Factors contributing to the mental wellbeing of community-dwelling older adults: A qualitative study from the Vancouver West End

doi:10.21203/rs.3.rs-2603067/v1

Background

For the first time in Canada, the population of people over the age of 65 exceeds those under 15 years old. With the aging of our population, there is a growing urgency to improve the mental wellbeing of the older adult population in Canada. It is important to understand the factors that affect the mental wellbeing of the diverse population of older adults to create interventions or services that will best address their unique needs.

Methods

We conducted semi-structured interviews with older adults from the Downtown West End of Vancouver, a highly diverse neighbourhood with various sub-populations that experience marginalization, to explore factors that contribute to their mental wellbeing. Four main topics were discussed: (a) perceived (self-reported) mental health, (b) contributors to good mental health, (c) access to mental health services, and (d) future mental health interventions.

Results

Our findings generated four overarching themes that contribute to the mental wellbeing of the population: 1) having a sense of stability over personal circumstances, 2) being able to do, 3) positively impacting others, and 4) feeling a sense of belonging.

Conclusion

The themes that were captured in this study can allow community-based and health organisations to build interventions or services that target the mental health concerns of diverse CDOA in Canada and beyond. Additionally, the results can be used to aid future researchers in developing interventions and services that put the mental health needs of older adults at the center of creation and design.

Mental health

community-engaged research

community-dwelling older adults

marginalized populations

diversity and inclusion

health access

Most Global North countries, including Canada, are experiencing population aging triggered by low fertility rates and rising life expectancy (Statistics Canada, 2022). Recent data from Statistics Canada found that over 861,000 people aged 85 and older were reported in the 2021 Census, which equals to 2.3% of the total population in Canada. This represented 90,000 more people than in 2016 and double the number in the 2001 Census (Statistics Canada, 2022).

Late-life mental health concerns are often overshadowed by physical health in older populations. However, mental health challenges are commonly experienced in older adult populations, with estimates suggesting that depression is more common than dementia in later life (Allan, Valkanova, & Ebmeier, 2014). Late-life mental illness has been associated with impaired independent and community-based functioning, impaired cognition, poor medical and health outcomes, increased comorbidity, compromised quality of life, and increased rates of disability and mortality (Laborde-Lahoz et al., 2015). Poor mental health among older adults has also been correlated with increased rates of health care utilization, placement in long-term care homes, burden on medical care providers, and higher annual health care costs (Aschbrenner et al., 2011; Zivin, Wharton, & Rostant, 2013). Despite the high prevalence of late-life mental health concerns and evidence for the efficacy of interventions to ameliorate these concerns, poor mental health is underrecognized and undertreated in this population. It is estimated that approximately half of older adults with recognized mental disorders do not receive mental health services (De Girolamo et al., 2012). Older adults are unlikely to use traditional clinic-based mental health services for a variety of reasons, including physical frailty, transportation difficulties, isolation, and stigma (Stewart, Jameson, & Curtin, 2015). Additionally, the presence of mental health challenges in older adults is associated with increased health care costs, even after accounting for mental health-specific treatment costs (Unützer et al., 2009).

Because poor mental health in the older adult population is under-recognised, it is important to use a community-based approach to understand the factors that impact the perceived mental health of older adults to support the investigation of crucial mental health resources and services that this population needs. Perceived mental health is a subjective measure of overall mental health status and does not directly correspond with diagnosed mental disorders, which is important and immensely affects quality of life (Mawani & Gilmour, 2010).

Additionally, we sought to understand the mental health priorities of community-dwelling older adults (CDOA), namely, how they define good mental health and how community-based services can support the mental wellbeing of this population. It is limiting to assume that all members of the older adult population share the exact same needs and require the same standardized mental health services. Canada has a diverse older population with substantial variation in terms of age, gender, culture, religion, language, socio-economic status, and sexual orientation (Statistics Canada, 2021). An expanded understanding of this field is necessary if the health system is to effectively serve the diverse aging Canadian population. As there is currently a paucity of mental health research on diverse CDOA (Garrido et al., 2009), this investigation aims to fill a gap in the literature and guide future community-based mental health interventions or services.

