Introduction

The Islamic Republic of Pakistan (hereafter “Pakistan”), is a country in South Asia, ranked 150^th out of 189 countries on the latest United Nations Human Development Index [1,2]. As per 2020 statistics, it is the world’s fifth-most populous country, with a population reaching 222,903,998 with a growth rate of 2.10% [3]. Currently, 6% of Pakistan’s population (7.3 million people) is over the age of 60 years, and 40% of households include an older individual [4]. The proportion of older people living in Pakistan is estimated to double by 2050 to 42.8 million older adults, accounting for 12.4% of the population and rising at a much faster rate than other population age groups [4–8]. In 2019, older people constituted 6.77% of the total population in rural areas and 6.38% in urban areas [1]. Pakistan’s average life expectancy has extended rapidly to reach 67.7 years (male: 65.8 years/female: 69.8 years) and is estimated to reach 76.7 years by 2050 [9].

Unfortunately, in Pakistan, most national policies focus on younger populations; older individuals are largely missing from national initiatives and programs [8]. A survey study by the Pakistan National Centre for Ageing (PNCA) in 2010, shows that 47% of older individuals do not have the capacity to pay for health care, safe shelter, food, and clean water [10]. Frailty, lack of knowledge of self-protection of rights, and poverty further contribute to poor quality of life and thus hinder active ageing [11–13]. Combined with a lack of resources, the extended family system is declining, with people moving towards the nuclear family structure [14]. This transition has resulted in lower numbers of older individuals residing at home with their families, with negative impacts on the older individuals’ involvement in decision-making, physical and emotional wellbeing, and social standing [5,15].

However, despite evidence exploring the circumstances of older people in Pakistan, there has been little research that has explored the subjective needs and priorities of older people and the stakeholders who look after them (family members caring for their elders as well as local caretakers hired to support an older individual). More research is needed to determine where to invest scarce resources to plan services which meet the explicit needs of older people. Additionally, contrasting the priorities of stakeholders with those of older people is likely to show whether stakeholders, who may have greater voice to influence change, understand and can articulate the needs defined by older people.

The World Health Organization defines healthy ageing as “a process of maintaining functional ability to enable wellbeing in older age” [16]. The aim of this study was to assess the needs and priorities for healthy ageing as expressed by older people and relevant stakeholders in rural and urban areas of Pakistan. A secondary aim was to characterize the mental wellbeing of the older people participating in the workshop.

Methods

Results

Workshops with stakeholders included 24 caregivers from Karachi (out of 35 invited) and 26 caregivers from Thatta (out of 30 invited) from various professional backgrounds, including community leaders and caretakers. Workshops with older people included 24 in Karachi (out of 35 invited) and 26 in Thatta (out of 30 invited). The average age of the older participants was 67.3 and 67.2 years in Karachi and Thatta, respectively (see S1 Table). In the Karachi workshop for the older adults, there were 66.7% females (16) and 33.3% (8) males. In Thatta, there were 5 females and 21 males. The elderly participants at the urban site were retired and hailed from a working-class background. Moreover, they all had received formal education up to an intermediate or undergraduate level. Most of the older adult participants recruited at the rural site hailed from the working labour class, farmers, and field workers and were either entirely uneducated or without any recorded formal education. Despite efforts to ensure equal gender representation, there was a significant difference in the number of males and females in the study group from Thatta.

For each of the group workshops, the complete list of responses to each question is shown in Fig 1.

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Fig 1. Ranked responses from the workshop participants.

https://doi.org/10.1371/journal.pone.0304474.g001

Contrasting the priorities of the respondent groups for healthy ageing

When comparing the top five prioritized responses of stakeholders with older people from the same geographical area, it was observed that were few areas of agreement between the two groups of respondents; 12 common responses out of the total 80 responses (Fig 2). With regard to the definition of ageing, the association of ageing with feelings of loneliness was common to both older adult and stakeholder groups in the urban area, while the two groups in rural Thatta found no common ground on the topic. With regard to areas of importance, the elderly and stakeholder groups from Karachi both prioritized good nutrition and adequate healthcare facilities as an area of importance. On the other hand, respondent groups from Thatta agreed only with the need for adequate income/ sufficient finances as a requirement for healthy ageing. Both the respondent groups from Karachi highlighted multiple issues under the theme of health, finances and government policies as barriers faced by elderly people. In contrast, the respondent groups from Thatta agreed only on the lack of finances as the main barrier to healthy ageing. According to the groups from Karachi the services available to the elderly were related to domestic financial support and discounted medical services to facilitate older people living healthy and active lives. However, there was no congruence between responses from the groups from Thatta with regard to services available to older people (Fig 2).

