Introduction

The growing number of older adults in the population necessitates greater attention to the health and well-being of this demographic. Recognizing vital needs related to ageing is essential for strategic planning to support the wellness and welfare of older adults [1]. In Pakistan, the older population was approximately 12.5 million in 2017, with projections estimating it could reach 40 million, or 8% of the population, by 2050. Globally, projections indicate that by 2050, one in six people will be 65 years or older, reflecting a significant demographic shift driven by declining fertility rates and increasing life expectancy [2,3]. Physiological changes accompanying ageing increase the risk of chronic conditions, a challenge strongly felt in low- and middle-income countries (LMICs) [2]. Many older adults also face various challenges, including financial instability post-retirement, often resulting in dependency on family members or caregivers [4]. These challenges, however, cannot be understood in isolation as they are shaped by the broader social determinants of health that influence how people age and the opportunities available to them.

Social determinants of health, i.e., the conditions in which people are born, grow, live, work, and age, significantly shape health outcomes. These factors include socioeconomic status, education, neighborhood, employment, social support networks, and access to healthcare. Research suggests that social determinants can impact health more significantly than healthcare or lifestyle choices, accounting for 30–55% of health outcomes [5]. Addressing these social determinants is crucial for improving health and reducing disparities [6]. Understanding how older adults and those who support them define and interpret healthy ageing, i.e., maintaining functional ability and well-being in older age, within these social contexts is therefore an important first step.

In Pakistan, distinct differences exist between life in rural and urban areas. These contextual differences not only determine access to resources but also create distinct forms of vulnerability. Poverty rates are highest in rural regions [7], and a substantial portion of the older population lives in poverty [8]. Conversely, older adults in urban centres typically have better access to nutritious food, clean water, and electricity [9]. Rural older adults often face material deprivation [10], whereas urban counterparts may experience social isolation and weakened community networks [11]. Understanding these contrasts is crucial to developing context-sensitive approaches to healthy ageing.

Most studies in Pakistan have focused on urban settings, exploring older adult needs, experiences, and challenges. Commonly reported issues include financial problems, social needs such as social interaction and religious involvement, limited employment opportunities, and loneliness [12,13]. As a LMIC, Pakistan faces disparities at both individual and sociocultural levels that influence healthy ageing [14]. These structural and contextual disparities often translate into barriers that limit older adults’ ability to age healthily and maintain autonomy [15]. Although few previous studies exist about the objective health outcomes and needs of older adults [8], those studies were quantitative and therefore do not fully capture ageing individuals’ lived experiences, perceptions, and priorities that shape well-being.

Given the strong influence of social determinants on autonomy, dignity, and quality of life [16], there remains a critical gap in understanding how older adults themselves interpret and navigate these factors within the Pakistani context. A qualitative approach is essential to explore how older adults perceive these determinants and navigate challenges related to ageing, healthcare access, and social inclusion. Collectively, this evidence not only contextualize quantitative findings but also sheds light on hidden barriers and enablers that shape well-being. Exploring what supports or resources enable older adults to remain active and engaged can reveal important facilitators of healthy ageing and inform the development of more person-centered interventions.

Neglecting older adult health and social needs can lead to increased healthcare costs and decreased quality of life for individuals and families, creating inter-generational impacts as younger family members take on care-giving roles. At the policy level, despite the introduction of national policy for older adult health in 1999, Pakistan is yet to implement it. Additionally, very few institutions in the country recognize geriatric care as a specialty with general practitioners and other specialists typically providing healthcare services to older adults [17]. These gaps highlight systemic weaknesses in Pakistan’s approach to geriatric care. Addressing these systemic gaps requires culturally grounded, context-specific solutions that reflect urban–rural disparities and promote equitable, dignified ageing through both policy and community-level action. Building on this evidence, this study aimed to understand ageing in Pakistan by examining how urban–rural differences shape older adult and stakeholder experiences, challenges, and opportunities for healthy ageing, and to inform policies that promote equitable and dignified ageing. It sought to capture perspectives from both older adults and key stakeholders to better understand how these determinants shape experiences of ageing. The study was guided by four overarching research questions: [1] how do older adults and stakeholders define healthy ageing; [2] what barriers hinder the achievement of healthy ageing; [3] what facilitators or enablers support it; and [4] what solutions or recommendations can strengthen the well-being of older adults across diverse contexts.

