Factors Influencing the Successful Aging of Iranian Old Adult Women.

BACKGROUND: Aging is an irreversible natural process characterized by a decline in both the physical and mental status of individuals. Because of multiple factors, this process and its consequences vary greatly between individuals. A successful aging (SA) is the target of current health policies and well-being of individuals. Knowing the factors that contribute to SA and its barriers would translate in measurements that increase the quality of life of elderly and reduce health costs.
OBJECTIVES: The aim of this study was to explore barriers and facilitators to Iranian elderly women's SA. PATIENTS AND METHODS: A purposive sample of 16 elderly women, aged 61 - 96 years, was recruited for this qualitative content analysis study. Study data were collected during 2012 -.2013 by conducting 16 face-to-face semi-structured in-depth interviews. We continued the data collection until reaching saturation. Study data were analyzed concurrently with data collection, by using the conventional qualitative content analysis approach.
RESULTS: Barriers and facilitators to Iranian elderly women's SA fell into five main categories, including availability of support systems, state of health, personal capabilities, personality characteristics, and lifestyle.
CONCLUSIONS: Availability of support systems, state of health, personal capabilities, personality characteristics, and lifestyle were the main interrelated factors affecting Iranian elderly women's SA. Accordingly, providing elderly women with strong educational, emotional, financial, cultural, and social supports can help facilitate their SA.

1. Background

Aging is a natural biological, continuous and irreversible process that is associated with the gradual deterioration of the structure and function of bodily organs (1). In this process, women experience aging in markedly different ways from men (2). The life expectancy at birth has risen to 76.5 years for women, in 2010 (3). With the increase of life expectancy, old age is associated with greater morbidity and disability (4). Therefore, women are major consumers of health care services. Accordingly, inattention towards the elderly women’s quality of life could lead to adverse social and economic consequences.

Although aging is a process that cannot be stopped, people’s longevity and quality of life can be improved by employing effective strategies for preventing or postponing age-related complications (5). The idea of successful aging (SA) is an effective strategy for reaching these goals. The SA is a process in which a person copes with aging-related alterations effectively and lives a positive, happy, and healthy life. This concept is located within a given cultural context, with accompanying culturally relevant norms and values (6, 7).

To the best of our knowledge, barriers and facilitators to Iranian elderly women SA have not been investigated in detail, yet. Accordingly, an in-depth study is needed for thoroughly identifying the factors that affect Iranian elderly women SA.

2. Objectives

The aim of this study was to identify barriers and facilitators to Iranian elderly women SA.

3. Patients and Methods

This was a conventional qualitative content analysis (CQCA) study. The CQCA is a useful approach for making valid inferences from textual data and developing new ideas, knowledge, and guidelines. The aim of this approach is to condense data and provide a rich description of the investigated phenomenon (8). In CQCA, the coding categories are derived directly and inductively from the raw data. This process includes: open coding, categories creating and abstraction (9).

Study population consisted of all women older than 60 years, who lived in Rasht and Tehran, Iran. The inclusion criteria were having the ability to speak and understand Persian, obtaining a score of 7 or higher in the Abbreviated Mental Test, and having the desire for participating in the study. Accordingly, a purposive sample of 16 elderly women was recruited from different settings, including the Iranian retirement home, physicians’ offices, city parks, elderly people’s workplaces, and health centers affiliated to municipalities. If participants were not willing to participate throughout the study, were excluded. Study data were collected during 2012 - 2013 by conducting 16 face-to-face semi-structured in-depth interviews. The main interview questions were:

- Would you please tell me about your life experiences, at this age?

- What has been most helpful to you in your SA?

- What has been most difficult for you in your SA?

All the interviews were conducted by the same researcher, the second author, either at her workplace or at her home. The interviewer had the experience of living with elderly and providing care for them in hospital setting. She wrote her preconceptions about factors influencing the SA, prior to defining the research question and throughout the research process, to mitigate the potentially deleterious effects of preconceptions that may taint the research process. We arranged the interviews according to participants’ preferences. Interviews ranged in length from 25 to 100 minutes. Interviews were recorded by a digital sound recorder and transcribed verbatim. Data collection was continued until reaching data saturation. We reached to data saturation after 14 interviews. Then, two other interviews were performed to confirm the saturation.