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Fig 2. Top five ranked responses to each question.

Red connecting lines indicate agreement between stakeholders and older people from each geographical area.

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Differences in priorities between geographical areas

The results showed marked differences between people from the same identity groups (either older people or stakeholders) by geography, with only 9 common responses out of the total 80 responses (Fig 3). For the definition of ageing, the most prioritized responses by the older people in Karachi were not ranked accordingly by older people from Thatta. Similarly, the stakeholders from the two geographically different regions did not share common ground on any of the definitions on ageing except for ‘feelings of dependency’. With respect to prioritized areas of importance; nutrition and finances, were the only responses shared between the older people from Thatta and Karachi. The stakeholders from both the regions ranked the importance of medical aid and emotional support from family members. The groups from both geographical regions considered lack of financial support and expenses as the main barrier towards healthy ageing, additionally the stakeholders prioritized the lack of affordable medical aid as the major problem encountered by the ageing population. The services available according to older people in Karachi did not overlap with any services voted for by older people of Thatta. The provision of post-retirement funds was the only service available to older adults, according to the stakeholders from both regions.

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Fig 3. Top five ranked responses to each question.

Red connecting lines indicate agreement within geographical area between each study group (older people and stakeholders).

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See S1 and S2 Figs for detailed maps exploring the linkage between responses and prioritized responses across participant groups and geographical areas.

Socio-ecological model

The categorization of the responses for each of the discussion questions using the socio-ecological model, showed that the societal factors were prioritized most frequently (32 responses), followed by individual (27), relationship (15), and environment (14) (Fig 4). When considering the first five ranked responses to each question, different categories of the socio-ecological framework were relevant, depending on the type of respondent and their area, although there were some similarities.

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Fig 4. Top five ranked responses for stakeholders and older people and their related socio-ecological framework category.

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For the definition of ageing, most responses were categorized as individual, regardless of geographical area or type of study population. Areas of importance for older people in Karachi were mostly categorized as societal whereas for stakeholders, most responses mapped onto individual and societal levels. For older people in Thatta, areas of importance covered all 4 levels with the highest ranked responses being classified as societal. In contrast, the responses of the stakeholders from Thatta were mainly societal level.

For barriers to healthy ageing, the older people from Karachi provided responses that were mostly societal, while stakeholder responses were categorized at the relationship level. In Thatta, responses of the older people to the barriers faced, related to the environmental level, while all stakeholders prioritized factors classified only at the societal level.

For the services available, the priorities of the older people in Karachi were mostly at the relationship level, whereas the Karachi stakeholders’ priorities were more focused on the societal level. In Thatta, responses for older people were mainly categorized as environmental and differed from the rural area stakeholder responses which were categorized equally as environmental and societal.

Discussion

There are limited data reporting the needs and priorities associated with an increasing ageing population in Pakistan. Moreover, previous studies exploring older populations in Pakistan have remained centric to a single study population and have not covered the scope of socioeconomic and demographic variation and its impacts on healthy ageing. This is the first study in a lower middle-income country that aimed to identify and compare the views of older people and stakeholders on their definition of ageing and areas of importance, barriers, and resources needed to enable older people to live healthy active lives. Moreover, this study compares older adults and stakeholder groups across different geographical settings.

Residents of Thatta in comparison to residents of Karachi are severely deficient of basic health-care facilities and provisions [17] The data show significant differences between participants from Thatta and Karachi, with our analysis suggesting that the responses to questions about definitions, areas of importance, experienced barriers, and postulated enablers of healthy ageing, are influenced by the financial and physical hardships experienced by older adults living in a rural compared to an urban area of Pakistan.

