.’ A female participant, aged 78 years and diagnosed with diabetes, reported that she does not always have her diabetic insulin pen with her:

Examples of ignoring signs of age-related decline in health were observed. Participants acknowledged that they more or less intentionally ignored signs of the disease in the beginning such as pain due to osteoarthritis or heart palpitations. This often corresponded with requiring medical help at a late stage. As one female participant, aged 66 years, explained:

Other participants were not aware of the signs of health problems. A 77-year-old male participant spoke about the emergency care he required:

‘Yes, last Saturday, I almost needed emergency care. It was a close call. I ate fried rice. And then, a piece stuck in my oesophagus. Everything went completely black, so I thought, “Now I will die.” I could not stand, I could not lie. My wife wanted to call a doctor, but I said “No, don’t call a doctor.” After half an hour it went away. It was caused by the fried rice, I said to the doctor. But the doctor wanted to make an ECG immediately and advised us to call the emergency number immediately the next time. The ECG was okay. So, it was caused by the fried rice, it was way too dry.’

Mental health problems were described as being most restrictive to participants. None of the participants reported perceiving limitations due to cognitive impairments, but they mentioned being very anxious at the possibility of experiencing cognitive health problems, such as severe cognitive impairment, dementia, or behavioural problems in the future.

Participants appeared to use certain coping strategies to address health problems. Three primary attitudes were identified: acceptance of one’s situation, contentment, and having an optimistic view.

Health was perceived as a prerequisite for maintaining a degree of autonomy and independence and to be able to do the activities you desire. ‘Life happens to you’ is a much used expression. One participant, female and aged 65 years, described it as ‘If it is like this, so be it. That’s life.’ Another female participant, aged 77 years, indicated, ‘You’re not always in control; it just happens to you.’ This submission to life and its experiences signified acceptance of the situation, which is reflected in the manner in which participants perceived the process of ageing. Most say: ‘You will simply age.’ A participant, aged over 80 years, stated:

Participants mentioned that they adjust their activities according to their current capabilities. The same applies to their attitude toward death, as one female participant, aged 66 years, stated:

‘Everyone will come in its time. No one ever passed away before his time. There is nothing to say about it.’

There is a saying in the local dialect that ‘nagging and complaining will not help. You must just take action and manage with what one possesses.’ Participants stated that the emphasis falls on the things one is still capable of doing and managing. A female participant, aged 68 years, mentioned:

It appeared that this perception of life resulted in contentment with their situation. Participants reported little ambition to change their way of life and stated being satisfied with what they have achieved. Participants considered having children and grandchildren, being able to participate in leisure-time activities, and experiencing (relatively) good health as being sufficient to creating contentment in their lives. A male participant, aged 77 years, stated:

Even when life was or appeared to be troublesome, participants emphasised their contentment with all they have. It is illustrated with an example of a female participant, aged 67 years, with financial and personal troubles in her life:

‘I am well pleased. I have never been jealous of others, although I have acquaintances and family members that are much better off. I’ve never been jealous. I always had second hand things, but well, “if you make it your own and light a candle,” I always say. You look around and think, “Even though it is a scrambled bunch, it is still mine. It belongs to me.”’

Most participants exhibited positive feelings regarding their circumstances. They explicitly indicated that being optimistic in life is very important for overcoming difficulties, not only for their own wellbeing, but also for the sake of close relatives. A female participant, aged 77 years, illustrated this with an example:

‘I’m not saying that you should see everything in a humorous way, but you have to remain positive. If you continue to see the negative side, the whole family becomes negative. But one thing is certain; life comes with ups and downs. You have to keep seeing the positive side of life.”

To remain positive, participants compared themselves and their situation with others. The fact that everyone has their individual personal issues was also mentioned. Even if physical limitations were experienced, they mentioned that they would rather experience these than mental or cognitive limitations. They emphasised the opportunities they are given and their abilities to still be able to accomplish them. As illustrated by a female participant, aged 68 years:

‘Be happy! Many people can’t do it. I always look at the positive side. That’s the way I am. You weigh up the pros and cons. Some things I can’t manage anymore, others I still can. I rather prefer to stay 18, but I am getting older, and I have to accept that. The physical ailments of getting older do bother me sometimes, but fortunately my mental health is still fine.’

