Research Paper - Journal of Mental Health and Aging (2023) Volume 7, Issue 6

REFLECTIONS OF AGEING AMONG OLDER ADULTS IN A UGANDAN COMMUNITY: A QUALITATIVE ANALYSIS INTO THE BENEFITS AND PAINS OF AGEING

Gumikiriza-Onoria JL^1*, Nakigudde J¹, Kaddu Mukasa M², Tibasiima I³, Mayega R⁴, Nakasujja N¹

¹Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

²Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

³College of Humanities and Social Sciences, Makerere University, Kampala, Uganda

⁴School of Public Health, Makerere University, Kampala, Uganda

*Corresponding Author:

Gumikiriza-Onoria JL
Department of Psychiatry, School of Medicine
Makerere University College of Health Sciences
Kampala, Uganda
E-mail: gjoy.gumikiriza@mak.ac.ug

Received: 01-Sep-2023, Manuscript No. AAJMHA-23-110115; Editor assigned: 04- Sep-2023, Pre QC No AAJMHA-23-110115 (PQ); Reviewed: 18- Sep-2023, QC No. AAJMHA-23-110115; Revised: 21- Sep-2023, Manuscript No. AAJMHA-23-110115 (R); Published: 28- Sep-2023, DOI: 10.35841/aajmha-7.6.171

Citation: Gumikiriza-Onoria JL, Nakigudde J, Tibasiima I, et al . Reflections of ageing among older adults in a Ugandan community: A qualitative analysis into the benefits and pains of ageing. J Ment Health Aging. 2023;7(6) 171

Abstract

Background: The way societies comprehend and interpret aging has been in constant flux, mainly as life expectancy benchmarks increase and worldwide dynamics transform. Similar to many other nations, Uganda is experiencing this demographic shift. People aged 60 and above, who form a mere 2.7% of Uganda's population, are gradually emerging as a segment worth attention. This surge in life expectancy, which has increased from 50 to 63 years over the last decade, indicates a significant transformation in healthcare, lifestyles, and societal structures. Given this backdrop, there is a pressing need to delve deeper into the perceptions and experiences of this age cohort, especially in Central Uganda. This area mirrors the national trends. Methods: This study adopted a rigorous methodological approach. Individuals aged 60 years and above were selected through purposive sampling, which aimed to draw out rich and diverse narratives. These participants participated in seven in-depth Focus Group Discussions (FGDs) held in Wakiso District. To ensure accuracy in representation, all discussions were first transcribed in Luganda, the local dialect, before careful translation to English. Results: The participants presented a broad age spectrum from 62 to 90 years. The demographic data revealed a majority of female participants (54%), and a noteworthy statistic was that over half (51%) lacked a steady income source. Meticulous thematic analysis uncovered three themes. First, the journey of ageing encompasses physical, psychological, and social shifts, such as diminishing mobility, deteriorating health, and mounting social isolation. Second, the brighter side of ageing manifests in intangibles such as accumulated wisdom and a profound sense of life's accomplishments. The third theme echoed the harsher realities of aging, highlighting struggles with maintaining independence, looming financial challenges, and the sting of social exclusion.

Keywords

Life expectancy, Demographic shift, Uganda, Societal structures, Purposive sampling, Focus Group Discussions (FGDs), Ageing, Social isolation, Financial challenges, Social exclusion.

Introduction

All individuals undergo ageing, an anatomical and physiological process caused by molecular and cellular alterations in all types of cells throughout the body [1]. The older person population is a highly heterogeneous group, with considerable variation in the ageing process, i.e., some individuals express ageing as a significant decline. In contrast, others experience a less noticeable decline [1, 2]. Regardless of the various ageing rhythms to which the body is subjected, additional factors contribute to the phenomenon, such as the influence of genetic, physical, psychological, social, and environmental factors [2].