While older adults from the urban region included emotional changes i.e., loneliness and dependency within their top-ranked definitions of ageing, older adults from the rural area associated ageing with physical changes, and a decline in financial resources. Interestingly the responses of older people in Thatta included more physical and mental health features in their definition of ageing, than those in Karachi. These differences can be attributed to the fact that the population from the rural area were primarily men, fieldworkers and laborers, whose main source of income was through farming and labor-work, therefore a decline in their physical fitness with age reduced their ability to cater to themselves and their families’ financial needs. A previous study of older adults from peri-urban areas showed that the majority wanted to continue working and remain independent of their children’s earnings [29]. According to a recent study, most elderly adults above the age of 60 years want to remain active and be useful contributors to society. However, their old age limits their employability options. Moreover, pensionable elderly adults have reported that their pensions are not adjusted according to rising inflation patterns. Consequently, they find themselves financially handicapped and unable to access mandatory healthcare facilities or resources. This is consistent with another study which identified lack of support systems, aloof behavior of others, poverty and feelings of loneliness as drivers for elderly people to move to shelter homes [15]. On the other hand, elderly people from Karachi, were mainly retired pensionable individuals for whom major life-changes attributable to ageing were feelings of disconnect with family members, emotional decline and reduced importance in the household. The inclusion of domestic changes associated with ageing like ‘household importance’, and ‘reduced family attention’ among the responses may be linked to the fact that the urban group (unlike the rural group), was equally characterized by females. Unlike elderly people in Thatta, loneliness was mentioned only by the Karachi inhabitants, thus we inferred that the challenges of older people living in an urban area may be as a result of them living independently of younger working family members. Moreover, this reflects the recent transition of the Pakistani family system to nuclear families at a higher rate of progression in urban than in rural areas of the country [30,31]. The responses of the elderly groups, i.e., loss of emotional and financial support, uncontrolled changes, compromise, home-bound, inability to earn etc., may have arisen as a result of having low perceived control, reduced social support, and reduced self-esteem, that are commonly associated with ageing [32].

When questioned about areas of importance for healthy ageing, medical resources were the most frequent responses in the elderly and stakeholder respondent groups from Karachi and the aged of Thatta. However, this was not a top priority for the stakeholders from Thatta, rather they pressed on the need for employment and monetary funds for the children of elderly people. This seems at odds with the importance ascribed by older people to the maintenance of functional ability through improved health care, which is crucial to healthy ageing [33]. Other studies have also highlighted that major limitations in geriatric care are a result of the lack of awareness, poor support; carelessness and negative attitude of the stakeholders towards elderly population in Pakistan [34]. Caregivers and older adults from Sri Lanka also highlighted limited referral facilities, infrastructure, financial support, lack of trained personnel and geriatric services as barriers to quality of care in ageing [35]. Notably, the stakeholders from Karachi highlighted the importance of both mental and physical health as well as the need for financial stability and emotional wellbeing, indicating that the city’s youth and key individuals for shaping geriatric care acknowledged all the essential requirements for older adults. It was also noted that religion was repeatedly ranked as ‘part of ageing’ and an ‘important need’ for Thatta’s elderly people, while this was not the priority of elderly people in Karachi. Moreover, unlike the Thatta population, the elderly from Karachi prioritized social activities. This difference in the priorities results from the socioeconomic and cultural variation between the two regions which has determined the types of lives elderly people had led in their youth, and consequently their areas of importance for healthy ageing. This finding is similar to the observations of a study conducted in Iran, in which the participants responses suggested a marked effect of cultural and socio-economic status in the past, living in urban and rural areas, beliefs and attitudes, and financial capacity as the major the cultural and socio-economic factors influencing their opinions and behavior with aging [36]. Overall, the results showed financial constraints featured more frequently in the list of areas of importance for Thatta than Karachi, indicating the scarcity of resource and essential provisions in the rural area. Another study on urban elderly dwellers in China underscored the complexities of accessing care and lack of information as obstacles to care seeking [37].

