Adverse life experiences and quality of life among senior citizens of bhutan

ADVERSE LIFE EXPERIENCES AND QUALITY OF LIFE AMONG SENIOR CITIZENS OF BHUTAN NIDUP DORJI ADVERSE LIFE EXPERIENCES AND QUALITY OF LIFE AMONG SENIOR CITIZENS OF BHUTAN Nidup Dorji BSN, MPH Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Public Health and Social Work Faculty of Health Queensland University of Technology November, 2016 i ABSTRACT The world population is ageing at an unprecedented rate, which is faster now in the developing countries than in the economically developed world Asia accounts for more than half of the global population The number of Bhutanese older people (aged > 60 years) is expected to increase from 4.7% in 2005 to 11.2% in 2045, at a population growth rate of 1.8% per annum Improved health, increased access to education, and economic growth have contributed to longer life expectancy The steady growth of the older population presents many challenges to families, communities, and societies, particularly for sustainability of health care, pensions and social benefits, and the preservation of quality of life and wellbeing Older people have traditionally been held in high esteem for their wisdom, their roles as heads of families, and their effective mediation in conflict resolution However, trends such as urbanisation and modernisation, which tend to change family structures and cohesion, affect the support and care of older family members In Bhutan, many people have expressed concern about the survival of the much - revered traditions of extended family systems With more and more people moving to urban areas in search of a better future, senior citizens are being left behind in the rural communities, often to fend for themselves In Bhutan, there has been limited research into factors influencing quality of life (QOL) and wellbeing among older people Globally, however, research into determinants of wellbeing among elders has a long history and the findings are very complex The present study provides a broad overview of that research, but the particular focus here is on the effects of adverse experiences across the lifespan on Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan i ii quality of life of people aged over 60 years Adverse childhood experiences (ACEs) and stressful life events (SLEs), both distal and proximal during adulthood, are found to have significant associations with physical and mental health of adults In Bhutan, the impact of adverse experiences on health, wellbeing and QOL has not been explored among older people In order to address this gap, this study applied a sequential exploratory mixed-methods design to examine the relationships between adverse experiences - during childhood, in early and middle adulthood, and in the preceding year – and the QOL and wellbeing of Bhutanese older people The study commenced with an exploratory qualitative phase employing three focus group discussions (FGDs) and 30 in-depth interviews (IDIs) with older people of Bhutan Survey interviews were completed with 337 older people living in four geographical locations of Bhutan through face-to-face interviews by trained interviewers A survey instrument was carefully developed through the modification of relevant international instruments as well as the information from the qualitative phase The reliability and validity of the instrument were enhanced through systematic procedures Cultural appropriateness was considered in the design and implementation of qualitative and quantitative phases The IDIs and FGDs provided information about education, employment, wealth, property, and health conditions as the frequently reported factors influencing QOL Family-related factors, spirituality and meeting basic minimum needs in life also played important roles for QOL among elderly people Enforced child labour was the most frequently reported early adversity, while death of children was the most ii Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan iii serious life event during adult years The findings from the first phase were valuable and suggested important variables for the survey instrument development The quantitative survey confirmed that forced labour contribution followed by having to assume an adult role while still a child were the most prevalent early adversities The death of parents or children, a period of time when the person was not able to feed and clothe children due to severe poverty, loss of crops or animals impacting livelihood, damage due to natural calamities, and the experience of children leaving the household were common SLEs In terms of health and wellbeing, frequent back pain, visual impairment, disease of the joints, fatigue, depression, insomnia, memory decline, high blood pressure and diseases of the lungs were most commonly reported Various serious health problems, such as disease of the lungs, high blood pressure, diabetes, gout, visual impairment, depression, insomnia, and memory decline were significantly associated with ACEs A wide range of demographic characteristics, physical and mental health conditions, ACEs, SLEs, and social connectedness were significantly associated with reduced quality of life and wellbeing However, age and marital status were not found to be related to QOL After controlling for