The ageing process is a dynamic biological reality beyond human control [3]. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time is paramount [3, 4]. The age of 60 or 65, roughly equivalent to retirement age in most developed countries is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age [4]. Other socially constructed meanings of age are more significant, such as the roles assigned to older people; in some cases, the loss of roles accompanying physical decline is significant in defining old age. Thus, in contrast to the chronological milestones that mark life stages in the developed world, old age in many developing countries begins when an active contribution is no longer possible [3, 4].

In recent years, gerontology research has focused on successful ageing, including biological, psychological, and social factors [5]. Ageing is a journey whose awareness is noted with the first signs of perceived weaknesses and deficits in the psychosocial areas of one [6]. Individual perceptions of their ageing are essential correlates of well-being and quality of life. Several studies indicate that some older people tend to feel younger, more vibrant, and more energetic than they actually are [5-8], possibly due to delayed perceptions of physical, psychological and social feebleness [5]. Theoretically, positive selfperceptions of ageing indicate successful ageing, age identity, and self-regulation [5, 6]. There is consensus that positive self-perceptions sustain social activity and engagement levels, enhance self-esteem and well-being, and boost psycho-social and cognitive functioning, leading to successful ageing [6, 7]. Individual perceptions of ageing and ageing-related expectations, goals, and actions may differ across individuals, even at the same chronological age [8]. We aimed to describe older people’s reflections on ageing in Uganda.

Methods

Study design

This qualitative study used thematic analysis, especially narrative analysis and inquiry, to identify older people’s perceptions about ageing in central Uganda. We used the user’s mental model [9] to explore and describe how individuals name ageing, its causality and meaning, and its effects and benefits. The user’s mental model allows for the reflection of participants’ understanding of ageing and the internal explanations they have built about it. The model aids in understanding natural human responses to an unfamiliar situation and begins building explanatory models a little at a time while assessing how people communicate when discussing issues related to ageing.

Study setting

This study was conducted between March 2022 to July 2022. The study was conducted in the communities of two subcounties of the Wakiso district. Wakiso is a district in Central Uganda that encircles Kampala, the capital city of Uganda. Wakiso district is one of three popularly called the Greater Kampala Metropolitan District (KMD). This is due to their proximity to the central business district of Kampala capital city. It is home to nearly 2 million people who live in urban, suburban, and rural settings. Approximately 92% of the district’s population lives in the rural areas of the community. Regardless of the setting in which people live, the levels of poverty are significant throughout the district (UBOS 2017). The district has more than 400,000 older people aged 60 years and above. The two sub-counties of Nansana and Busukuma were purposively selected for their representation of both urban and rural populations.

Participants recruitment

FGD participants included local community members, council leaders, religious leaders, community elders, traditional healers, community development officers, and Village Health Teams (VHTs). These were selected based on their knowledge and experience with ageing. Participants were recruited through purposive sampling to ensure that the broadest range of information and perspectives was obtained. Age and gender guided the purposive sampling technique. Recruitment was stopped when saturation level and redundancy were reached. FGDs were stratified by gender to achieve optimum information from the participants.

Procedures

FGDs were conducted by the lead author (JGO) and two trained research assistants in June 2022. Each FGD comprised between 8-12 participants. Interviews lasted approximately 70–100 minutes, and the discussions were audiotaped. Participants were asked questions in “Luganda”, the local language spoken by participants. Audio interviews were transcribed verbatim in the local language, and then those transcripts were translated into English by research assistants with supervision from JGO. This process was chosen to ensure the original meaning of participants’ statements so that responses were not altered or lost. The Makerere School of Health Sciences review board and the Uganda National Council for Science and Technology approved the study.

Participants

We recruited participants that were formally part of an existing study about the burden of Alzheimer’s disease in Uganda, completed in the Wakiso district between August 2018 and April 2019. The parent study investigating the burden of Alzheimer’s disease in Uganda had a cohort of 500 elderly people recruited from the two sub-counties of Nansana and Busukuma. Participant locations were known, and their ages were identified. The current study recruited one person from every identified home to participate in the FGDs. Where we found more than one older person from an identified home, we wrote a number on a piece of paper and left others blank; we then shuffled the pieces and requested the older persons to pick the papers. The one who chose the numbered paper was included in the study. Ninety participants were recruited with a response rate of 100%.