Methods

Data collection

We conducted ten focus group discussions (FGDs) with older adults and stakeholders in Karachi and Thatta, holding five FGDs separately with older adults and stakeholders in each location. There were 24 older adults and 24 stakeholders in Karachi, and 26 older adults and 26 stakeholders in Thatta, with each focus group consisting of 4–6 participants. A quota sampling technique was used, with the study team recruiting a fixed number of older adults from the target populations for convenience. For details about the recruitment process, refer to the main study.

The semi-structured guide was developed using literature and expert opinion [20]. The study teams in both Karachi and Thatta undertook training on qualitative data collection procedures. The study team from Aga Khan University moderated in-person FGDs. Discussions lasted 1.5 to 2 hours in Karachi and 2 to 2.5 hours in Thatta. Separate focus groups were conducted for older adults, with gender-segregated groups in the rural site (Thatta) to respect cultural norms. Translators fluent in local languages, i.e., Sindhi, were present to ensure that all perspectives were accurately understood.

The data collection was aimed at achieving data saturation. The discussions were audio-recorded, transcribed, and subsequently translated into English. An overview of the data collection and analysis process is presented in Fig 1.

Download:

• PNG
  larger image
• TIFF
  original image

Fig 1. Data collection and analysis workflow for the qualitative study conducted in urban Karachi and rural Thatta, Pakistan.

https://doi.org/10.1371/journal.pgph.0005916.g001

Results

The mean age of older adults was 67.3 years in Karachi and 67.2 years in Thatta, while the mean age of stakeholders was 31 years in Karachi and 36 years in Thatta, respectively. This study identified perceived barriers and proposed solutions for older adults in our population, categorized into three levels: individual, sociocultural, and structural (refer to Table 1).

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Summary of key barriers and corresponding solutions to promote healthy ageing across multiple levels of influence.

https://doi.org/10.1371/journal.pgph.0005916.t001

At the individual level, major concerns included physical weakness, stress, loneliness, and technology barriers. At the sociocultural level, primary concerns were the need for family support and affection, respect and dignity, and a lack of socialization opportunities. At the structural level, concerns centered around the need for government support, limited access to health services and essential medicines, financial instability, and inadequate infrastructure and public services.

The proposed solutions at the individual level included fostering a sense of purpose, practicing gratitude, and engaging in religious practices. At the sociocultural level, recommended strategies involved encouraging family support through quality time, shared responsibilities, and joining community networks.

Structural

This component involved most concerns at the state policies and governance levels. The themes related to concerns were government support, access to health services, medication support, financial stability, and infrastructure. The identified themes within the proposed solutions included the provision of medicines, senior citizen subsidies, the provision of basic facilities, and improved access to health facilities.

1. A. Barriers

Lack of government support and insufficient pension systems affect the financial security of older adults.

Many participants, especially those from rural areas, expressed concerns about their eagerness to continue working but were unable to do so. Older adults who were still working complained that their daily wages or salaries were delayed for months, emphasizing the need for a pension system. They pointed out that although a pension system exists, it is limited to retired government employees. Given that a large proportion of the population works in the private sector or is self-employed, these individuals are not eligible to benefit from the government pension system when they grow old.

If the government cannot help them financially, then they should provide small jobs to the elderly so they can work and earn. – FGD2 SK1

Limited access to affordable healthcare and necessary medical supplies challenges the health and well-being of older adults.

All the participants raised concerns that medical services were expensive, and many older adults develop conditions like diabetes and hypertension and require a regular supply of medicines. A few participants also demanded the provision of wheelchairs and ambulances, especially for older adults.

The absence of a medical clinic in our village is a source of stress for us. There is a medical store. – FGD4 ST2

Poor infrastructure, including pollution and lack of public facilities, negatively impacts the health of older adults.

The participants, predominantly from Karachi, complained about air pollution and the lack of clean green parks and roads. Few participants from the rural site raised concerns about public toilets.

In our country, the government is not doing anything. There is too much dirt over here, which is hazardous to our health. – FGD3 OK1

1. B. Solutions

Enhanced access to healthcare and medicines is essential for addressing the needs of older adults.

A few urban stakeholders mentioned that online services should be utilized in this regard, including online delivery of medical supplies or online mental health counselling services, e.g., Tele-clinics for older adults.

(We) need a proper healthcare system for that, from where you can buy free medicines, the government should give us free medication and free check-ups. – FGD3 OK3

Subsidies and priority services for senior citizens are crucial for financial and social support.

Many participants, particularly from Karachi, compared the senior citizen benefits, including ration cards, discounts on bus fares, and priority service while waiting in lines at pharmacies, banks, or any other public place where token system tickets are being issued with their settings. They mentioned that these services are available in our neighboring countries and proposed that such schemes should also be available to them.