In-depth semi-structured interviews were used to understand the participants’ mental health priorities. The interviews explored four main topics: (a) perceived (self-reported) mental health, (b) contributors to good mental health, (c) access to mental health services, and (d) digital mental healthcare delivery. The interview guide included questions such as “what are some of the mental health services that you have used?”, “what are the barriers or difficulties you face when accessing mental health services”, “in your life, what has been the biggest contributor to your mental health (positive/negative)?”, and “describe your mental health in the past month”.

The semi-structured interview process was chosen to encourage the interviewees to openly discuss their own feelings and experiences of mental health while maintaining some structure to the interviews. Semi-structured interviews are neither free conversations nor highly structured questionnaires (Galetta, 2013). This approach allows researchers to regulate the order of the questions to match the flow of the conversation and enables respondents to expand their ideas and speak in detail rather than relying only on pre-defined concepts and questions. This is especially important when speaking about stigmatised and difficult topics, such as mental health, as the participants will have control over the flow of the conversation (Magaldi & Berler, 2020). Additionally, in-depth semi-structured interviews are inclusive in allowing participants with low levels of literacy to participate, as completing surveys or questionnaires may be difficult (Guion et al., 2011).

Recruitment

Older adults from the Downtown West End (DTWE) of Vancouver were recruited to participate in semi-structured interviews to understand the beliefs, experiences, attitudes, and underlying feelings about mental health of CDOA. The DTWE senior population is highly diverse, with various sub-populations that experience marginalization and discrimination due to their race, ethnicity, socio-economic status, and gender/sexual orientation (Frank et al., 2010, p. 8). We therefore focused on these sub-populations during recruitment. The inclusion criteria for recruitment included: older adults over the age of 65, living in the DTWE at the time of recruitment, living in the community (i.e., not an assisted living facility or other care homes), able to speak and understand English, and able to understand and consent to this study.

Data Collection

A semi-structured interview guide was used for the interviews. This guide was developed by three of the authors (IR, LK, and SD) to understand and capture the unique factors that impact the mental health of CDOA. All the interviews were conducted by one researcher (IR) and the questions asked were open-ended and designed to encourage participants to provide rich descriptive data. Interviews were no longer than 60-minutes and were conducted through the interviewee’s preferred video-communication platform (e.g.., Zoom) (N = 12), or in-person (N = 3) following COVID-19 social distancing protocols. Interviews were audio-recorded, and memos of participant information and any non-verbal cues that emerged during the interviews were created. Honoraria of $25 in the form of a gift-card were provided for participants.

Analysis

Following Braun, Clarke, & Hayfield’s (2015) approach to thematic analysis, we began with transcription of the interview recordings and performing line-by-line coding using NVivo 12, a data analysis software. Notes were created for each interview by the researcher to keep track of the basic characteristics of each participant and any relevant field notes, aiding with the creation of initial codes. The initial codes were then read, reread, and organized into higher order codes. The higher order codes, along with relevant quotes from the transcript, were migrated into a Microsoft Excel sheet where themes were developed. Exemplar quotes were reviewed by three authors (IR, LK, and SD) to ensure consensus on the content and nature of the themes. IR has been an active member of the DTWE community and was able to provide unique and personal input on the analysis and interpretation of the data.

The participant sample consisted of 15 CDOA over the age of 65 who volunteered to participate after reading the study description and consent form. CDOA were initially recruited through our community partner, a senior-serving non-profit organisation in the DTWE. Seven of the 15 older adults recruited identified themselves as members of the Lebian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) community and the majority (10 out of 15 participants) are ethnic minority older adults. The characteristics of the study participants are presented in Table 1.

