https://orcid.org/0000-0003-0676-2113
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Abstract
This exploratory qualitative study investigates older adults’ unmet needs in the age-friendly city of Ipoh, Malaysia. Seventeen participants were interviewed, including ten older adults residing in Ipoh City for at least six months, four carers, and three professional key informants. Interviews were conducted using semi-structured questions based on the WHO Age-Friendly Cities Framework. A 5P framework for active ageing based on the ecological ageing model was adapted for data analysis. The 5P framework consists of domains of person (micro), process (meso), place (macro), policymaking (macro), and prime, which allows for the dissection of older adults’ unmet needs in planning for multilevel approaches, which were employed for analysis. Person: the personal needs requiring improvement included digital divide disparity, inadequate family support, and restricted sports activities attributed to physical limitations. Process: There were fewer social activities and a lack of low-cost and easily accessible venues for seniors. Economic challenges include expensive private healthcare services, variation in the quality of care in older residential care facilities, and limited savings for retirement. Place issues include unequal distribution of exercise equipment, public open spaces, the need for more conducive parking for seniors, and a place for social activities. Difficulties assessing public transportation, digitalized services, and unaffordable e-hailing services are common among seniors. Housing issues for seniors include a lack of barrier-free housing design and unaffordable housing. Policymaking: Insufficient private sector commitment to improving services to older adults, lack of policy governance on the quality of nursing homes, and insufficient multidisciplinary governance collaboration. Prime: Health promotion for preventing age-related illness is required to preserve health in old age, and full-time family caregivers’ psychological well-being is often overlooked.
Citation: Lim X-J, Chew C-C, Chang C-T, Supramaniam P, Ding L-M, Devesahayam PR, et al. (2023) Perceived unmet needs of an age-friendly environment: A qualitative exploration of older adults’ perspectives in a Malaysian city. PLoS ONE 18(6): e0286638. https://doi.org/10.1371/journal.pone.0286638
Editor: Ahmed Mancy Mosa, Al Mansour University College-Baghdad-Iraq, IRAQ
Received: February 15, 2023; Accepted: May 20, 2023; Published: June 6, 2023
Copyright: © 2023 Lim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data collected includes interview sessions. This data belongs to the Clinical Research Centre under the Malaysian Ministry of Health. This research has been approved by the Medical Research and Ethics Committee, Ministry of Health Malaysia, which specifies that all records and data are to be kept strictly confidential and can only be used for the purpose of this study, and all precautions are to be taken to maintain data confidentiality. There, to ensure the data collected is kept confidential, it cannot be shared publicly. However, with a reasonable request, should any party require the data, they can send their request via this link (https://nihdars.nih.gov.my/research/view/102/details). The data depository is under the management of the Biostatistics & Data Repository, Office of NIH Manager, National Institutes of Health, Ministry of Health Malaysia, and with the permission from the Malaysian Director General of Health prior to its being shared with any party.
Funding: This research is funded by Ministry of Health Malaysia (Warrant Number: 91000782). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Globally, the number of people aged 60 and above is set to double from 1 billion to 2.1 billion between 2019 and 2050 [1, 2]. In Malaysia, 11.2% of the 33.6 million population aged 60 and over in 2021 [3] will increase to 14.5% by 2040 [4]. Ipoh, Malaysia’s third-largest city with the highest number of older people [5], recognized the critical need for an age-inclusive city and joined the Global Network for Age-friendly Cities and Communities (GNAFCC) in 2018 to initiate the changes [6].
The World Health Organization (WHO) established the GNAFCC in 2010 to unite cities, communities, and organizations to build conducive places for ageing. Within this network, a framework that determines age-friendly cities is described by eight domains: outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community, and health care. Having these domains addressed in planning a city’s structures and services would promote the development of age-friendly cities and communities in urban life [7]. However, these domains could be too broad for local policymakers to implement specific interventions. Besides, these domains are not independent and may be interconnected.
Developing age-friendly cities goes beyond striving to attain specific goals or pre-determined outcomes. A more inclusive and intersectional approach with implications for policymakers, urban planners, and health professionals should be considered [8]. It should be able to adapt and alter efficiently to sustain the structure of age-friendly cities and ultimately answer the unmet need of older adults. This fundamental element can be seen in the ecological concept. This concept views ageing as a dynamic interaction between an individual and adaptability to the physical and social environment [9]. The principles of the ecological system manifest systemically at all levels, allowing researchers to dissect older adults’ experiences into microsystems, mesosystem, and macrosystems [10, 11]. In addition, the ecological concept is envisioned as nested structures surrounded by and inside one another that allows us to examine the interaction and interplay structure between the layers adapting to the real situation to promote an age-friendly city [12].