socio-demographic characteristics, multiple linear regression found that cumulative health problems and psychological distress, spirituality and social connectedness were significant and independent correlates of overall QOL The cumulative health problems and psychological distress also predicted wellbeing and health-related quality of life (HRQOL) Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan iii iv This is the first study to investigate QOL and its determinants among older people in Bhutan applying both qualitative and quantitative methods The study contributes insights into previously un-researched issues affecting older people in Bhutan and may assist development of socially and culturally appropriate interventions to promote health, wellbeing, and QOL of older people Hopefully, the work will be used to inform policy makers about the probable effects of adverse life experiences, especially the adverse childhood experiences that appear to have impact into late adulthood iv Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan v KEYWORDS Bhutan, quality of life, health related quality of life, wellbeing, aged, older people/senior citizens, adverse childhood experiences, stressful life events, spirituality, psychological distress, prevalence Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan v vi TABLE OF CONTENTS Abstract i Keywords v Table of Contents vi List of Figures x List of Tables xi List of Abbreviations xiii Statement of Original Authorship xiv Acknowledgments xv Dedication xviii CHAPTER 1: INTRODUCTION 1.1 Background of the Study 1.2 Background of the Kingdom of Bhutan 1.3 Healthcare System in Bhutan 1.4 Study Locations and Sample 1.5 Significance of the Study 10 1.6 Structure of the Thesis 11 CHAPTER 2: LITERATURE REVIEW 13 2.1 Search Strategy 13 2.2 Global Ageing Scenario 14 2.3 Definitions of Quality of Life and Health-Related Quality of Life 16 2.4 Wellbeing 19 2.5 Determinants of Quality of Life and Wellbeing 20 2.6 Influence of Health Status on Quality of Life and Wellbeing 27 2.6.1 Physical Aspects of Health, QOL and Wellbeing 27 2.6.2 Psychological Health, Quality of Life and Wellbeing 28 2.7 Physical Activity and Leisure 29 2.8 Sexual Activity and Quality of Life 31 2.9 Culture and Respect for the Older Adults 32 2.10 Social Relationships, Social Connectedness, and Social Activities 34 2.11 Effects of Religiosity/Spirituality on Quality of Life and Wellbeing 38 vi Adverse Life Experiences and Quality of Life among Senior Citizens of Bhutan 327 …I went to contribute my labour not only in the construction of highway but also in the construction of fortress We have to carry enough rations to feed us during the time of labour contribution We were not paid anything Instead we use to receive scolding and at times the site supervisor(s) use to flog us Life was difficult especially in those days….we were almost treated like animals “I went to contribute my labour not only Compulsory labor in the construction of highway but also contribution in the construction of fortress We have to carry enough rations to feed us during the time of labour contribution We were not paid anything Instead we use to receive scolding and at times the site supervisor(s) use to flog us Life was difficult especially in those days.” Adverse childhood experiences …the most stressful life events that affected me the most was the death of my children It has given me lot of pain I have noticed my body being tortured with pregnancies and at the end of the day I found them dying helplessly I lost six children in total Perhaps I had no luck to have them alive with me…nothing can help console a mother to see their dear ones dying in front of you If the dead child is buried, I felt like going there and dig it out…… “The most stressful life events that Death of children affected me the most was the death of my children It has given me lot of pain I have noticed my body being tortured with pregnancies and at the end of the day I found them dying helplessly I lost six children in total Perhaps I had no luck to have them alive with me.” Stressful life events Appendices 327 328 APPENDIX L: SUPPORTING ANALYSIS Table 1: Prevalence of psychological distress among elderly people in Bhutan by gender Psychological distress (item wise) Tired for no good reason? Nervous? So nervous that nothing could calm you down? Hopeless? Restless and fidgety? So restless you could not sit still? Depressed? That everything was an effort? So sad that nothing could cheer you up? Worthless? Psychological distress Psychological distress Median (min-max) Level of distress Low (10-15.99) Moderate (16-21.99) High (22-29.99) Very high (30-50) Yes n 110 64 14 92 95 19 95 64 12 83 143 Male No % n 58.2 79 33.9 125 7.4 175 48.7 97 50.3 94 10.1 170 50.3 94 33.9 125 6.3 177 43.9 106 75.7 46 14.00 (10-30) % 41.8 66.1 92.6 51.3 49.7 89.9 49.7 66.1 93.7 56.1 24.3 Yes n 122 84 13 86 93 23 93 59 19 76 132 Female No % n 82.4 26 56.8 64 8.8 135 58.1 62 62.8 55 15.5 125 62.8 55 39.9 89 12.8 129 51.4 72 89.2 16 17.00 (10-40) p-value % 31.2 56.1 92.0 47.2 44.2 87.5 44.2 63.5 90.8 52.8 18.4 0.000*** 0.000*** 0.644 0.085 0.021* 0.130 0.021* 0.256 0.041* 0.175 0.001** 15.00 (10-40) 0.028* 91 (48.1) 64 (33.9) 25 (13.2) (4.8) 89 (60.1) 46 (31.1) 12 (8.1) (0.7) Note: n=Number of participants; *p-value