In this study, we aimed to explore how community-dwelling, older Dutch adults living in socioeconomically deprived neighbourhoods address ageing issues; we used in-depth interviews to gather the information. We observed gaps in the participants’ knowledge of the consequences of health issues. Despite these knowledge gaps, we noticed patterns of a shared attitude regarding life and health problems in the participants’ responses. The participants: Possess an optimistic view of life Accept their situation Are content with the resources and capacities they still have.

All participants mentioned that health is the most important aspect of life. Still, not all the participants are aware of how to adequately address age-related health problems.

In the current study, older adults living in deprived neighbourhoods mentioned being content with their lives even if their lives were difficult or troublesome. Literature shows that, in general, older adults’ perspectives on quality of life are heterogeneous (Borglin et al, 2005; Murphy et al, 2009). Furthermore, longitudinal cohort studies show that quality of life will decline with older age (Netuveli et al, 2006; Zaninotti et al, 2009). However, in the current study, this decline was not reported by the older adults.

We also observed a similarity in the way participants deal with perceived health. Even when participants developed a disorder, they mentioned feeling blessed with their current health. In literature, this incongruence is known as the disability paradox (Albrecht and Devlieger, 1999). The fluid and complex nature of the reality that the participants presented is difficult to capture in a theoretical model.

Nurses, who comprise the vast majority of professionals in health care, are faced with an apparent contradiction. On the one hand, nurses should recognise and acknowledge the remarkable resilience of older adults living in deprived neighbourhoods. However, on the other hand, nurses should not lack awareness of the deficits in the older adults’ health knowledge. Nurses should be aware of what Whitehead (1953) refers to as ‘the fallacy of misplaced concreteness’. A patient’s attitude may differ from actual reality owing to his/her inadequate health literacy. It is essential for nurses to assess the patient’s level of health literacy and identify those at risk for inability to adhere to health-care recommendations (Speros, 2005). Health education by community nurses may be an essential tool to support older adults in coping with age-related adversities. We suggest that the acknowledgment of patients’ resilience, affiliation with the patients’ wishes, and talking about the consequences of disorders and possible care actions might result in health benefits for the patients.

Some methodological strengths and limitations may be relevant to interpret our findings. First, investigator triangulation was used to verify the validity of data interpretation. The transcribed data were coded independently by two researchers. These results were discussed with a third colleague within the field of study in order to optimise the validity of the analysis. All evaluators concurred with the final codes and categorisation. This strategy resulted in a comprehensive understanding of the issues and maximised confidence in our findings. In addition, we collected data until saturation occurred and no new themes or insights emerged (Morse and Field, 1995). A methodological limitation in this study was that participation in the study was entirely voluntary. Therefore, it is plausible that persons with fewer resources and probably a less optimistic perception of life were hesitant to participate. To diminish this selection bias, vulnerable participants were personally invited by familiar acquaintances.

We evaluated the demographics of the participants, and it appeared that we recruited a broad study sample considering age, gender, living status, and health status. Therefore, we assume to have studied a representative sample of older adults living in the specified deprived neighbourhood. In this study, we noticed a shared attitude toward health among the participants. Nevertheless, it raises questions on the transferability of the observed attitude. Is the shared attitude toward health common for all older adults living in deprived neighbourhoods, including more urban regions, or is it a common outlook in the northern regions of the Netherlands? To investigate the influence of culture on people’s attitude, additional qualitative studies are recommended in multiple deprived areas.

In this qualitative study, we explored how community-dwelling, older, Dutch adults living in socioeconomically deprived neighbourhoods address ageing issues. We observed deficits in the older adults’ health knowledge that influence the manner in which these people addressed ageing issues and frailty. Despite these gaps, it appeared that these older adults possess an optimistic view on life, accept their situation, and are content with the resources and capacities they still have. The ability to deal with setbacks and to take life as it is has indeed been remarkable but may unintentionally mask the deficits in the patients’ health knowledge. Nurses will be challenged to recognise the coping strategies of these older adults, especially considering their deficits in health knowledge. BJCN

Accepted for publication: 15 July 2015

Declaration of interest: The authors have no conflicts of interest to declare.

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References

Bielderman, A., Schout, G., Greef, M. de, & Schans, C. van der. (2015). Understanding how older adults living in deprived neighbourhoods address ageing issues. British Journal of Community Nursing, 20(8), 394–399. https://doi-org.proxy-library.ashford.edu/10.12968/bjcn.2015.20.8.394