We used the MAXQDA computer software (VERBI GmbH, Berlin, Germany) to manage and analyze text data from interviews. Data analysis was conducted simultaneously with data collection. We used the CQCA approach for data analysis. Primarily, we read and reviewed the interview transcripts and the field notes for several times, to gain a general understanding of the data. Then, we read each interview transcript, line by line, and identified and coded the meaning units. Primary codes were constantly compared with each other and grouped, according to their similarities and differences. Groups were also compared with each other and categorized into higher-level categories and themes.

We employed the four criteria proposed by Lincoln and Guba, credibility, dependability, confirmability, and transferability, for enhancing the trustworthiness of the study findings (10). Credibility of the findings was established by using techniques, such as prolonged engagement with the study and the data, maximum variation sampling (in terms of participants’ age, education, marriage, family size, employment, and residence), and member checking. During the member checking process, we provided participants with a copy of the codes and asked them to check the congruence between their own experiences and the generated codes. We also employed member checking technique for enhancing the dependability and the confirmability of the findings. Accordingly, two external qualitative researchers were invited to check the congruence between participants’ experiences and the findings. Finally, we strived to clearly describe the study sample and setting, for enhancing the transferability of the study findings.

3.1. Ethical Considerations

The ethics committee of Tehran university of medical sciences, Tehran, Iran, approved the study (N0.3550). Obtaining the permission to conduct this study from the ethics committee and to audiotape each interview from participants, obtaining written informed consent after explaining the objectives and methods used in the study, the purpose of using a tape recorder to record the conversation, voluntary participation in the study, possibility of participants to withdraw at any stage of the study, as well as assuring the confidentiality of the participants regarding the material presented and maintaining anonymity were ethical considerations, in this study.

4. Results

Study participants ranged in age from 61 to 96 years, with an average age of 74.5 years. Most of the participants (56.25%) were housewives. Only two participants (12.5%) were childless. Regarding marital status, 43.75% of the participants were widowed, 40.0% married, 12.5% divorced, and 6.25% were single. Regarding educational level, 12.5% were illiterate, 31.25% under diploma, 37.5% diploma, and 18.75% completed higher education. Most of the participants (93.75%) were living in urban areas (Table 1).

Table 1.

Characteristics of the Participants

Participant Number	Age	Education	Marital Status	Number of Children	Type of Residence	Living With Whom	Job Status
1	61	Diploma	Married	5	Urban	Living with spouse	Housewife
2	70	Literacy (reading and writing)	Married	5	Urban	Living with spouse	Housewife
3	86	Diploma	Widowed	7	Urban	Living with son and his family	Retired
4	65	Diploma	Widowed	3	Urban	Living with single child	Retired
5	76	School (Second Grade)	Widowed	5	Urban	Independent Living	Housewife
6	84	Diploma	Divorced	4	Urban	Living with single child	Retired
7	63	Diploma	Married	---	Urban	Living with spouse	Retired
8	83	Illiterate	Divorced	5	Urban	Independent Living	Housewife
9	70	Bachelor	Married	3	Urban	Living with spouse	Retired
10	96	Doctorial	Widowed	3	Urban	Living with care giver	Retired
11	66	Bachelor	Single	---	Urban	Independent Living	Retired (Returning to work)
12	81	Illiterate	Widowed	6	Rural	Independent Living	Housewife
13	70	Literacy (reading and writing)	Widowed	6	Urban	Living with spouse and single child	Housewife
14	68	Diploma	Married	2	Urban	Living with spouse and single children	Housewife
15	77	Literacy (reading and writing)	Married	3	Urban	Living with spouse	Housewife
16	76	Literacy (reading and writing)	Widowed	4	Urban	Independent Living	Housewife

A total of 743 codes were derived. The codes fell into five main categories, including availability of support systems, state of health, personal capabilities, personality characteristics, and lifestyle. These categories are explained in what follows.

