DOI: https://doi.org/10.21203/rs.3.rs-2022410/v1
The process of ageing involves a combination of biological, psychological, and social factors. The rising proportion of older adults and increase in life expectancy have increased interest in maintaining and promoting cognitive health in later life. Participation in cognitively stimulating activities has been considered to maintain or strengthen cognitive skills, thereby reducing age-related cognitive decline. An important aspect of healthy ageing is the promotion of good mental health and well-being in later life.
The aim of the study was to examine the effect older adults’ empowerment on their cognition, mental and physical well-being in the community.
: A sample of 20 purposively selected older adults in the community were empowered in their different vocation of choice. Data was collected via in-depth interview and observations. An interpretive-descriptive analysis was used to facilitate data analysis.
The associated benefits of empowerment of older adults to improve their cognition emerged into five themes: quality of life; increased physical function; social interaction; socio-economic effect; and mental stability.
Empowerment-based programs should be provided for older people in the society for them to take advantage of the opportunities to feel safe, supported and optimistic about life and its possibilities.
Aging of the population is a universal problem, imposing considerable and rapidly increasing health care and socio-economic burdens (Allison et al., 2013; Lin et al., 2010). There are several challenges associated with aging, one of which is decline in cognitive function. Cognitive functions refer to memory, thinking, reasoning, problem-solving, planning, and processing speed and generally described as aspect of human intellect (Hal et al., 2016). Cognitive impairments refer to damage to one or more of the cognitive functions and consequently influencing the memory, learning, and decision-making capacity of individuals in their daily life (An et al., 2016).
Over the years, interest in maintaining and promoting cognitive health in later life has greatly increased. Only 1 in approximately 100 older adults experience healthy cognitive aging (Petersen,2011). Different studies have highlighted that the prolongation of the life span is associated with deterioration in psychological, physical, and cognitive conditions (Hall et al., 2017; Stenzelius et al., 2005). Report found that the older population is projected to rise to 78 million in 2030 and 139 million in 2050. Globally, around 55 million people have dementia, with over 60% living in developing countries (WHO, 2021).
Epidemiological and neurological studies suggest that low educational level, poor social contact and relationships, lack of robust occupation and low income can influence the risk factors of cognitive decline including dementia (Okamoto, 2019). Sustenance of independent living (Deary & Gow, 2008) and a high quality of life (Webb et al., 2011) is linked with maximal levels of physical and cognitive functioning.
Active involvement in mental activities throughout lifespan has been shown to promote cognitive health (Gow et al., 2017; Valenzuela et al., 2008). Findings indicate that meaningful activities in alignment with social health promotion programs are beneficial to brain health as aging progress (Carlson et al., 2015). It is therefore safe to say that empowering the older adults on social, physical and cognitive enriching activity has the potential to mitigate cognitive decline associated with aging.
Researchers have deliberated on investigating interventions targeted towards empowerment that promote health among older adults (DeCoster & George, 2005; Keller &Fleury, 2000). Wallerstein define empowerment as “the process of social action that promotes the participation of people, organizations, and communities to take control of their own lives in the community and wider society” (Wallerstein et al., 1988).
Early intervention targeted towards population at risk is imperative in order to reduce the social, financial and medical burden of cognitive decline and in due course decrease the incidence of dementia (Mowszowski et al., 2010). The World Health Organization Ottawa Charter for Health Promotion highlights the need for an empowerment-based approach to improving individual skills and strengthening community activities to promote health (WHO, 1986).
Some studies have explored the use of physical activity, exercise, social engagement to empower older adults to improve cognition. In a study conducted by Hertzog et al (2008), it was concluded staying active physically and intellectually promotes healthy cognitive aging. To the best of our knowledge, this is the first study to investigate the effects of empowering older adults’ individual skills in order to improve and maintain their cognition. We intend to test the formulated hypothesis for this study which states that social and economic inclusion contributes to the cognitive and mental well-being of older adults. A strategy-based approach could be to facilitate older adults’ vocational skills through financial empowerment with the aim of maintaining a reasonable level of physical activity, ensuring constant social relationship and improving their level of income. Such activities will subsequently be of utmost benefit to their physical, mental and cognitive well-being. The aim of the study was to examine the effect older adults’ empowerment on their cognition, mental and physical well-being in the community.
Study design
This study adopted a qualitative observational study design to provide answers to the objectives of the study.
Study population
Participants of the study were purposively selected community-dwelling older adults (n=20) of a rural community with maximum variability technique. The inclusion criteria for selecting participants were as follows: (i) older adults who are aged 60 and above (ii) older adults who are seemingly healthy i.e. normal ageing, (iii) older adults who are low-skilled. Selected participants consist different age group, vocation and gender. Informed consent was obtained verbally from all participants before the commencement of the intervention.