An integrated structure between the WHO GNAFCC framework and ecological model not only addresses the requirement of creating an age-friendly city but can provide a more comprehensive understanding of the unmet need of older adults, and designing measures tackles the issues from the core component basing it on the ecological concept of ageing [10, 13]. This can be achieved by adapting the pillars of the WHO GNAFCC that functions as a main guide in elucidating the experiences and needs of older adults for an age-friendly city while the incorporation of the ecological model of ageing with the multidimensional concepts enables multifaceted intervention to be carried out simultaneously.
This study aims to explore the perceived unmet needs of older people based on the perspectives of the ecological ageing concept and, at the same time, fulfilling the requirement of the WHO GNAFCC in creating an age-friendly city by using Ipoh city as a study model. The opinions of key informants, including caregivers and healthcare professionals, in the context of an age-friendly city are explored.
Materials and methods
Design & study population
This was an exploratory qualitative study conducted between August and November 2021. Respondents were 60 and above, Malaysian, residing in Ipoh City for at least six months. The cut-off of 6 months is based on the fact that most older adults experienced psychological changes within the first six months of stay at a new place; the change tended to level off after about six months. However, the changes’ duration varies depending on the person’s medical and psychological health [14, 15]. The potential respondents were purposively selected based on their employment status (employed and retired), ethnicity (Malay, Chinese, and Indian), and income (high, middle, and low) in order to obtain a variety of data. These respondents were identified from a pool of participants who agreed to be contacted for in-depth interview (IDI) when they responded to a large-scale population survey study for aged city preferences [16].
Caregivers of older adults and professional key-informants were invited to give their opinions to triangulate the findings from the older adults. We interviewed family caregivers, volunteer caregivers from non-profit organizations (NGO), and paid caregivers from nursing homes. Paid caregivers from nursing homes were identified via recommendations by healthcare providers, while those from NGOs were found through websites and contacted by telephone calls. Professional key-informants, including clinical specialists, geriatricians, and government officials, were identified upon completion of the analysis of IDI with older adults and caregivers.
Instrument
The development of an interview guide for older adults was guided by the WHO GNAFCC eight domains (transportation, housing, outdoor spaces and buildings, social participation, respect and inclusion, civic engagement and employment, community support and health services, and communications and information) [13]. The content of the semi-structured questionnaire was then confirmed with literature and expert opinions, including geriatricians and officers of the State Health Department and Ipoh City Council. The interview guide was initially created in English and then translated by native speakers of Malay and Chinese.
In this study, "perceived unmet needs" are defined as the gap between an individual’s self-assessment of long-term care needs and the actual resources available to address those needs. The unmet need assessment is not limited to self-report, but also caregivers’ or providers’, and care-recipients’ perspectives on perceived unmet requirements for services and the environment for ageing [17–19]. The interview guide for caregivers and professional key-informants was developed based on issues identified by older adults. The questions were structured with the aim of triangulating the perspectives of older adults with the opinions of caregivers and key informants, as well as gauging the unmet needs of older adults for healthy ageing.
Data collection
We approached consented respondents in the previous questionnaire survey to seek their interest and agreement to participate in the IDI. Interviews were conducted virtually via conventional telephone calls, through a cloud-based video communication platform without requesting respondents to turn on their video (ZoomⒸ) or face-to-face based on the respondents’ preference, in view of the COVID-19 pandemic. Each interview session was conducted by two female interviewers (XJL-medical doctor, MSc. PH, and CCC-pharmacist, MSc. both had at least 3 years of experience in qualitative research and were full-time researchers at the time of the study). The respondents were not known to the interviewers. Prior to the IDI, all respondents were informed regarding the purpose of the study and given verbal consent to participate. With permission from the respondents, audio recordings took place during the interview sessions to facilitate transcription and data analysis. All IDIs were conducted virtually, except for one conducted face-to-face, which took place in a private room of the hospital facility where the interviewers worked. Each IDI session lasted approximately 30 minutes to an hour without any repetition of IDI; any information gaps were probed in a subsequent interview with another respondent. None of the respondents was contacted again for new opinions. The transcripts were not returned to the respondents for comment, and memo were taken during the interview to facilitate debriefings between the interviewers at the end of each IDI, and the information gap requiring further exploration were highlighted for the next IDI. The interview guide for older adults was revised following the preliminary analysis. The data collection among the older adults was stopped once saturation was achieved at the seventh older adult, whereby the coders identified no new information. Three additional older adults were invited for the IDI as a confirmatory measure to ensure no new emerging information was found. The findings were then discussed further though IDI with the key informants.