4.1. Availability of Support Systems

The availability of support systems throughout life was a determining factor in our participants’ SA. The five sub-categories of this category were supportive policies, culture, welfare facilities, family background and relationships, and social interactions.

4.1.1. Supportive Policies

Suitable educational opportunities during formal education had helped our participants develop different skills and abilities that made their life happier and facilitated their SA. “In our school, they offered us different art classes. One of my current recreational activities is doing those art works that I learned at school”.

Ineffective health policies had negatively affected the lives of our single and divorced participants, who had lost their husbands’ financial support. “Healthcare costs, as well as drug prices, are too high. I can’t afford to go to a doctor. We have neither insurance, nor (a supportive) hospital (system)”.

Ineffective economic policies, high inflation, and low retirement pension had also made our participants worried about being unable to meet household expenditures. “My income has reduced since retirement. My children are going to marry and [hence,] need money. I can’t meet these expenditures with such a small retirement income”.

4.1.2. Culture

Iranians mostly have deep respect for and positive attitude towards elderly people. Accordingly, they have the tendency for using elderly people’s knowledge and experiences. According to our participants, this tendency gives elderly people a deep sense of usefulness. “Fortunately, elderly people’s knowledge and experience are valued and drawn on in our society. This helps an elderly person like me feel being still effective at this advanced age”.

However, negative stereotypes about elderly people’s abilities prevented our participants from being active in society. Those participants who could overcome the major barrier of stereotypes had a sense of empowerment. “These silk rugs that I have woven and still weave are my achievements. Everybody remarked, ‘You can’t weave more at this age’; but, I proved that it is possible”.

4.1.3. Welfare Facilities

Unavailability of adequate welfare facilities had faced our participants with many difficulties, as well as health issues. “I have back and leg pains because of the considerable difficulties that I have experienced in my life”.

Financial insecurity and having no ownership of a private house had also caused difficulties for our participants, damaged their mental and physical health, and affected their satisfaction with life. “It has been for several years that I want to go to a spa, but I can’t, because I don’t have enough money. My life is just limited to counting the days until reaching death”.

4.1.4. Family Background and Relationships

A strong family background was a facilitator to our participants’ SA. “As we had a good mother, we were raised with happiness. Our childhood happy memories have been imprinted on our minds”.

Moreover, our participants’ parents had an important role in helping them develop their life skills. “I had active and healthy parents. They were economical, generous, humanitarian, and sociable. They were religiously devoted. They taught us how to come up with a good life. We learned from them how to be economical and save money. They effectively taught and nurtured us”.

Having a good supportive husband was also another facilitator to our participants’ SA. When explaining the reason for being in a good health state, compared with her peers, one of our participants said, “I didn’t have and still don’t have any major worries in my life because of having a good supportive husband. Worries can cause disease”.

A very important facilitator to our participants’ SA was their satisfaction with their own children’s achievements, well-being, welfare, and prosperity. Our participants equated their children’s achievements with their own success. “I feel literally successful when I see my children’s achievements”.

According to our participants, strong family support could help satisfy elderly people’s emotional needs and boost their moods. “When I see with my own eyes that all my family members pay attention to me, I become happier and more cheerful”.

Being with children was also a morale booster and hence, a facilitator to our participants’ SA. However, children’s preoccupation was a barrier to being with each other. “I feel happy when all family members join together in the same place; however, we can’t be with each other very often because of my children’s intense preoccupations”.

On the other hand, children’s distresses and problems were among the major barriers to our participants’ SA. Additionally, a wide age gap between parents and children had negatively affected the participants’ family relationships. “We, the elders, have our own thoughts; however, youths think differently. For instance, they say that we should avoid punishing children. There is a big unbridgeable gap between the generations. Anyway, we had to cope with them”.

Elderly people, who lived independently, were apparently satisfied with their independence; however, they also referred to living with their children, as a facilitator to their SA. “My son and daughter-in-law, who live with me, help me greatly. When I want to go out, my daughter-in-law takes me out by her car or when I need something, she does the shopping for me”.