Intervention Procedure
The intervention was primarily designed to increase the income and level of engagement of community-dwelling older adults to ultimately improve their physical, mental and cognitive well-being. An initial need assessment was carried out to ascertain needs of the enrollees. During the intervention process, participants were engaged in their various vocation activities of choice such as trading of different household items, which included selling of raw food items, fruits, kerosene, edible food items, bottled water and drinks and skills such as carpentry, farming, recycling of waste polythene nylon. This was done through allotment of a designated amount of fund to reinforce their vocation.
Monitoring Schedule
They were closely supervised to ensure the funds were used for the actual purpose in which it was given. This was done by rendering assistance in the area of purchase, profit making and social engagements. They were encouraged to continue in their vocational activities and the research assistant kept track of participant adherence. Visitation was carried out on monthly basis over a period of three months for effective and result based outcome.
Data collection and analysis
A semi-structured, in-depth interview was conducted after the intervention process with each of the 20 recruited older adults by a qualified research assistant. The interview guide used for conducting the interview was designed by one of the investigators and piloted among 3 participants. Questions in the interview guide include: Can you please compare your quality of life before and after the empowerment? What are the effects of this empowerment on your mental well-being? How well have you been able to relate with people during the period of intervention? In what other areas do you think this empowerment has been of benefit to you? Face-face interview and informal dialogues between research assistant and participants enhanced expression of honest feelings. Participants’ responses led to further probing questions from the research assistant. This was done at the various homes of the participants using open-ended questions. Research assistant visited at different periods for observation on the continuance of vocational activities and general well-being of the participant.
Interviews and observations produced data about the experience of the participants. The interviews were recorded with voice recorder and anonymized. Observations were also documented appropriately. Recordings of participants’ interview were transcribed verbatim and subsequently translated to English language. An interpretive descriptive analysis was used. Codes and themes were generated separately by two investigators and harmonized through an iterative process. These were triangulated with data from observations documented during the course of the interview and study in general. Quotes that capture the themes were identified and reported.
Twenty older adults participated in the interviews. Participant characteristics are presented in Table 1 below. The mean age of participants was approximately 69 years. 65% of the participants were female. 70% had no education, 20% had primary education and 10% had at least a secondary education. 85% are into petty trading of various kinds.
| Participant No | Age | Gender | Level of Education | Vocation | Marital Status |
|---|---|---|---|---|---|
| 1 | 72 | F | None | Trading | Widow |
| 2 | 63 | M | Primary | Farming | Widower |
| 3 | 79 | F | None | Trading | Widow |
| 4 | 80 | F | None | Trading | Widow |
| 5 | 65 | F | None | Trading | Married |
| 6 | 75 | M | None | Trading | Married |
| 7 | 66 | M | Primary | Trading | Married |
| 8 | 65 | F | None | Trading | Married |
| 9 | 75 | F | None | Trading | Widow |
| 10 | 67 | F | None | Trading | Widow |
| 11 | 78 | F | None | Trading | Widow |
| 12 | 70 | F | None | Trading | Widow |
| 13 | 62 | M | Primary | Trading | Married |
| 14 | 80 | M | Secondary | Electronics | Married |
| 15 | 70 | M | None | Carpentry | Married |
| 16 | 65 | F | None | Trading | Married |
| 17 | 40 | F | Primary | Trading | Widow |
| 18 | 65 | F | None | Trading | Widow |
| 19 | 65 | F | None | Trading | Married |
| 20 | 75 | M | Tertiary | Trading | Married |
The effect of the intervention was assessed through the use of probing questions to understand the experiences and self-perception of participants.
Thematic analysis of the interview transcripts was done with manual coding techniques using Aronson’s four stage thematic analysis methods (Aronson, 1995). Key direct quotes were identified and common idea paraphrased and related patterns were combined into themes. Five themes corresponding to three broad categories (physical, mental and cognitive well-being) emerged. The following are the themes identified: (1) quality of life (2) increased physical function (3) social interaction (4) socio-economic effects (5) mental stability
Theme 1: Quality of life.
Most participants showed their concern towards maintaining a good quality of life irrespective of their aging experience. They found fulfillment and comfort in their various engaged activities, reassuring them for the future. They expressed that performing in meaningful activity is vital to good feeling and improved quality of life.
“This empowerment has helped me in living a financially independent life, a degree of comfort and a sense of belonging in my community” (Participant 13)
“…I have experienced more patronage and sales as compared to when I had no financial support to expand the business and sincerely…my standard of living is now better” (Participant 15)
Theme 2: Increased physical function.