Analysing the responses to ‘services available’, it was inferred that the Thatta population, regardless of age group, mainly identified provision of basic infrastructure, i.e., schools, natural gas, self-owned houses, crop produce, hospitals, rather than services specific to the needs of elderly people. On the other hand, the inhabitants of Karachi, regardless of age, considered benefits additional to basic services, such as elderly discounts, old homes, elderly-friendly recreational areas, post-retirement schemes and emotional support as the most important services. This discrepancy in the resource type level highlighted by the two geographically different groups reiterated the lack of resources and systems for older people in rural areas and highlighted severe inequality in the two populations’ living standards.

Moreover, it was observed that while the stakeholders of Thatta frequently mentioned financial and medical support as services available to elderly people, the older adult groups did not. Therefore, it may be inferred that the stakeholders from the rural areas are somewhat disconnected from the actual experiences of elderly people in terms of ability to access and receive support. This highlights an important issue prevailing in the rural areas of Pakistan; key opinion leaders and those individuals actively involved in the development sector perceive that adequate systems are in place for everyone.

In terms of barriers to healthy ageing, the inhabitants of Thatta highlighted fundamental infrastructure-related issues such as water supply and cleanliness. The stakeholders from Thatta focused only on financial limitations. In contrast, the inhabitants of Karachi prioritized problems relating to old-age needs, such as pensions and family support. Moreover, stakeholders from Karachi mentioned the lack of emotional support from family as one of the issues faced by elderly people. Also, it was noted that while the stakeholders from Karachi considered emotional support to be a significant barrier for elderly people, the elderly themselves did not consider this issue among their priorities. Unlike other topics discussed, the stakeholders and elderly from Thatta both ranked financial limitations as a barrier, which showed that the stakeholders acknowledged this problem. However, the rural stakeholders did not prioritize infrastructure-related issues, suggesting that they did not realize the severity of resource limitations. The socio-ecological mapping showed that the majority of the areas of importance and barriers related to ageing were categorized as societal, while a majority of the responses for the services available were mapped into environmental and relationship levels. This disconnect potentially highlights the lack of actioned policy and enabling services which could facilitate health and well-being in older age regardless of whether in an urban or a rural area. That said, policy for older people does exist, some of which has been put into action. In 1976, the Old Age Benefit Scheme 1976 [38] was launched to provide financial support to older individuals and in 2014, Pakistan passed the Senior Citizens Act, which laid the policy proposals and implementation of senior citizen safeguarding under the Senior Citizen Welfare Council which aims to improve access to financial and healthcare resources for older adults [8]. As a result of these policies, senior citizen homes have been established, as well as a senior citizens card that provides free access to public spaces, separate access to medical treatment, and financial support for those in need [39]. Alongside the Senior Citizens Act, many provinces established individual welfare councils and programs to protect the older community in the smaller provinces. However, despite these initiatives, provisions such as shelter/ housing, income support program, social security, free medical care, and financial stability are not readily available [40,41], reflecting the barriers reported in our study. Additionally, only 2.3% of the population older than the statutory pensionable age in Pakistan actually receives an old-age pension (contributory, non-contributory, or both) [8,42]. The private sector of Pakistan is working towards providing better facilities to the elderly alongside non-governmental organizations such as the Aga Khan foundation and Edhi Trust. However, these have limited coverage and localized effects [34]. This is reflected in the finding that while NGOs were mentioned as one of the resources available by elderly people, income and finances were seen as top ranked areas of importance and barriers for older people regardless of location. Despite the likely greater wealth of people living in Karachi compared with Thatta, which is one of the lowest performing districts in terms of socio-economic development in Pakistan, financial limitation was a problem highlighted by both groups of elderly people [43]. These findings are supported by a recent study that found older adults in care homes in Pakistan reported poverty as a major barrier to life satisfaction, followed by negligence by children [14].