4.1.5. Social Interactions

Having strong and friendly relationships with other people, including friends, neighbors, peers, and young adults, significantly contributed to our participants’ happiness, life satisfaction, coping ability, and SA. “When I feel down, I go to my neighbor’s house and speak with her”.

Moreover, being in the circle of friends had an important role in bringing hope to our participants. “When I am in the circle of my friends and visit them, I feel I am at the age of 50. Then, I feel (great) hope”.

However, loneliness and seclusion had caused many emotional and mental problems for the study participants. “When I am alone, my preoccupations, concerns, and health problems put me under intense pressure”.

Having the ability to engage in social activities was another factor affecting our participants’ SA. Those participants who had higher social status had greater opportunities for establishing social interactions, performed more influential social roles, and hence, had a more meaningful life. “I have a meaningful life (because) all people refer to me for seeking advice”.

Doing difficult and demanding jobs had caused different physical and mental problems for our participants and hence, was a barrier to their SA. “I had a very difficult job. When I retired, I was totally exhausted”.

However, receiving strong professional support was an important factor in our participants’ job satisfaction, as well as their mental and physical health. “I am completely satisfied with all the aspects of my job. Although I had a difficult job and considerable work-related stress, my managers’ support has protected me from facing mental problems”.

4.2. State of Health

The second main category of the study was the state of health. Our participants’ state of health was a significant factor, contributing to the way they could spend their lives. Health problems were among the major barriers to their ability to perform activities of daily living. “I clean my house on my own. But, when I am sick, I just lie in bed”.

The presence of chronic diseases had significantly increased our participants’ household expenses and imposed a great financial burden on them. “I have a heart problem and receive medication for it. I need to go to a doctor for monitoring my blood pressure and cholesterol. All of these need money”.

Physical problems, such as visual disturbances and sleep disorders, had greatly undermined our participants’ mental health and impaired their ability to participate in social activities and pursue personal interests. “When I need to avoid eating because of my disease, I become too preoccupied with my disease. I like reading. I’m, however, profoundly sad about being unable to read because of having an eye disorder”.

On the other hand, being in a good state of mental health was a significant factor in our participants’ life satisfaction and SA. “My mind is working properly. I see that I have no problem with my thinking ability”. Therefore, I say “Thanks God, my mind is healthy”.

4.3. Personal Capabilities

The third main category of the study was personal capabilities. Our participants’ capabilities, skills, and abilities that had been acquired during life, significantly contributed to their perception of SA. This category consisted of two sub-categories, including gained experiences and efficacy.

4.3.1. Gained Experiences

According to our participants, elderly people, compared with others and also with their own past, are more experienced and hence, can use their experiences for managing their own and others’ problems. Accordingly, their considerable experiences greatly helped them to effectively cope with age-related problems. On the other hand, the use of experiences for helping other people manage their problems gave our participants a great sense of usefulness. “I can now use my past personal experiences for managing my problems, I am (also) useful to both my children and other people”.

Moreover, skills and abilities that had been acquired during life also helped our participants have a happy life. “I sew clothes for myself at this (advanced) age. When others ask me, ‘Where did you buy these clothes?’ I answer, ‘I sew them myself’. This really excites me”.

Having the opportunity for pursuing education had also greatly helped our participants advance in their job, receive higher income, and have a better SA.

Despite having two children, I continued my education, got diplomas, and got that position. Consequently, my income increased and my life became better. Those efforts helped me have a more comfortable life at this age.

4.3.2. Efficacy

Those participants who were able to perform more constructive roles had a happier life and a better SA. Successful role performance had prevented our participants from feeling senile. “I don’t feel that I have become old. I even support my children (at this old age), and take care of my grandchildren”.

Moreover, having independence and not being a trouble to others gave the study participants a strong feeling of contentment. “I feel happy with being able to perform my activities independently, as well as with not being a burden to anyone”.

4.4. Personality Characteristics

The fourth main category of the study was personality characteristics. Our participants’ personality characteristics, such as their attitude, personal beliefs, and temperament also contributed to their SA.

4.4.1. Attitude

Having a positive attitude towards the realities of life helped our participants accept the realities of aging. Those participants, who had more positive attitudes, were more successful at coping with aging. “We need to make the most of our current state of health. We have to be hopeful about the future. These would help us have a better life”.