Data analysis
In identifying ecological model of ageing, a framework—the 5P framework for active ageing—that takes into consideration the ecological concept by considering the preferences for ageing from a personal, spatial, socioeconomic, governance, and health perspectives was selected to guide the data analysis [10, 20]. The 5P framework adapted the ecological approach of ageing that consists of micro, meso, and macro dimensions and further divided into five layers: "Person" (micro), "Process" (meso), "Place" and "Policymaking" (macro), and "Prime". This framework specifically emphasizes the inter-relationship between the 5P layers [20]. This framework is appropriate to be used in analysing the unmet needs of ageing as it takes into consideration of WHO’s eight domains of ageing [13], as well as incorporates the interconnectedness of individual layers of 5P and demonstrates the relationship between a person and the environment required for ageing. This approach allows various levels of interaction between the environment, human situations, and their relationships.
The data were managed using Microsoft Excel© and Atlas.ti version 9. Each completed IDI was immediately transcribed and analysed by a pair of data coders (XJL, CCC, and CTC-pharmacist, MSc, and PS-researcher, BSc.), and the results were analysed separately. A series of discussions over the findings were discussed among the interviewers, coders, and a senior qualitative researcher (LLL- medical anthropologist, Ph.D). Should any disagreements be raised during the discussion, the opinion of the senior researcher was sought, and a literature search was performed to justify the coding. A consensus was achieved over the finalized results. The interviews that were done in Malay were transcribed without translation. The analysis was carried out in both English and Malay. The transcripts were read in its original language before being coded in English. For the purpose of publishing, the Malay quotes were translated into English.
Triangulating different sources of information, inter-coder agreement, analyzing and resolving disconfirming data, and supervision from a senior qualitative researcher all contributed to the findings’ credibility.
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia [KKM/NIHSEC/P20-217 (7)]. The study was also registered with the National Medical Research Registry under the protocol number: NMRR-19-3191-51748 (IIR). Informed consent from the respondents was obtain prior to data collection.
Results
Demography
A total of 17 respondents, including 10 older adults, four caregivers, and three key-informants participated. The median age of older adults was 68.0 (IQR: 6.5), with six (60.0%) females. The majority of them were retired (60.0%) and had a low monthly income (60.0%). One of them was found staying alone. A paid caregiver, a volunteer caregiver, and two family caregivers participated. The key informants were comprised of a geriatrician, a rehabilitation specialist, and a social security officer from an organization that provides protection to employees and their dependents based on joint responsibility through the pooling of resources, sharing of risk, and replacement of income [21] (Table 1).
5P ecological model of ageing
The respondents’ perspectives of unmet needs for age-friendly environments were grouped into five domains and 13 sub-domains of the 5P Ecological Model of Ageing (5P model). Table 2 summarises the findings of unmet needs and includes selected quotes from respondents.
Person
The theme "person" refers to the impacts of personal characteristics and behaviours on ageing [20].
1.1 Personal characteristics.
Personal characteristics in the ageing process encompasses the dimensions of health, age, genes, educational level and socio-economic status, family background and self-efficacy [20]. Lower socio-economic status and inadequacy of family support were identified in the prospect of personal needs in this study.
"Digital divide," defined as unequal access to the internet for activities, was highlighted for the older adult in the lower socio-economic status [22]. Digital illiteracy and the high cost of internet usage limit their opportunity to internet access. The digital need among older adults was magnified during COVID-19 among those without internet access before the pandemic. The respondents appreciated the telco company’s free internet access of up to 1GB.
Family support is essential for older adults, ranging from direct care to complex health care and social service [23]. This support is crucial for those undergoing rehabilitation or residing in nursing homes. However, the current healthcare system does not provide adequate training for family members to continue geriatric care at home. Those who reside in a nursing home are often neglected by their family. Older adults who live alone face physical deterioration, lack skills, and live with limited incomes, requiring assistance accessing food, health, and essential daily services. This study found that family support is not limited to direct family members; extended family members such as relatives were important in assisting with the basic needs of older adults living alone.