Data collection and tools

JGO developed a semi-structured FGD guide in consultation with NN, NJ, and TI. Questions were developed based on the user’s mental model for understanding how humans form explanatory models about occurrences. The interviewer used semi-structured questions and probed for clarity while following participants’ leads. The FGD guides were pilot tested in a community not part of the study. The FGD started with introductions in which either the moderator or the first author JGO, explained the purpose of the research. The opening question was: “What is the first thing that comes to mind when you think about growing old?” Participants were then asked about their definition of ageing and what they liked most. They were also asked to share their experiences with ageing.

Data management and analysis

Data were transcribed verbatim in Luganda by the research assistants and checked by JGO against the audio recordings for the accuracy of information. TI reviewed transcripts to ensure that the data collection and methodology were accurate. Thematic analysis was used to analyse the data. Different pattern in responses were considered after a complete content analysis of the data. JGO did the initial coding, and after that, data were reviewed and organised into categories in search of relationships. Coding was performed by comparing participant statements and searching for uniformity, patterns, and contradictions.

Trustworthiness

To ensure the trustworthiness of our research, we implemented several measures. Firstly, we protected the credibility of our data by assigning each respondent a unique code to ensure anonymity and prevent their identities from being revealed. Secondly, we established an environment that fostered trust and commitment to confidentiality, ensuring respondents felt comfortable sharing their perspectives and experiences. We also ensured voluntary participation, where respondents had the choice to be or not be part of the research. They were also allowed to decline participation even during the interviews where they felt uncomfortable.

Moreover, we adhered to the transferability principle by describing our research methods and sample selection criteria. This ensures that readers can assess the applicability of our findings to their contexts.

Lastly, we ensured the conformability of our data by obtaining informed consent from all participants, which ensured that they were fully aware of the research purpose and procedures. Additionally, we maintained confidentiality by keeping all data confidential and secure. This helped to ensure that the data presented in our research accurately represented the perspectives and experiences shared by our participants.

Results

A total of seven FGDs were conducted for our study. 4 FGDs were from the Nansana town council, while three were from the Busukuma town council. Two groups were homogeneous well as five were heterogeneous. 90 participants (41 men and 49 women) participated in FGDs. Participants were aged between 62 and 90 years. (Table 1) shows the demographic characteristics of the participants. (Table 2) shows the three major themes that emerged from the aggregated data: (a) Growing is a process, (b) the Pains of growing old, and (c) the Benefits of growing old.

Table 1: Demographic distribution of the FGD participants.

Table 2: Summary of emerging Themes and sub-themes.

Theme 1: aging as a process

In our study, participants described ageing as a process. The most common label was ‘okukula kw’obwongo’ which means the process in which the brain ages. Other labels that emerged from the data were ‘okukula mu mubiri’, which means body changes as we grow, ‘okukula mu birowoozo’ meaning growth in one’s thoughts, and ‘Okubeera n’amaka ag’omuntu’ meaning having a home of one’s own. For example,

“Someone might tell you, you have grown, and you say, no, I am in my 50’s then you begin growing in your thoughts, and you remember someone told you, you are in your 50s, so when you make 60 and 70, the thoughts go up, and the brain grows.” (FGD female)

“Here in Buganda, growing up is having your home protecting your family and wealth, and you have the authority to give them out. You need to have land/ property here in Buganda to get responsibility.” (FGD Male)

Further, participants attributed the ageing process to three sub-themes grouped as (i) physical, (ii) psychological, and (iii) behavioural processes.

Physical processes

Some people attributed growing to physical weight, height, and posture changes. Growing was also attributed to the many diseases that result from old age, like ‘pressure’ meaning high blood pressure, ‘sukalu’ meaning diabetes, ‘okuwulira obulumi mmagumba’ meaning feeling pain in the bones.