Table 1. Demographic table of participants

Demographic Variable	Category	Frequency	Percent
Age	65-70	7	46.6
	71-75	5	33.3
	76-80	2	13.3
	80+	1	6.6
Gender	Male	5	33.3
	Female	10	66.6
Household Status	Living alone	14	93.3
	Living with other family members	1	6.6
Highest Education Attainment	Grade School	1	6.6
	High School	4	26.6
	College diploma	4	26.6
	Undergraduate	3	20
	Master's	2	13.3
	Doctorate	1	6.6
Identify as low-income*	Yes	12	80
	No	3	20
Ethnicity	Caucasian	5	33.3
	South Asian	3	20
	East/Southeast Asian	4	26.6
	Persian	3	20
Identify as LGBTQ+	Yes	7	46.6
	No	8	53.3
* LICO cutoff <$26,620/year Based on poverty line in urban areas of Canada, with a population of 500,000 or more

Based on our thematic analysis, four themes were derived from the interview data demonstrating the factors that most significantly impact the mental wellbeing of CDOA in the Downtown West End of Vancouver. These include:

Sense of stability over personal circumstances
Having the ability to do
Creating a positive impact on other peoples’ lives
Feeling a sense of belonging

Sense of stability

All participants expressed that, as they age, their mental health has been affected because they feel that they are losing control over their life at an old age, an age where they are supposed to feel the most stable. Thai includes control over their bodies, their judgements, their time, and their independence. One participant (F, 78) referred to “stability” as being “in control, even when everything is spiraling down”. The two senses of stability that participants mentioned most often were financial and relationship stability.

Financial stability was mentioned by majority of the participants as an important factor that impacts their mental wellbeing. Many of the participants who reside in the DTWE are low-income older adults. A lack of financial security was identified as a factor that participants felt contributed to having a good quality of life, including having access to healthy diets, proper housing, transportation, and adequate health services (i.e., dental, vision, and mental health services). One participant (M, 67) said:

“Every now and then, I can certainly feel that I should be saving [money] and that I should have saved. I certainly worry about money more than most seniors, and this really gives me anxiety. I'd like to see some counseling services provided for free or for low cost to those seniors who can't afford it. Because mental health is just as important as physical health, and seniors have made an enormous contribution to our society. They deserve the respect and consideration and help if they need it.”

Participants identified that factors impacting one’s sense of stability also included relationship stability (the ability to rely on others). Many older adults find comfort and unwavering support in a good network of family or friends as they age, as well as the routine that they have built, such as one participant (F, 74) who said:

“I have very good friends who are around my age and who live near me. So, and we've all – I wouldn't call it a family relationship, but we're very good friends, and we're there to support and help each other and just to [have] social action, just to get together for a drink every week. It makes me look forward to it.”

On the contrary, social isolation — especially during and after the COVID-19 pandemic, where social restrictions have prevented people from communicating face-to-face — had a detrimental effect on the mental health of CDOA. One participant (F, 72) mentioned the fear and anxiety that they experience living in isolation:

“I fear of something happening to me and having no one around. Like, my husband was sick for several years and then I took care of him until he passed. And… but now, there's nobody for me.”

Additionally, when the COVID-19 pandemic occurred, many older adults found difficulties with maintaining their interpersonal relationships. This is especially true with those who had limited access to technology. One participant (M, 82) explained the difficulties with activity continuation using technology:

“I used to go down to [a community center] for a physical meeting with my choir. It’s sort of a seniors’ choir and songwriting class. Since the pandemic, it's all virtual and online, so we're doing zoom meetings, but there's always some kind of technical issues with some people or me not being able to join or start the video… And I had troubles, because I had a really old computer and then I had to buy a new computer”.

Having the ability to “do”

Many participants mentioned that dealing with their ongoing health issues and experiencing physical decline has been the most significant barrier to performing hobbies and activities that they used to do, which in turn negatively impacts their mental wellbeing. One participant (F, 70) explained:

“When you're aging, you’re dealing with more health issues. For example, I suffer from high blood pressure, so I take high blood pressure pills. I also suffer from osteoporosis, so I take medication for that. You know, you're finding that you can't really do some of the things that you used to do in your youth. You can't walk as far without feeling some pain. You know, your mental facilities, although I try to keep myself as engaged as possible, your mental facilities sort of declined.”