However, having to fear and anxiety over an approaching death was a major barrier to our participants’ SA. “I’m extremely old. I see my peers die one after another. I think I’m also nearing death. I fear death. This [fear] makes me anxious”.

4.4.2. Personal Beliefs

Religious beliefs and faith in God, as well as seeing life events as God’s will, were among the major facilitators to SA. “I have accepted that I should get ready for disability, I shouldn’t nag and complain about it and I should accept whatever happens to me. All things are the God’s will; life and death are also His will”.

Religious beliefs and practices had an important role in facilitating our participants’ coping with life events. Their religious beliefs got strengthened as they were getting older. “I have slept here alone for many times. I have held Quran in my arms and felt peaceful and quiet”.

On the other hand, holding erroneous health-related misconceptions, such as the ineffectiveness of treatment and dietary regimens in alleviating age-related health problems, were major barriers to having a healthy lifestyle, at old ages. Our participants’ health problems, resulting from their misconceptions, had significantly affected their lives, as well as their ability to perform the activities of daily living. “I like travelling, but, I can’t travel because of my leg problem. However, I don’t go to doctor. What can a doctor do, after all? What can he do for my fragile bones?”

4.4.3. Temperament

The third sub-category of the personality characteristics category was temperament. Those participants, who were cheerful, lively, energetic, and good-tempered, were able to perform religious practices, engage in social activities, establish happy relationships with others and live a happy life. “Don’t ask me to stop working. Working keeps me alive. I’m inherently happy and have no sense of senility”.

4.5. Lifestyle

Lifestyle was the fifth main category of the study. Study findings revealed that lifestyle also significantly contributed to our participants’ SA. This category consisted of two sub-categories, including life management and healthy lifestyle.

4.5.1. Life Management

Possession of life management and decision making skills were other important factors affecting our participants’ SA. “If I had made a better choice for marriage, I would have had a better life by now”.

Moreover, effective management of family budget also played an important role in having greater comfort later in life and also, in successfully managing age-related financial problems. “I have a good and easy life because I was always concerned with saving money for the sake of precaution. Now, if I encounter a problem, I can use my savings”.

4.5.2. Healthy Lifestyle

Having a healthy lifestyle from childhood and closely adhering to it during advanced ages were the important factors in protecting health and preventing and alleviating age-related problems. “We had healthy games and foods. I am energetic now because I had a healthy lifestyle”.

Seeking information regarding healthy lifestyle habits helped our participants improve their quality of life. Some of them strived to acquire up-to-date health-related information from media and books. “I read articles and books on health, healthy eating, healthy diet, and good morale. I read materials on what to eat and what to do for having a good morale and a healthy body”.

Dietary restrictions, imposed due to the potential risk for developing new diseases or complications, had helped our participants manage their health problems. However, such restrictions also made them extremely anxious. “I strictly adhered to the prescribed dietary regimen and avoided eating unhealthy foods. Consequently, I’m healthy now. “When they prevent me, at this age, from eating my favorite foods, I get upset. This fact affects my morale”.

5. Discussion

Study findings revealed that supportive policies and organizational support greatly affected elderly women’s physical and mental health, as well as their capabilities. Results of a longitudinal survey have shown that supportive policies, such as the medical insurance policy and the health inequity of the elderly, can improve health status of the elderly and their “outdoor activities” (11). Culture was another factor affecting Iranian elderly women’s SA. Rational cultural beliefs about elderly people’s abilities greatly contributed to the study participants’ emotions and mental health. However, negative stereotypical images about elderly people’s abilities interfered with their creativity, liveliness, and Low (2013) addressed that cultural perspectives affect the care priorities of older people (12). Negative stereotypes and misconceptions about elderly could restrict their participation in social, political, commercial activities and interfere with their successful and dignified aging (13). Culture is an important factor in making health-related decisions and interventions (14). Consequently, paying careful attention to cultural issues, when designing health policies, can improve elderly people’s perceptions of SA. We also found that welfare facilities greatly contributed to the study participants’ mental and physical health, life satisfaction, and SA. Generally, there is a reciprocal relationship between people’s economic status and their state of health. In other words, health problems limit people’s ability to participate in business activities and, on the other hand, poor economic status restricts their access to healthcare services (15).