More than half of the participants identified that their level of physical function has greatly improved through engagement in their various vocational skill. The empowerment has assisted in expansion of their businesses and in turn increased their mobility and physical activeness. They perceived physical functioning as useful for health other than living a sedentary lifestyle.
“I walk down to market myself to re-stock when my goods are almost sold out. More movement has helped me cope with the leg pains that I have whenever I sit down for a long time. When my customers come around, I have to stand up and attend to them” (Participant 12).
“As you can see, I’m involved in carpentry work which doesn’t allow me to sit down for too long. I stand for almost 5 hours daily making furniture though I take few breaks in-between. I can say this has kept me strong rather than sitting and staying idle throughout the whole day” (Participant 15).
Theme 3: Social interaction.
Loneliness which is one of the vices associated with aging was clearly stated out as a root-cause to depression. Participants reported enhanced interpersonal relationships between them and their customers making them relate more than before as some of them are widowed and living alone.
“After I have been empowered, I expanded my business to include more packaged snacks. This has increased patronage from the younger population (children) and those of middle age. Another thing I noticed is that I interact better with them…some of them keep me company whenever they come to buy things from me” (Participant 12)
“I buy fruits like banana and plantain on the farm to sell at market. All this while I have it in mind to also sell at the mosque where I pray but financial constraints denied me of doing so. When I was given the fund, I maximized it and was able to meet demands at my religious centre. This is a plus for me because I relate well with other members as they come to buy my good” (Participant 16)
Theme 4: Socio-economic effects.
A shared belief among participants was revealed through interviews. It was highlighted that the empowerment was a form of practical support which improved the socio-economic status of the older adults especially in terms of income.
“I’m happy with the profit I make nowadays…I have more money at hand and I can buy whatever I want. The business is really improving alongside my general well-being” (Participant 6).
“self-confidence is one of the benefit I’m enjoying due to the stable source of income that I now have, it has made me more active in my community” (Participant 1).
“Old age has been a fear to me because while growing up, I see a lot of old people around totally dependent on their family. Some of them don’t even have responsible children, some were neglected. I have been selling few household items initially; the small profit I make is what I used in sustaining myself. At times, things are difficult because I don’t even get enough as I wanted. The empowerment has greatly helped me to increase the strength of my business and more profits are coming” (Participant 9).
Theme 5: Mental stability.
Some of the participants reported that, the act of buying and selling has helped them to remember things. They identified that their thinking ability, analytical skills and information processing speed has greatly improved as they have constant engagement with customers.
“I have seen people of my age having difficulty in managing money. Having transaction on daily basis between me and my customers has really helped my mental ability. When they pay for the goods, I quickly calculate to ensure I collected the right amount” (Participant 6).
“Constant interaction has made me maintain mental consciousness. I respond well when people come around to my shop” (Participant 11).
“This eye problem is an issue that has affected the continuation of my business. This was almost leading into mental depression. Immediately I got the financial reinforcement, I continued in the business with the assistance of my (wife). I can’t see anyways but the fact that my occupation is sustained gives me joy” (Participant 13).
Participant 17, although outside the age range, was empowered to fill the gap for her husband’s death. Her husband was the selected participant according to the inclusion criteria but the trauma happened prior to the disbursement of funds to participants.
This study has explored a distinct means of empowerment of older adult as a means of enriching their lives. It specifically explored the empowerment of older adults using a strategic means of financial reinforcement to enhance occupational activities and eliminate related constraints. The need for this has been recognized considering the menace of rising cognitive decline, its demands in older adults and the causative factors. In general, this finding has shown positive participants’ experiences, and revealed associated benefits. Analysis for results established the following themes: quality of life, increasing physical function, social interaction, socio-economic effects and mental stability.
Studies suggest that enhancing instrumental activities of daily living ability in older adults could improve their health-related quality of life (Chan et al., 2009). Another study emphasized that a reduced quality of life is associated with decline in cognition (Ostbye & Crosse, 1994). Data obtained from the interview identified that proper channeling of empowerment for older adults enhances quality of life. Participants described the empowerment as a means to a boosted self-esteem, self-expression, and sense of belonging and active participation in the community. Prioritizing an active lifestyle promotion in cognizance of its potential benefit to the cognitive and general well-being of the older adults should be considered.