“Doing” is more than just participating in current activities, it is also about the loss of one’s ability to do an activity and finding joy in compensating. With declining physical health, some have taken an interest in less physically involved activities. Many older adults have gained newfound enjoyment in art-based activities such as music or painting, hobbies that were not in their repertoire in their younger days. One older adult (F, 73) took up a new activity and reported:

“When I retired when I was 71, I took up singing lessons. I had never sung in choirs, but I decided – I’d never done singing lessons, so now I'm taking singing lessons, and they bring me huge joy, I have to say, I get to sing whatever I want! So, right now, I'm singing Bach, who could believe that? I can do whatever.”

However, for participants who feel that they are still physically able and active, often their biggest barrier to pursuing activities is their safety. As racially-motivated crimes in the DTWE have increased after the COVID-19 pandemic, particularly towards the Asian/Pacific Islander population in Canada, some older adults found that their daily walks around the neighbourhood, which once brought them joy, have become burdensome. Two Asian-Canadian participants (F, 68; F, 68) said:

“I was attacked by a white man, about a month ago. I was taking a photo of a tree and then I turned to take a selfie, and I heard a man's voice saying, “hey, I want to ask you a question!”. And I knew, with the tone and the loudness of where it was coming from, behind me, I knew that something bad was going to happen, but I had to look to see who it was. I turned around and that's when he just, boom! Pushed me to the ground.”

“Someone said to me: “you know, it's Kung flu!” and blaming [COVID-19] on China, you know, and those people think that way. a lot of times, like a LOT of times, I even forgot that I was Asian, until I got attacked. Then I [remember] oh yeah! I have to be careful now, you know, because I look Asian to people. But in my mind, I'm Canadian. I love going for a walk, I walk around the Seawall, walk around Stanley Park, and usually, I would go by myself. But now, after the attack, it’s… different.”

Creating a positive impact on other peoples’ lives

Helping others has allowed older adults in the community to feel empowered. For older adults with the skills and capacity to volunteer, it was said that it is “one of the greatest gifts that I can leave behind for the community.” The idea of changing other peoples’ lives for the better has been reported by one participant as a major contributor to their mental health:

“I work as a volunteer peer support person. So, I have four clients right now and I talk to them once a week or more than once a week. One of them I'm going to start with Zoom next week. So, it keeps me in contact with other people, how are they doing. I'd like to think I contribute somewhat to their mental health, their good mental health, so that in turn helps with mine.”

Teaching is one of the many ways that older adults can positively contribute to the community. One participant mentioned that teaching gave them a “sense of purpose” and positively impacted their mental wellbeing.

“I still contribute to my community in whatever way I can. I teach yoga because that gives me a great deal of pleasure. I also have education, which is not a professional degree but a diploma. At some point, when I got more out of my shell, I found that I really liked to teach. I like to help people turn their light bulbs on and partially that was because I learned so much, I learned more than my students ever learned.”

Feeling a sense of belonging

As many of the older adult residents of the DTWE belong to under-represented groups, the feeling of belonging to and acceptance within their community has been a life-long objective. LGBTQ+ participants specifically spoke about breaking away from social labels, which allowed them to live authentically, start thinking of their own goals in life, and do what makes them happy. One participant (M, 67) stated:

“Part about mental health, I think, was the fact that we were encouraged to be who you are. One can be a doctor, the other can be a cashier in a grocery store, and both can be happy, and neither is elevated, and I think having the opportunity to challenge that within yourself is part of the ongoing condition of mental health.”

Breaking away from stereotypes can feel uncomfortable, but it begins the path to self-acceptance. Part of feeling a sense of belonging is accepting oneself and creating a sense of purpose. As one participant (M, 70) described:

“Satisfaction with yourself, and I don't mean a self-satisfied image, I mean a true acceptance of who you are and what you've done is everything. And I suppose there's also a component there that you still have a place in the world. A very big one, that what you can do could still matter in the world.”