“Ageing is seen when you start having some wrinkles, and you no longer walk as straight as you used to. People start to feel pain in bones and cannot do the garden work the way they used to.” (FGD male)

Psychological and behavioral processes

Ageing was perceived as both a psychological and behavioural process. Often participants combined the psychological and behavioural perceptions in one statement. For example; Change in the direction of one’s thoughts, respect for self and others, and having many children were all seen to denote ageing.

“To grow means a change in appearance and behaviour (you become tall and big, you have many things to cut yourself from, your head can no longer do the same things you used to do, you can no longer put on short clothes now you put on longer clothes, even hair you stop taking care of it, the dress code also changes, the way you take care of children and grandchildren at home also changes, when you are young you don’t take those responsibilities) and having many thoughts and worries that you did not have before.” (FGD female)

Theme 2: pains of ageing

Participants described ageing as a painful process. And commonly described as ‘okukaddiwa kuku??aanya ebizibu bingi’ meaning ageing is a collection of many problems/ challenges. Participants cited disturbance, especially from the young, poverty, high blood pressure, and other diseases that come with old age, loss of body control, over urination and at times urinating on oneself, disrespect and neglect from one’s children as some of the pains of growing old. Such as;

“Back pain, pressure, ulcers, leg pain, and pain in the hands I cannot peel my matooke and sweet potatoes as I used to. Can you imagine that even cassava is hard to peel, so I start massaging my hands? I can spend a week without using the washroom, old age comes with its own diseases it is a painful process.” (FGD female)

“What hurts me is a child you give advice to and even correct and they despise me like I do not understand. This happens a lot with children in this digital era, they disrespect us and even abuse us because we are old.” (FGD male)

Participants also highlighted psychological pain, relational challenges, incapacitation, and the Crisis of generational gaps as subthemes denoting the pains of growing old.

Psychological pain

Ageing was perceived as a painful process involving immense psychological pain for many persons. Sadness for losing loved ones, failure to achieve the financial status you hoped for while younger, stress of your children disappointing you, and loss of property all contributed to the painful ageing process. For example,

“You have children whose behaviours are being talked about negatively (bad-mannered, thieves,) you get diseases that affect you and hinder you from being able to do many things and your children start stealing and selling your property because you have grown old.” (FGD female)

“We have lost many people, our friends, our spouses, our children and we do not have many people to support us. This makes us very lonely and we feel extremely sad.” (FGD female)

Relational challenges

The pain of growing old was often related to challenges in relationships. Participants reported having strained relationships with their loved ones, mostly the children. They reported that their children live them to fend for the grandchildren and do not support them even with food and basic needs. Many participants found it rather disturbing that their children and extended family they supported while still youthful do not support them financially in any way.

“When children are growing you have to pay for school fees and you forget to plan for yourself, so now we have to suffer. We are old and our children do not mind taking care of us. The times when we were strong we spent it on the children, now we need them but they do not care, all they do is produce and damp their children here without any support.” (FGD female)

Participants also reported that their children want to snatch property from them instead of supporting them in their evening years.

“My children want to steal my property; I even had to report to the police because they were bringing people to buy my land.” (FGD male)

Incapacitation

Incapacitation was seen as a pain of growing old. Participants mentioned illnesses like back pain, poor eyesight, reduced hearing capacity, frequent UTIs, and several noncommunicable diseases like high blood pressure, heart disease, and diabetes. They reported that, because of these, they could no longer do activities as they used to while younger.

“When I started growing old, my back began to trouble me, it constantly hurt and I could no longer bend. Even my legs started painting so much. I am a man who used to dig and have food, but now I cannot because of these pains. So, I now have to depend on others to get food to eat.” (FGD male)

“Some of us here have diabetes, pressure, back pain, and many diseases that came when we started advancing. These diseases have turned us into vegetables, we only sit and do nothing productive. We are now very lonely, get easily angered, and feel sad and helpless.” (FGD male)

Generational gap crisis

Participants found the generation gap crisis as the pain of growing old. They expressed failure to understand the slang used by youth, inability to appreciate the youth's discussions, and inability to access and use the increased technology used for communication as a shortfall that comes with ageing.