1.2 Behaviour.
A healthy lifestyle with adequate physical activity is vital for older people’s physical well-being to sustain healthy ageing [20]. Older adults and caregivers recognize the importance of physical activity, but their activities, especially in sports, are constrained by age. However, older adults can identify activities, such as tai-chi or dancing, that are age appropriate and can get pleasure at the same time.
Process
Social, economic, and cultural environments are essential elements in creating barrier-free daily activities for the ageing process [20].
2.1 Social environment.
Independent, activity, coherence, peer support, and social networking are the fundamentals of a healthy social environment [24]. A lack of engagement by youngsters, unaffordable venues, and a lack of inclusion for wheelchair-bound older adults can reduce the interest of older adults in social activities. Their physical, financial, digital, and environmental requirements are factors to be considered to facilitate their participation in social programmes.
2.2 Cultural environment.
The cultural environment is an important factor in how people make sense of a place by integrating physical forms [25]. Older adults are more likely to identify a place within their communities, enabling them to continue living in the environment they are familiar with [26]. In general, our respondents preferred to age in their own house due to a secure feeling.
The quality of the exterior environment, service quality, and place dependency are all important factors in a place’s uniqueness [26]. In the neighbourhood, the respondents claimed that the quality of services and infrastructure has been decreasing over time with poor maintenance, leading to inadequacy of leisure spots.
2.3 Economic environment.
Health care services, insurance coverage, pensions, socio-economic status, and employment were the context of the economic environment.
Malaysian citizens can choose to obtain their health services from a government-funded public arm or a pay-per-use private arm, and the population aged ≥ 60 is free of charge for public healthcare services [27]. On the other hand, the older adult perceived that the healthcare cost of the private sector was high and unaffordable without regard to the age group.
Research shows that insurance coverage that offers more comprehensive, accessible, and affordable coverage for healthcare services would increase the utilization of healthcare services [27]. Even though older adults in this country are offered free access to public healthcare, a study found that people are more willing to utilize public healthcare services despite holding private health insurance coverage [28]. People with health insurance can use healthcare services more appropriately and associated with better health outcomes [29]. However, the respondents in this study perceived that only a small proportion of Malaysians purchased health insurance and the current insurance policy limited eligibility due to a predetermined age limit or financial incapability.
Older adults demonstrated different preferences in their long-term care centres, which may have influenced their long-term health outcomes [30]. The respondents identified several care facilities for older adults, such as nursing homes, old folks, and day-care centres. Nursing homes were perceived to be costly and unfavourable for healthy ageing, while older adults may be put at risk due to the quality of care. Day-care centres were perceived to be expensive and out of reach for low-income families. Some of the caregivers in this study deemed that the government should subsidise day-care centres services among financially incapable families.
Older adults are motivated to continue working due to limited pensions and retirement savings, allowing them to self-sustain without relying on others financially. Physical limitations associated with ageing and employment policies, such as the retirement age, affect employment opportunities. Besides, a key informant pointed out that employers prefer young workers and are unlikely to continue to employ older adults even though they are suitable for that position. Continuing employment was vital for older adults who were alone without a direct family member to support them in sustaining their needs. Financial assistance from the government was a medium to reduce their financial burden.
Place
The theme of "place" refers to environmental features that encourage active ageing and improve senior well-being, which are comprised of optimal land use, good accessibility, safe public open spaces, and age-friendly housing modifications.
3.1 Land use.
Land use is defined as the diversity, quality, composition, and arrangement of amenities and facilities such as recreational parks, parking spaces, markets, aged-care facilities, banks, post offices, health clinics in a neighbourhood [20].
Older adults need recreational parks to exercise and socialize, and outdoor fitness equipment is becoming increasingly popular in Asian countries. However, some respondents raised that there was an unequal distribution of recreational facilities, especially in neighbourhoods with lower socio-economic residents. Family caregivers highlighted the lack of outdoor places for older adults with disabilities and suggested a centre or space allow social interaction.
Older adults who have experienced physical function changes may face difficulties encountering narrow parking spaces. They proposed that parking spaces be made broad enough to reduce the risk of collision and provide parking spaces in the vicinity of the desired destination for older people.
3.2 Public open spaces.
Public open spaces encompass safe pedestrian crossings and adequate maintenance of the landscape [20].