Aside from self-acceptance and individuality, most participants mentioned that feeling a sense of belonging ultimately stems from being part of a community. Whether it is a spiritual or religious community, communities based on identity (e.g. queer communities, communities based on ethnic backgrounds), or geographical-based community such as the DTWE, they ultimately allow people to feel like they belong. One participant (F, 74) stated:

“I'm on the board of a community of an organization that’s just reinventing itself. And I've been part of it for five years, it's trying to have an impact on the condition of LGBT seniors in Vancouver. I feel like it’s where I’m supposed to be, considering my own identity and what I have been through.”

To further this point, another participant (F, 68) explained that belonging to an online community allowed them to gain support and initiate conversations around the hate crimes, which helps them cope and not feel alone in dealing with a traumatic experience:

“I've joined an Asian-Canadian Writers [Facebook] Group and I started to post things about Asian hate crime rising, because I've seen things on the news. And so, no sooner after I posted something like that, other people were talking about it in the group. So, it had so many responses from people I don't even know, and all supporting me! So, it does help.”

This study identifies key factors in the lives of CDOA that improve or worsen their mental wellbeing. These factors highlight actionable items for community-based senior-serving organisations to improve the mental wellbeing of members of their community.

Having a sense of stability, including financial stability, was one of the major points discussed by all participants, as many older adults who live independently in the west end community are low-income. The topic of money was not part of the interview guide, but participants were quick to speak on their financial situation when asked about the biggest contributor to their mental health as an older adult. In the ethnically diverse neighbourhood of DTWE, lack of financial stability has caused CDOA to worry about housing, food, and preventative medical treatments (such as dental, vision, and mental health services). Consistent with our results, previous studies have shown that stress over money is the main cause of mental illness in ethnically diverse neighbourhoods due to lower education and generational poverty that are prevalent in racialised communities (Jimenez et al., 2012).

CDOA in the DTWE have always relied on activities in the neighbourhood to fulfill their social and physical needs. DTWE falls in the “Sweet-spot” neighbourhood (relatively high walkability/low environmental pollution) of Metro Vancouver, which attracted many older adults to age in place in this community (Frank et al., 2010, p. 8). Walking to the grocery store, bank, and community centre for seniors’ activities have always been achievable by those who are not homebound. However, the COVID-19 pandemic has halted many activities and events that older adults usually attend (Lebrasseur et al., 2021). In a population who rely on mostly in-person community events to create and maintain social relationships and perform physical activities, the circumstances of the COVID-19 pandemic were debilitating. The pandemic has also affected the community members’ feeling of belonging as it hindered face-to-face communication, which distanced community members from one another. This was especially difficult for marginalised members of the community as the pandemic restrictions prevented cultural-based or LGBTQ-based activities that foster feelings of belonging. This study highlights those with marginalized intersections of identities, including those within gender and ethnic minorities, found that having a sense of belonging, specifically having chosen families, is one of the main factors that contribute to good mental health. The shared adversity and feelings of “otherness” that many marginalized groups face, lead to feelings of isolation and loneliness (Shankar et al., 2017). Participants have mentioned that being with others who can relate to their stories and treat them with kindness is ultimately the main factor that can alleviate their isolation and improve their mental health.

Based on the results, senior-serving organisations should incorporate programs and services that foster stability (independence), leisure, positive actions, and social connectedness. Programs such as social prescribing (Drinkwater, Wildman, & Moffatt, 2019), volunteering opportunities, artistic clubs, language classes already exist in-person and have been shown to have had a positive impact on older adults’ mental health. However, one major area of improvements that still needs to be done is in the area of digitally-delivered programs and digital literacy. With the COVID-19 pandemic and lack of access to mental health services for CDOA, there is a push towards the creation and popularisation of digital-based mental health services and interventions (Cosco et al., 2021). The four themes identified in this study can be used as a framework to create a digital curriculum that can allow older adults to tackle these factors that impact their mental wellbeing using technology. This can particularly be useful for homebound or isolated older adults who may not have the opportunities to attend existing in-person social programs or services.

Additionally, the themes identified in this study can be used by senior-serving organisations to see the shortage of important services within their neighbourhood or organisations. For example, this study has highlighted the importance of financial stability on the feeling of independence and the mental wellbeing of CDOA. Therefore, there is a need for a financial education program for older adults or leisure activities that are free of charge within communities.