Theme 3: benefits of ageing

In addition to the challenges associated with ageing, the study revealed that participants saw some positive attributes related to growing old. Participants suggested that growing old has essential benefits, including respect from peers and the younger generation. The elderly are often revered in many cultures, and participants in this study also noted that being respected by others was one of the benefits of growing old. Additionally, having grandchildren and great-grandchildren was identified as another positive aspect of ageing, as it provides an opportunity to watch future generations grow and flourish.

Participants also noted that living longer than most of their peers was a positive attribute of growing old. They saw it as an accomplishment and something to be proud of, demonstrating their resilience and ability to persevere through life's challenges. Furthermore, participants reported feeling happy for their friends and children when something good comes their way, which they attributed to their own experiences in life and the wisdom that comes with growing old. Finally, participants noted that being looked up to by others as someone with wisdom was a significant benefit of ageing. They reported feeling valued and appreciated for the knowledge and experience they have gained, which they are happy to share with others.

“My friends believe growing old is bad, but not all of it is bad. You see, when you grow old, you are respected. People admire you because not many people live to see our age. Me, I am 83 and you see how everyone kneels to greet me, even those who don’t know me, humble themselves when talking to me” (FGD Female).

Discussion

This qualitative study was conducted in the Wakiso district, with a representative sample from two sub-counties. Participants were recruited from their homesteads and were willing to participate. Focus Group Discussions (FGDs) were held in local churches in each village. Some interview questions resonated with the participants unexpectedly, as Gumikiriza-Onoria reported [10]. At times, participants also had expectations other than the research objective, such as requesting the research team to advocate for government considerations for older persons' social and economic well-being.

Ninety older persons, with a mean age of 69.6 ± 9.1 years, participated in this study. The age distribution of the participants is similar to that of the Uganda population census of 2018, which indicates that the majority of older persons aged 60 and above fall within the 60-69 age category (UBOS 2022). Additionally, the study had a higher proportion of females than males, consistent with the Uganda population census 2018, reflecting the higher percentage of women in the 60 and older age bracket. More than half (51%) of the respondents had no source of income and relied on financial aid from children, relatives, and friends. This trend is common across most low-income countries in Sub-Saharan Africa [11]. Most respondents had medical comorbidities, with hypertension and diabetes being the most prevalent. This reflects the situation in Africa, where 55% of the older population has hypertension [12]. According to studies, hypertension is more prevalent among older adults residing in African urban areas [13].

In this study, we identified three main themes in the data: the ageing process, the benefits of ageing, and the pains of ageing. Our analysis showed that ageing is not simply a biological process but a multi-component process involving intersubjective factors that shape how individuals perceive and experience ageing. Participants described ageing as a gradual process that affects different aspects of their lives, including physical, psychological, and social aspects. These findings complement the work by Gilleard and Higgs (2000), which described ageing as a process involving physical changes, such as decreased mobility and sensory function, and psychological changes, such as changes in mood, self-concept, and cognition [14].

Interestingly, some participants highlighted that ageing is also influenced by the number of children one has, which suggests an inter-subjective element to the ageing process. Additionally, participants noted that ageing involves changes in their thought patterns, including a shift towards more tremendous respect for self and others. These findings are in line with Kleinspehn-Ammerlahn [8] work, which suggests that ageing exhibits unique characteristics in different organs and systems and with Bernardes & Pinheiro and Oliveira & Pinto, who emphasise the role of various physical, psychological, social and environmental factors in shaping the ageing process [2, 15].