One of the most important findings of the study was the role of family background and relationships in elderly women’s SA. Our participants viewed their children as the fruits of their lives. Accordingly, children’s success in life contributed to the study participants’ life satisfaction and SA. Moreover, having a strong family support was a determining factor in their SA. Given the significance of age-related problems and disabilities, family support can play an important role in elderly people’s successful coping with aging. Moreover, families can help their older members’ adopt a healthy lifestyle and improve their physical and mental health and well-being (16). Toepfer (2010) also noted that family support is associated with sociability, self-confidence, and stress management ability (17).

Study findings revealed that loneliness and isolation could aggravate mental problems of elderly. Previous studies have also shown that strong social interactions and voluntary participation in social activities significantly decrease elderly people’s morbidity and mortality, prevent their cognitive disability, alleviate their depressive symptoms, and improve their mental well-being and quality of life. Conversely, loneliness can negatively affect physical and mental health and cause depression and physical problems (18-20). We also found that social status was a major facilitator to elderly women’s participation in social activities. According to Britton et al. (2008), holding higher positions in the society can increase the probability of having a healthy and SA (21).

Study findings also revealed that the state of health greatly contributed to SA. Age-related physical and mental problems had negatively affected our participants’ abilities and increased their dependence on family members. von Faber et al. (2001) also reported that SA is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity (22).

We also found that our participants’ capabilities, skills, and abilities helped them effectively cope with aging, gave them a great sense of usefulness, and facilitated their SA. Matteson et al. also noted that life skills (coping and role performance skills) greatly facilitate elderly people’s coping and SA (23). Study findings also revealed that our participants’ educational status greatly contributed to their welfare, during aging. According to researchers, higher educational status helps individuals get more decent and better-paid jobs (24). Elderly people who have higher educational status are able to receive stronger support (25). Moreover, we found that having the ability to effectively perform constructive roles greatly contributed to experiencing stronger feelings of happiness and self-worth and having a better SA. Perceptions of their own role performance ability directly affect their state of health (26). In addition, capability and skillfulness are important factors in elderly life satisfaction (27).

Another factor affecting the study participants’ SA was their personality characteristics. According to researchers, personality is among the most important factors contributing to elderly people’s coping with age-related problem (23). Personality is playing a significant role in life and adaptation in old age is influenced by personality (28).

We also found that recourse to spirituality was effective in coping with age-related problems. such as loneliness, despair, and diseases. The women paid much more attention to spirituality when they developed diseases or age-related complications, lost their independence, or suffered a terrible loss. Previous studies have also shown that religiousness significantly enhances elderly people’s mental health and coping ability (29, 30).

Our participants’ life management and intellectual abilities also were among the facilitators to their SA. Effective life management was associated with greater financial security and spiritual comfort. Evidence shows that lifestyle factors have as much important effect, as genetic factors do on the process of aging. Moreover, major traumatic life events that happen during childhood or adulthood can significantly affect individuals’ coping ability and personality development. Traumatic life-changing events can even lead to severe depression (31). Finally, we found that elderly women’s lifestyle was a determining factor affecting their health and SA. Previous studies also supported the strong effects of lifestyle habits on elderly people’s mortality rate, health maintenance and promotion, quality of life, and the risk of developing diseases and physical disabilities (32, 33).

The findings of this study highlighted the paramount importance of educational, emotional, financial, cultural, and social support for facilitating elderly women’s SA. Providing elderly women’s with ample opportunities for participating in social activities can help boost their morale and foster their sense of self-worth. The study findings can be used for developing educational strategies for promoting elderly women’s SA.

This study was conducted on women and cannot be generalized to older men. It is recommended that a separate study to be performed on men, for comparison. Researchers have tried to adhere to the maximum variation in the sample. However, the lack of generalizability is one of weakness of qualitative studies. Describing the participants and sampling, with maximum variation, help to be judged by readers.