We want our organization to provide us with financial aid. We do not have enough strength to make money on our own. We need external support. – FGD4 OT4

Access to basic utilities and financial stability are essential for improving the quality of life for older adults.

Most participants, especially from the rural site, demanded proper provision of facilities like electricity, gas, and water from the government, while some urban participants demanded some aid with groceries.

In terms of facilities, they are the same as those that I mentioned earlier, like the availability of electricity, water, and gas. Other than this, having a stable and good income is important. – FGD4OT1

These findings informed the development of an integrated framework illustrating urban–rural disparities and potential pathways for promoting healthy ageing in Pakistan (Fig 2).

Download:

• PNG
  larger image
• TIFF
  original image

Fig 2. Integrated Framework for Addressing Urban–Rural Disparities in Healthy Ageing in Pakistan.

The framework highlights distinct and shared barriers, mechanisms for change, and tailored solutions that bridge urban–rural gaps to promote equitable, inclusive, and dignified ageing.

https://doi.org/10.1371/journal.pgph.0005916.g002

Discussion

Through the FGDs at an urban and rural site of Sindh province in Pakistan, the study explored older adult and stakeholder priorities regarding barriers and solutions at three levels of the socio-ecological model. Healthy ageing has become a primary area of focus globally with the increasing older adult population [24]. Being a LMIC, the study’s overall concerns about urban and rural older adults were similar and were primarily directed toward providing basic amenities.

At the individual level, one of the identified themes included mental health concerns, loneliness, and stress. In community-dwelling older adults across Asia, factors such as having a spouse or partner, living with family, maintaining a large social network, frequent contact with friends and family, and receiving emotional and practical family support are all associated with fewer depressive symptoms and greater life satisfaction [25]. Some older adults in the study also reported that these reasons were associated with depression. A 2022 systematic review by Lapane et al. on older adults in congregate long-term care settings found that loneliness was prevalent among residents, even though they lived with other older adults. This loneliness was associated with increased risks of depression and suicidal tendencies [26]. A 2023 scoping review by Mazumder et al. on mental health interventions found that older adults in South Asia face significant disparities in mental health. While depression and anxiety were the most commonly reported issues, other outcomes included poor quality of life, cognitive decline, low self-esteem, and reduced physical capability. The review proposed solutions such as meditation, behavioural and educational interventions, technology-assisted approaches, and music therapy [18].

Participants also noted a technology barrier at the individual level, particularly in urban areas, where many older adults expressed an interest in learning to use smartphones and social media applications. A recent systematic review on Mobile Health (mHealth) use among older adults also found limited technological capacity in this group, highlighting that motivation and social support are essential for sustained engagement. However, none of the studies in this review focused on older adults from LMICs [27]. A Canadian study on older adult technology use similarly reported smartphones as the preferred device, but, in contrast to the study’s findings, it found that most older adults could self-learn technology [28] without relying on their children or grandchildren.

A study from the UAE explored the rights of older adults in Islam and their country and reported that Islam supports providing shelters and senior homes for older adults without successors or relatives. These homes should be constructed based on Islamic programs, services, and foundations. Neglect of older adults is considered agonizing, and it contributes to the worsening of their health and psychological problems [29]. Pakistan is also an Islamic country, and the laws and sociocultural norms are mainly based on Islamic teachings. Many older adults in the study noted that their sense of contentment increased as they practiced religion more at this stage of life. However, they also highlighted the scarcity of senior homes at the sociocultural and structural level, proposing that such facilities should be established. This finding aligns with a study from Bangladesh, which highlighted the need for senior homes and reported that financial constraints often contribute to the hardships the older adult population faces. To address this, the study suggested expanding and equitably distributing social security programs [30]. Interestingly, the participants in this study did not mention any existing social security programs.

A study by Chantakeeree et al. conducted in Thailand emphasized the importance of older adults taking personal responsibility for their health, through consistent medication adherence, healthier lifestyle choices, and cultivating spirituality to enhance emotional resilience [31]. While this focus on individual agency is important, it must be understood within the broader structural context. For instance, a study from Michigan, USA, revealed that many older adults struggled with external determinants of health, such as the affordability of healthcare, especially mental health services, concerns about access to safe water, and dissatisfaction with local infrastructure [32]. These findings note that personal responsibility, though vital, is often shaped and constrained by systemic conditions, highlighting the need for an enabling environment to support older adults in managing their health effectively. Similarly, this study also found that self-reliance was often proposed as a more sustainable solution compared to dependence on government support. In line with this, Parra et al. explored older adult views on physical activity and mindfulness, showing that mindfulness workshops enhanced self-awareness, nurtured self-compassion, and strengthened social connections. These findings align with the results of this study, where participants emphasized the importance of preparing for healthy ageing in advance [33].