Limitations

The findings of this study must, however, be interpreted within the context of its limitations. Firstly, the overall demographic profile of older adults in the DTWE is not known. Purposeful sampling was done by IR, who is an active member of the DTWE community and a volunteer at the senior serving organisation located in the neighbourhood. The purposeful sampling of LGBTQ+ and ethnic minority older adults was based on the demographic of the active members in the senior organisation and may not accurately represent the demographics of the neighbourhood.

Additionally, as the study was conducted during the height of the COVID-19 pandemic, the researchers were unable to conduct interviews within the homes of older adults, which may have caused us to miss important cues and information stemming from interacting with this population within their personal environment. Further, as recruitment was completed through physical posters within the community organization and through social media, our study is unable to account for the experiences of homebound older adults who do not use technology.

Finally, the topic of mental health can be quite sensitive, particularly within the older adult population. Confidentiality was emphasized when speaking to the participants. However, some individuals may still have felt uncomfortable speaking about their personal struggles with mental health and well-being due to the sentiment that it is a private matter. For some participants, especially those who are of Asian descent, mental health was generally viewed as having a successful life (career, family, finances), and they may have been brought up in life with that mentality (Kudva et al., 2020). Due to the interviewer’s positionality as an Asian woman, these participants may have had difficulty speaking openly about any distress they were experiencing because it may be embarrassing to “admit failure.”

Future Directions

Our study has pinpointed strengths and limitations with using a community-based approach, specifically in using semi-structured interviews to discuss mental health with marginalised populations. Future research on this topic should consider the positionality of the interviewers when conducting semi-structured interviews with community members. Additionally, interviews regarding this topic should be conducted in-person whenever possible to capture any non-verbal cues. In-person interviews are also important to make the opportunity to speak about this topic more accessible to those without access to technology and those who are homebound.

This study has expanded the conversation on late-life mental health and pinpointed important factors that contribute to the mental health of diverse older adults. We found four overarching themes that contribute to the mental wellbeing of CDOA: 1) Having a sense of stability over personal circumstances, 2) being able to do, 3) positively impacting others, and 4) feeling a sense of belonging. The themes that were captured in this study can allow community-based and health organisations to build interventions or services that target the mental health concerns of diverse CDOA in Canada and beyond.

CDOA: Community-dwelling older adults

DTWE: Downtown West End

LGBTQ+: Lesbian, gay, bisexual, transgender, Queer, and others.

Ethics Approval and Consent to Participate

Signed informed consent form was obtained from all participants recruited. The experimental protocols of this project has received the ethics approval from Simon Fraser University Research Ethics Board (REB# 30000236). All methods were carried out in accordance with guidelines and regulations that were approved by the research ethics board at Simon Fraser University.

Consent for Publication

Not applicable.

Availability of Data and Materials

The informed consent form and interview guide are included in the supplementary information files of this article. The datasets analysed for the current study are not publicly available due to the presence of identifying information in the interview transcripts. The datasets used and analysed in this study is availabel from the corresponding author upon reasonable request. The datasets will be de-identified prior to distribution.

Competing Interests

The authors declare that they have no competing interests.

Funding

IR is supported by Mental Health Research Canada (MHRC), Mitacs Accelerate, Simon Fraser University Community-Engaged Research Initiative (CERi), and AGE-WELL. The views expressed are those of authors and not necessarily those of MHRC, Mitacs Accelerate, CERi, or AGE-WELL

Acknowledgements

Not Applicable

Authors’ Contributions

All authors contributed to the development of this manuscript. IR developed the research objectives and questions, conducted recruitment, interviews, data analysis, and prepared the manuscript. TDC supported in refining the research question, provided data analysis expertise, and contributed to the final draft of the manuscript. LK, SD, SH, and VA supported the editing and revising of this paper and have approved the final manuscript for submission.

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No competing interests reported.

Factors contributing to the mental wellbeing of community-dwelling older adults: A qualitative study from the Vancouver West End

Status:

Version 1

Abstract

Background

Methods

Recruitment

Data Collection

Analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1