The respondents pointed out that, older adults require longer crossing times at intersections. Providing a shorter crossing distance or a longer green interval is crucial for safe crossing among the older population. Regularly maintaining the crossing aids was instrumental in ensuring a safe road crossing.
The respondents reiterated regular and properly maintained lawn and outdoor facilities. They emphasized that administrators should ensure regular mowing and scheduled repair of broken park equipment when the current amenities of the parks are currently not well maintained.
3.3 Access.
Access is defined as the connectivity to different areas in a community, the availability of different routes, street infrastructure, and public transportation options [20].
The respondents deemed that public transportation is essential for older adults, especially when they have lost the ability to drive and those staying alone without the financial ability to purchase a vehicle. They suggested that the bus stops should be located close to the housing areas, with safe pavement conditions to improve walkability. Bus design should meet the needs of older people, with low-floor entrances, handrails, priority seats, and wheelchair space. The issue of public transport was exacerbated during COVID-19, with one of the main reasons being fear, besides the age factor. Some respondents felt that e-hailing is more convenient than other modes of public transport, but the cost outweighs the convenience.
Access should extend beyond physical connections and include a range of digital services. The digital services should be tailored towards accessibility for older adults who may not be as technologically savvy. Besides, some respondents noticed that priority lanes for seniors in obtaining services are not provided in all the service areas, and priority is only given to consumers who are physically disabled, even though the older adults have the needs.
3.4 Housing.
Neighbourhood safety, home support interventions, quality residential care facilities, universal design of housing, and affordable housing are all important aspects of age-friendly housing [20].
In key informants’ opinions, home modifications such as residential grab bar installations, conversion of squat-to-sit toilets, construction of an attached bathroom, and wide door steps for wheelchair entry were some safety features proposed to accommodate older adults’ needs. However, home safety measures to facilitate ageing is lacking, with many older adults unable to afford a house due to financial, psychological, or technical barriers. Owning a home was perceived as necessary but limited by the realistic conditions in which it was unaffordable for the group of older adults without technical skills, living alone, and not earning sufficient incomes to secure a bank loan in house purchasing.
Policymaking
Tolerance, fairness, social justice, and good governance are key concepts for sustaining urban planning development for an age-friendly city [20]. Five subthemes are governance and implementation, multidisciplinary collaboration, performance orientation, openness, transparency, integrity, and inclusiveness.
4.1 Governance and implementation.
A well-planned policy design requires network governance, in which government activity is linked to the private sector and civil society players in order to aggregate recipients’ actual needs [31].
Policies promoting an age-friendly city were perceived as lacking and received inadequate attention from stakeholders, such as caregivers of nursing homes. Some of the current policies allow the private sector to operate older adult care services, but their implementation may not be adequately monitored by governing bodies and may result in inconsistent service quality for older people
4.2 Multidisciplinary collaboration.
Network governance emphasizes the importance of organic, collaborative structures for active ageing [31, 32]. Inadequate collaboration among multi-disciplinary members is a major barrier to successfully implementing integrated geriatric care. Collaboration can be achieved through a coordinator and administrative support from the top management to eliminate barriers to multi-disciplinary collaboration.
4.3 Performance orientation.
The governance paradigm must consider the expert opinion, people’s perceptions, and experience. The governance model must be public policy to engage multi-stakeholder partnerships to ensure successful ageing city development [31, 33].
Inadequate governance commitment in strategies and operation of policies can lead to the termination of age-friendly policies. Meanwhile, the non-performance of policies is also evident in the domiciliary care service—a home-based rehabilitation program to ensure continuity of care at home—lacked coordinated referral mechanisms.
4.3 Inclusiveness.
Inclusiveness is a key principle of good governance, promoting fairness and a fair distribution of decision-making authority [34]. Policies should consider older adults’ basic needs and be more comprehensive before implementation. Policies should consider older adults’ basic needs and be more comprehensive before implementation. For instance, the issue involving motor vehicle license issuance to older adults is complex. Age is not the sole factor but the older adult’s physical, cognitive, and functional abilities. Furthermore, that requires a comprehensive discussion of all stakeholders to exert fair distribution for an age-related policy.
Prime
Prime represents any factors and components that influence the health of older adults. Within this context, the “prime” theme consists of physical health, mental health and social health.