It was recognized that the intervention, although aimed at improving cognition, resulted in broader health benefit for the overall well-being of the participants. Typically, older adults tend to live a sedentary lifestyle (Matthews et al., 2008) which is detrimental to their cognitive health (Akdag et al., 2013; Kim et al., 2010). Many of the participants concluded that the outcome of the intervention, themed ‘increasing physical activity’, motivated them to continue in their vocation. Specifically, a participant stated that engaging in the activities served as a means of non-strenuous exercise. According to animal studies, neuroplasticity and the cognitive function are enhanced by physical activity (Magnon et al., 2018). Encouraging older adults to improve or continue in a healthy lifestyle including active physical lifestyle is crucial given that healthy lifestyle changes have beneficial effects on cognitive function even among dementia susceptible individuals (Solomon et al., 2018; Lourida et al., 2019)
Some of the participants are widowed and live alone. The theme “social interaction” that emerges poses a positive effect and likelihood to mitigate persistent feeling of loneliness, a risk factor for depression, which is one of the vices associated with being old. Tang & Lee (2011) reported the importance of expanding social support networks for older adults. Loneliness and social isolation has a consequential outcome of worse cognitive function most especially among participants with low education level (Shankar et al., 2013). Building social relationship is a key element in old adulthood.
The “socio-economic effect” theme indicates great influence of the empowerment on the income of the older adults. There is a common trend of older people being dependent on their family due to frailty and low financial power. From the result, there is higher likelihood of positive impact on the socio-economic aspect of participant. This study reaffirms that it is important that stakeholders consider consistent interventions that provides comfort and aids healthy aging in the vulnerable.
Mental stability was another theme that emerged from participants self-perception. This aligned with previous study that suggests that longer working lives with reduced work strain and desired schedule tend to maintain general well-being including mental aspect (Calvo, 2006). This finding was also consistent with previous research that suggests that mental activities among older individuals help to maintain cognition as older adults not working experience considerably lower cognition than those who remained working (Lee, et al., 2019). The empowerment was found to enhance mental stimulation through the engagement of significant activities.
Our findings highlight that participants enjoyed both economic and noneconomic benefits. Empowerment approach in this regard should be given further attention in creating a thriving environment to the older adults. Programs that motivate active participation of older adults in productive activities will help improve physical, mental, social and cognitive well-being. Development of policies that focus on social and economic inclusion of older adults is a key factor that should be taken into recognition.
The results may not be generalizable due to a small sample size and homogeneous study population (older adults with healthy cognition).
This study highlights that age-friendly empowerment targeted towards enriching the older adults help in cognitive maintenance and ultimately leading better lives. It provides an evidence-based practice to past review which suggests that emphasis on life-long acquired individual skills and access to required resources may be a more sustainable methodology. Funding will foster future research to test the outcome of this approach in older adults with a different cognitive characteristic i.e., mild cognitive impairment.
Acknowledgements
We appreciate everyone that has one way or the other contributed to success of this study.
Funding: No funding was gotten for this study
Availability of data and Materials: The data that support the findings of this study are available using the following url - https://figshare.com/s/c0ee58ca63838b3a18a2
Ethical and Consent to participate: Ethical approval for this study was sought from the Oyo State Ministry of Health Ethical Review Board. Approval number AD 13/479/44509B. Permission to conduct the study was also obtained from relevant LGA authorities, community leaders and heads of households. All methods were carried out in accordance with relevant guidelines and regulation according to declaration of Helsinki. Written informed consent was obtained from all study participants. Respondents were informed of their right to decline or withdraw from the study at any time without any adverse consequences.
Confidentiality: Data collected was used only for research purposes and will be kept confidential. Names and addresses were not included in the questionnaire so as to prevent linking the data to any particular individual. Research assistants were also trained on keeping the information they obtained confidential.
Beneficence: Respondentswhose children were found to weigh less than expected for their age were given nutritional counseling. They were also counseled on the benefits ofexclusive breastfeeding and child-spacing. Findings from the study will be communicated to all relevant authorities so that action can be taken in bridging the identified gaps.
Non-maleficence: Minimal harm to respondents was envisaged, in this context, minimal harm was in terms of the time the respondents took to answer the questionnaire.
Written consent to participate were obtained from the study participants
Competing interest: Authors declare no conflict of interest
Consent for Publication: Not applicable
Authors contribution
Study design and conception: Temitope H Farombi
Data collection: Olajoke Akinyemi, Damilola Adelaja
Data analysis and interpretation: Temitope H Farombi
Drafting of the article: Temitope H Farombi, Olajoke Akinyemi
Critical revision of the article: Hafiz Khan, Olufisayo Elugbadebo
Author’s detail :Temitope H. Farombi1,4, Olajoke Akinyemi2, Damilola Adelaja2, Olufisayo Elugbadebo3, Hafiz Khan4
1 University College Hospital
2 Brain Health Initiative Nigeria
3University of Ibadan
4 University of West London