The prioritized responses of older individuals and the stakeholders also contrasted substantially, both when considering the responses as captured and when categorizing these using the socio-ecological model. This may be explained by the differences in lenses of respondents, with older people responding based on their lived experience in contrast to stakeholders who may have the experience of caring for someone who is older in a personal capacity in addition to responding to questions in a professional capacity. A striking example of the difference in responses between stakeholders and older people was highlighted when considering the definition of aging, where stakeholders were more likely to define Individual characteristics, whereas older people included more external Society or Relationship factors, suggesting that the lived experience of ageing is very different to that observed. Like many developing countries, old age in Pakistan is set at 60 years and older [4,15] similar to high income countries, despite there being substantial differences in current life expectancy. Being an older individual, on the other hand, is not simply a function of chronological age and the diseases and physiological changes which are associated with this process [44]. In Pakistan, the word frailty (Kamzori) is often used to characterize old age (Burhaapa), and old age is also commonly defined by the role of eldership [4,15], but this seems in contrast to the individual socio-ecological categorization given to the definition, especially by stakeholders. It is reported elsewhere that many older individuals verbalise the ageing process and declining culture of reverence as one of the leading causes of distress and anxiety [45].

When considering areas of importance, there was also a divergence in priorities between stakeholders and older people. Stakeholders were focused on factors that could be provided by society, and whilst societal factors featured in older peoples’ priorities, they included a breadth of other categories of areas of importance, again reflecting differences in the experiences of healthy ageing and the associated barriers and enablers.

The differences in prioritized responses between urban and rural participants as well as the differences between old people and their caretakers is important to recognize. This suggests that a one-size-fits-all approach to improving health and wellbeing in older populations will not work. It also suggests that the views of stakeholders, who may be more often listened to in discussion of needs to inform planning and policy, especially if they are from an urban area, may not adequately reflect the needs of the people that they supposedly represent. Consulting the population relevant to developing services, perhaps using community participatory methods would likely bridge this gap. A similar divergence in priorities between geographical areas and stakeholder groups was found in another study in Rwanda [46].

Finally, we found that respondents from Thatta reported a higher geriatric depression score, i.e., moderate to severe depression, in contrast to those from Karachi, who reported a lower geriatric score, i.e., no to moderate depression. The results of our study are consistent with previous studies, noting a higher prevalence of depression in rural areas as compared to their urban counterparts [47,48]. According to a study on the factors strongly associated with depression in elderly people of rural India, age above 70 years, financial dependency and having one or more severe comorbidities were identified [48]. These findings also concur with findings from the workshop where stress, mental illness, and feeling helpless were responses in the definition of ageing given by both older people and stakeholders in Thatta. Respondents based in rural settings such as Thatta are more likely to present with increased severity of depression due to a variety of possible reasons. These may include inaccessibility to adequate healthcare services, financial constraints, family problems, deteriorating health, and more [18,48]. Previous studies also note some of the critical determinants contributing to higher depression in rural areas, namely economic disparity, familial disputes, regressive cultural norms, unemployment, and health-related concerns, including poor access to healthcare [17,47,49]. Moreover, it is important to acknowledge the role of a lack of awareness regarding mental health in rural settings. Urban settings are generally more well-informed about concepts like mental wellbeing in contrast to rural settings where mental health wellbeing is generally underestimated. Individuals may present with the signs and symptoms characterizing a mental health condition; however, they may not acknowledge or recognize it owing to a lack of mental health literacy [50].

This study is not without limitations. Even though the comparison of two cities in Pakistan in this study focussed attention on a number of important commonalities and differences, and participant responses appeared to reflect the current inter-regional disparity regarding healthcare, financial, infrastructure etc., services/provisions for the elderly across Pakistan, they may not fully represent the whole ageing population of this country. As time and resources limited data collection to one urban and one rural area, these results may not represent all rural and urban areas in Pakistan, where approximately 14 million adults aged over 60 years currently reside. The under-representation of older females in Thatta, mainly due to cultural norms of the rural areas is another limiting factor. We also acknowledge the limitation of using small group methodologies such as the Nominal Group Technique; while the most suitable technique to address our research questions, it restricted numbers of participants and workshops. However, we would like to emphasise that this was an exploratory study, which was intended as a springboard to stimulate more engagement and dialogue between older adults and the key stakeholder groups who care for them. Owing to the study’s exploratory nature, we aimed to acquire an in-depth understanding of the concepts around ageing in a setting where such concepts had not been explored in the past. Despite the limitations, these workshops provided opportunities to grow a small body of literature on healthy ageing needs and priorities in LMICs.

Supporting information

Acknowledgments

The authors thank Professor Janice Thompson, University of Birmingham, UK, for her helpful advice regarding data analysis.