5.1 Physical health.
One of the major determinants of physical health includes health promotion as a preventive measure for age-related disease [35]. Additionally, healthcare professionals play an important role in promoting lifestyle factors, such as routine exercise and dietary supplements, to improve physical health and prevent age-related bone loss and osteoporosis.
5.2 Mental health.
Older adults’ cognitive functioning and psychological well-being are essential components of mental health [20]. Mental illness is prevalent among nursing home residents. Older adults with dementia, major depressive disorder, delirium, and other psychotic disorders may face challenges due to inadequate knowledge of geriatric care among healthcare providers, nursing home caregivers, and family members. A better system is needed, including specialized nurse training, appropriate use of psychotropic medications, and geriatric care in handling the unspoken needs of older residents to ensure timely actions and referrals. The psychological wellbeing of family caregivers who provide long-term care for older adults at home has not been adequately addressed by the health policymakers. This was due to the lack of the respite care concept being introduced to the local population.
5.3 Social health.
Social engagement is a major determinant of social health as it offers older adults a sense of identity and fulfilment [20]. Engagement in activities, such as family activities and leisure activities, can foster interpersonal interactions. However, the activities may not be affordable for older adults, especially when there is no privilege or discount for them in obtaining the entertainment.
Discussion
This qualitative study explored the perceived unmet needs of older adults of an aged-friendly city based on the 5P ecological model of ageing (5P model). The model depicts micro, meso, and macro dimensions based on health environment and explains the dynamic interaction of these dimensions through the lens of ecological concept [20]. The ageing population should be given the resources to maintain a balance of physical and mental health at the micro level including personal characteristic, social well-being, and spirituality, transcendence at the meso level, while living in a favourable environment at the macro level which involving policy making. The findings of this study helped to define and guide town-planning policies and implementations, and the interconnections between the five dimensions of ageing would allow for repercussions in almost all other dimensions if any of the dimensions were to be intervened in.
Microsystem
The micro aspect of the 5P model focuses on a person’s physical characteristics, resources, patterns of activity, roles, and interpersonal relationships to improve their digital literacy and address personal needs [22, 36]. Digital access was a mounting concern by the majority of respondents in terms of unmet personal requirements. Prioritising digital skills training for older adults with decentralisation and targeted training at different levels. Additionally, an integrated system with collaboration among government and non-government organizations with internet providers should be sought to eliminate gaps in internet affordability and accessibility for seniors. Low-cost internet access for seniors, even if they are on a fixed income, is advocated for in the U.S.A, as it can help them develop digital citizenship and eliminate social exclusion [37, 38].
Family support and caregiving are vital, it has a direct and ongoing impact on an older adult’s everyday life. This study showed that family caregivers are frequently underequipped and lack the specialised knowledge and skills in caregiving. A protected transition period prior to discharge should be reserved for the caregiver to allow for a structured training session. Necessary aids for family caregivers, including respite care services, should be provided to allow short-term relief from stress [39]. Community health care experts can assess needs, provide information, generate referrals, and integrate care into a larger support plan [40].
Physical activities have a direct effect on the likelihood of healthy ageing, but there is a negative relationship between age and sports engagement [41, 42]. Poor outdoor exercise equipment is associated with sports needs for ageing; therefore, tailored exercise prescriptions should be tailored to age-specific needs. Preserving seniors’ range of movement and muscle strength is key to improving their locomotion ability and functional independence [43], upper body muscular strength and physical functions [44]. It is important to allocating resources with a variety of stakeholders, including healthcare providers, community groups, and commercial enterprises, as well as customising activities tailored to the functional needs and physical abilities of older adults.
Mesosystem
The mesosystem in the ecology of ageing describes the interrelationships between two or more major settings, such as health care and retirement [45]. Insufficient savings can lead to catastrophic health expenditures due to insufficient income and lack of medical insurance. Social welfare services are often the safety net, but funding is minimal and fragmented [46]. Moreover, the existing insurance system does not cover outpatient treatment or pharmaceutical costs, leaving older adults or their families to shoulder the out-of-pocket healthcare costs [47]. The pre-determined age limit of insurance purchase and coverage was a concern the respondents raised when the interviews took place in 2021. In 2023, a private insurance company raised the coverage period to 100 years old, with the maximum entry age set at 70 years old [48].
