Demographic changes such as the increase in people aged 60 years and above have created a structural lag in many developing countries of South-East Asia like Pakistan that lack organizational structures and institutional capacities to meet the demands of older persons [1, 2]. According to the latest available statistics, Pakistan was ranked the 5th worst country for older adults [3]. There are more than 15 million people aged 60 years and above in Pakistan, and the projections show that the number will become 40 million by 2050, making them 12% of the total population [4]. A similar trend can also be observed in other South-East Asian countries bringing challenges such as the provision of healthcare facilities, transportation, jobs, recreation, housing, and increasing the number of different types of senior care facilities such as old age homes, nursing homes, assisted living facilities, retirement homes, and residential care facilities for older adults [2, 5–7]. Some of the studies from this region conducted on senior care facilities have stressed to increase the number of such facilities due to the increasing population of older adults, demand for healthcare systems, housing, changing preferences of older persons to live in such settings to avoid loneliness, abandonment of parents by the children due to changing norms of filial piety and familial care-giving, and increased abuse and neglect of older adults in home settings [1, 2, 6, 8–11]. Abuse and neglect of older adults is a significant public health problem. However, there is no nationwide screening system in Pakistan for such abuse available yet [12]. Some of the academic studies have reported high prevalence of abuse in older adults in Pakistan. For example, Hashmi et al. found that 53.3%, 39.3%, and 53.5% of the older adult’s in two hospitals in Lahore, Pakistan, reported abuse, neglect, and loneliness, respectively. Of those who reported abuse, 56.6% were females [12]. Likewise, a study by Zaidi et al. [13] reported appalling condition of older adults in relation to abuse. Mushtaq and Ali [14] found that 42% and 41% of the older adults in Quetta, Pakistan experienced neglect and abuse, respectively. A study in Nepal found domestic abuse to be one of the significant motivations for older adults to move to old age homes [8]. It is important to highlight that older adults may be at higher risk of experiencing abuse and lower well-being in these senior care facilities as described in many studies [15–19].
Old age homes are the common residential setting for older adults in South-East Asian countries providing accommodation, food, clothing, recreation, and basic healthcare. However, they are often stereotypically labeled as homes for older adults who have been neglected and abandoned by their families [2, 5, 20, 21]. Gerontologists and Geriatricians point out that low life satisfaction, lesser perceived control, and poor well-being may not be an outcome of aging as older adults in vulnerable settings are at a higher risk of experiencing these negative consequences as compared to other groups of older adults [1, 2, 5]. For example, studies have found that older adults who relocated to senior care facilities were at higher risk of having lower well-being and higher depression than community dwellers [22–24]. This can be theoretically explained by the continuity theory which posits that older adults seek stability and consistency in their environment instead of change. In this context, the physical environment such as one’s residence represents a sense of self, personhood, identity, meaning, and a network of embedded relations [25, 26]. This argument gains strength from the person-environment model which explains that relocation to a new setting entails detaching oneself from the meanings that the previous residence held for the person, resulting in negative consequences such as loneliness, loss of social ties, maladjustment, depression, and lower well-being [26–29]. Studies on relocation point out that voluntary relocation to senior care facilities involving choice and control followed by a supportive environment at these settings and compatibility of new residence with the previous one are the primary determinants of well-being [29, 30]. Well-being has long been considered to be an important indicator of general health in older adults and, thus, a significant determinant of successful aging [31, 32]. Many researchers have conceptualized well-being as a multidimensional construct and stressed to measure it along the three dimensions of physical, psychological, and social well-being [33–35]. Nevertheless, very few studies conducted on senior care facilities have focused on all three types of well-being [33, 34].
The published research literature on senior care facilities in Pakistan is scant. Very few studies have been conducted on old age homes, and the exact number of old age homes and the older adults residing in these senior care facilities in Pakistan is not known [1, 2, 5, 6, 11, 36]. Some of the studies conducted on these facilities have reported poor quality of life of older adults due to a lack of financial, structural, and social support [1, 2, 5, 6, 36]. No study was found that empirically investigated the well-being of older adults in these settings. Therefore, this study is the largest of its kind in Pakistan. The aim of this study was both empirical and normative, because it investigates the factors that determine the well-being of older adults in old age homes, a marginalized and neglected setting in Pakistan [1, 2]. It is very important to oversee and evaluate the working of such facilities to ensure the well-being of older adults. The study hypothesized that higher relocation autonomy, lower loneliness, and higher satisfaction with staff and services will be related to higher well-being of older adults living in old age homes of Punjab, Pakistan [22, 33]. Although abuse and neglect were not measured directly in this study, proxy variables such as relocation autonomy, loneliness, satisfaction with staff and services were considered to be reasonable indicators to assess neglect experienced by older adults in old age homes. The study has the potential to expand the current knowledge on (i) neglect of older adults by assessing loneliness, autonomy, and their living conditions, (ii) relocation of older adults to senior care facilities, and (iii) factors determining older adult’s well-being in these facilities. Additionally, the study contributes to clinical and research practices by providing psychometric validation of different scales that can be administered to older adults in old age homes and other senior care facilities. By providing pragmatic interventions, this study is also expected to sensitize policymakers and relevant governments in Pakistan to address the problems of older adults living in old age homes.