Regarding the benefits of ageing, our findings suggest that older people in this community view ageing as an achievement that elicits respect from peers and the younger generation. Having grandchildren and great-grandchildren, living longer than one's peers and witnessing the success of friends and loved ones were all seen as pride-worthy achievements. Participants also noted that being viewed as a wise person due to one's age improved their overall outlook on life. Ageing was described as a benefit to one’s life that elicited respect from peers and the younger generation. It was also regarded as a pride-worthy achievement, evidenced by having grandchildren and some great-grandchildren, living for much longer than most of your peers and being happy when you see friends and loved ones attain something. Further results show that being viewed as a person with wisdom because of old age often improved the overall outlook on life among older people. This is in line with Levy’s embodiment stereotype theory. According to this theory, cultural beliefs and stereotypes about ageing are internalized by individuals and can have a significant impact on their physical and mental health outcomes. In this case, the cultural belief that ageing benefits one's life and is associated with respect, pride, and wisdom can make older individuals feel optimistic about their ageing process. These positive beliefs can also translate into better physical health outcomes and a more positive outlook. Moreover, the idea of ageing as a pride-worthy achievement, as evidenced by having grandchildren and great-grandchildren, can reinforce the importance of intergenerational relationships and social connectedness in older adults' lives. These social connections positively impact mental health outcomes, such as reducing depression and loneliness [16].

Conversely, our analysis also revealed that ageing is not without its challenges. The pains of ageing were described as including psychological pain, relational challenges, and physical pain leading to incapacitation. For instance, participants discussed the pain of losing loved ones, financial instability, children's disappointment, and property loss. This highlights the inter-subjective nature of ageing, as relational challenges and disappointment from children are not purely biological factors but are shaped by social and cultural factors. Physical pain was also a significant issue, with back pain, poor eyesight, reduced hearing capacity, frequent UTIs, urinary incontinence, and various non-communicable diseases like heart disease and diabetes all contributing to the pain associated with ageing. These findings support the work of Juma, Kenneth et al., Mitchell-Fearon et al. and Flacker, who have highlighted the prevalence of geriatric syndromes among older persons and their significant impact on quality of life [15-19]. Overall, our study highlights the complex intersubjective processes that shape the ageing experience in this particular community [20-23].

Limitations

The study was conducted in two sub-counties in the Wakiso district, and the findings may not be generalizable to regions outside of Central Uganda. There may be a need for similar studies in other regions of the country to confirm our findings.

Conclusion

In conclusion, the study provides insights into the reflections and conceptualisations of ageing among elderly people in Uganda. The findings highlight the need for interventions that address the physical, psychological, and social aspects of ageing. There is a need to provide holistic care to the elderly to cater to all aspects of ageing. Additionally, the study emphasises the importance of promoting positive attitudes towards ageing and creating opportunities for the elderly to share their experiences and skills with others. The study's findings can inform policies and programs that promote the well-being of the elderly and improve their quality of life. This is especially true not just for Uganda but for many developing countries. Besides, considering the attitudes of the elderly toward ageing can help open avenues for other studies on ageing and mental health to be carried out. These could include issues regarding hospice care, community and health support and psychosocial support.

Availability of Data and Materials

The datasets used and analysed during this study are available from the corresponding author upon reasonable request.

Author Contributions

J.L.G-O.: Has been involved in proposal development and writing, data collection and analysis, and manuscript writing.

J.N.: Has been involved in proposal development and manuscript writing.

I.T.: Has been involved in the analysis and manuscript writing.

R.M.: Has been involved in proposal development and Manuscript writing.

K.M.M.: Has been involved in data interpretation and manuscript writing.

N.N: Contributed to proposal development and writing and preparation of data collection tool, reviewed and revised drafts.

Acknowledgements

We acknowledge the NURTURE ADRD support, the BRAIN Health support and the participants who participated in this study.

Funding

Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke and Stroke of the National Institute of Health under Award Number D43NS118560 and by the D43TW010132 Grant supported by Office of The Director, National Institutes of Health (OD), National Institute of Dental & Craniofacial Research (NIDCR), National Institute of Neurological Disorders and Stroke (NINDS), National Heart, Lung, And Blood Institute (NHLBI), Fogarty International Center (FIC), National Institute on Minority Health and Health Disparities (NIMHD). Its contents are solely the authors' responsibility and do not necessarily represent the official views of the supporting offices.

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