The Minimum Retirement Age Act 2012 sets the retirement age at 60 [45]; it is suggested to increase the retirement and re-employment age to 65 and 70 to support older citizens who wish to continue working [49]. If a higher mandatory retirement age was implemented, there is a concern that the job opportunities for the younger generation may be lesser. Nevertheless, study shows that different generations have different expectations when selecting careers [50]. Recruiting seniors as mentors to coach youth in employment could benefit both generations [51].
Macro system
The macrosystem comprises laws, law enforcement practises, government agencies, political parties, social policies, healthcare resources, and various forms of influence that create the social, political, and financial contexts for development [52]. Although not directly experienced by the older adults, the outer layer of 5P model, or macro system, can have a substantial impact on the microsystem that affects the aged. This study found that well-structured transportation system, housing design policies, home visit services, older adults’ residential homes, domiciliary care, and geriatric care training concerning the macro level are directly affecting the micro needs of the older adults in their daily routine.
Transportation is essential for older people’s independent lifestyle, but age-related constraints can make driving difficult [53, 54]. Older adults were disadvantaged by the long-distance walking to the bus stop and the high bus-boarding step. Malaysia’s rollout of low-floor, non-step buses with ramps accessible by wheel-chair has been slow, and macro-level planning should include efforts to renovate all bus stops with kerbside access, wheelchair-friendly and able to deploy the ramps [55].
Ageing may impair physical and cognitive functions, leading to the need for broader parking spaces and signals for street crossing. Audio-visual signals provide meaningful stimulation, which could be related to walking faster across the street [56, 57]. It is suggested that auditory and visual signals be installed at signal-controlled junctions. This safety feature should be mandated in all town planning. Safe road crossing facilities protect older pedestrians and users from all age groups, including people with disabilities.
Although aged-friendly housing development is paving its way to meet the need of the older community in certain cities, including Ipoh (the study location), the concept of an aged-friendly city should be mandated in all housing development as a measure to consider the future demands of tenants [58]. The home safety features for an older adult should include wider doorways, grab bars, and non-slip flooring. Additionally, aged-friendly neighbourhoods should consider the amenities such as healthcare facilities, fitness centres, and social spaces.
When implementing policies, age-friendly city initiatives, such as the home visit programme, should consider sustainability, promotions, and public competency. Financial resources and human capital are needed to implement these initiatives, particularly for long-term, large-scale endeavours [59]. Domiciliary care service, a home-based rehabilitation, is an effective intervention to reduce mortality [60]. The Malaysian Ministry of Health (MOH) has offered this service since 2016, the implementation has been limited by human resource dependency and a lack of promotion among healthcare personnel [61]. Organisations and coordination from multiple bodies are essential for the sustainable implementation of a service.
Impact of COVID-19
The COVID-19 pandemic has had a significant impact on the lives of older adults, from personal, environmental and habitual factors, due to the pandemic. These impacts included worsening psychological symptoms, increased loneliness, reduced quality of life, increased depression, service access issues, sleep disturbances, and reduced physical activities [62]. It is understood that older adults’ unmet needs, particularly in terms of personal, social, and domestic prospects, may be more significant than those of pre-pandemic, as experienced by some of our respondents.
Limitations
Recruitment problems were seen in the pandemic, where research team did not reach out to people who were wheelchair- or bed-bound and lived in nursing homes. Nevertheless, caregivers were invited to the study to gain insight into the needs of these populations. The IDI conducted via telephone limits the opportunity to build good rapport between the interviewer and the respondents. However, the interviewers reassure that the conversations were kept confidential, that it was informal chatting, and that the voice record will be deleted after transcribing the words. This study managed to recruit only one older adult who is staying alone; future studies could explore further aspects this population. The perspective of an older population living in a city for less than ten years needed further research, as all our respondents have lived in this city for more than 10 years.
Conclusion
Our findings underscore the perceived unmet needs of older people across several dimensions, including micro (person), meso (process), macro (place and policymaking), and health (prime). The broader implications of this study enable each level to be contextualised and explored in its own right. Multilevel planning approaches to address gaps from different levels concurrently or in a novel form of synthesis are likely to be practical and beneficial.
Acknowledgments
We would like to express our sincere gratitude to older adults and key-informants participated to this study, thanks to Norhazlina Ramlee for her technical help and writing assistance and thanks to everyone who had helped and guided our group in this study. Sincere thanks to Ju-Ying ANG and Suria JUNUS for their contributions in proposal development stage. We would like to thank the Director General of Health Malaysia for permission to publish this article.
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