Many older adults in this study, particularly from Thatta, expressed a strong desire to work despite their advanced age, motivated primarily by economic need but also by the wish to engage in meaningful activities. This finding aligns with other studies suggesting that post-retirement work is associated with enhanced emotional well-being and greater satisfaction [34]. Additionally, the World Economic Forum reports that the global retirement age is expected to rise to accommodate an ageing population and boost productivity, with several European countries already leading the way in this shift [35].

In our study, sociocultural issues were primarily associated with family support, receiving respect, and opportunities for socializing. Beaudry et al. conducted a similar study among the older adult populations in India and Sri Lanka, emphasizing that family and community support are essential for long-term care. Many older adults, especially those managing disabilities or chronic illnesses, identified insufficient support as a primary factor leading them to seek residence in long-term care facilities. Additionally, these facilities largely depended on community assistance for daily operations due to minimal support from both family members and the government [36].

A Swedish study examining solutions for sociocultural issues among older adults highlighted how social media networking complemented traditional phone conversations, encouraging participation in social activities, events, and transportation support. Participants described engaging in community-oriented activities, such as walking a neighbor's dog, joining a church, cooking for others, or providing transportation, which fostered a sense of purpose and value [37]. Similarly, social support was seen as essential in this study; however, the participants in this study predominantly relied on their children or close family rather than community or neighborhood support for these interactions.

At the structural level, access to and utilization of healthcare services and medications remain a constant concern for older adults, as highlighted in our study. A recent study from India also reported that multi-morbidity significantly increases outpatient visits, hospitalization costs, and overall healthcare utilization, with affordability being a primary barrier to accessibility [38]. While cancer-related costs were especially burdensome in that study, the older adults in our study expressed more concern over managing conditions such as osteoporosis, hypertension, and diabetes.

A study from Malaysia identified several medication-related challenges among older adults, primarily involving administration, adherence, accessibility, and polypharmacy. It found that 44% of older adults skipped medications due to perceived ineffectiveness, and 60% experienced difficulties when changes occurred in medication color, size, or shape. Additionally, 15.5% reported trouble accessing information about medications from their primary physicians, and 62.3% felt they were on an excessive number of medications. Only 52.7% were aware of possible side effects. Dissatisfaction stemmed from long waiting times, insufficient guidance, and a lack of follow-up care [39]. In this study, participants similarly noted a need for family support in administering medicines and reported long hospital waiting times that led to missed follow-up visits. However, unlike the Malaysian study, this study’s participants, both older adults and stakeholders, did not express concerns about polypharmacy, side effects, or difficulty accessing information. This difference may reflect the limited health literacy or lower awareness of polypharmacy risks among participants from low socioeconomic backgrounds in our study.

Rajwar et al., in their scoping review protocol on income support programs in South Asian nations, highlighted several government initiatives aimed at reducing income insecurity among older adults. For example, India has established schemes such as the Indira Gandhi National Old Age Pension Scheme, the National Social Assistance Program, and the Senior Citizen Savings Scheme. Similarly, in Nepal, the government launched programs in 1994, including Old Age Allowances for all seniors over 60 years who are not covered by pensions and allowances for widowed, impoverished, or homeless older adult women. Bangladesh, with support from the World Bank, implemented similar programs over the past decade. Sri Lanka also has an Elderly Assistance Program, which provides cash transfers to older persons over 70 who lack income opportunities [40]. Notably, the review did not mention any comparable programs in Pakistan, although Pakistan does have pension systems and an Old Age Benefits Institution for government employees [41].

Conclusion

This study highlights the complexity of issues affecting ageing populations and emphasizes that these issues are not only personal but also deeply rooted in structural and sociocultural contexts. At the sociocultural level, addressing the lack of family support, respect, and avenues for socialization can be achieved by fostering community networks, promoting family time, and encouraging the delegation of responsibilities. On the individual level, physical and mental health concerns, as well as technological barriers, underscore the importance of personal preparation, gratitude, religious practices, and fostering a sense of importance. Overall, these findings emphasize the complexity of issues facing ageing populations and can be used to guide the creation of comprehensive plans and policies that support and empower healthy ageing.

Supporting information

Acknowledgments

The study team is thankful to the data collection team for their hard work.