Determining the Psychosocial Needs of ElderlyPeople Living in the Turkish Republic of Northern Cyprus

Background:The Turkish Republic of Northern Cyprus (T.R.N.C.) is an island country that has experienced war due to its geographical location, and which has had a tragic recent history. It is believed that those who are currently elderly mayface many psychosocial problems as individuals who have experiencing this historical process.Identifying these psychosocial problems will help to planpsychiatric services for these individuals. Methods: The data was collected through focus group interviews, which are a qualitative research method. 20 elderly people aged 65 and above living in Northern Cyprus were interviewed on a voluntary basis. Therewere 6-8 people in each focus group. A questionnaire developed by the researchers was utilised during the interviews. Results:After the focus group interview, we divided the results into four categories (psychological, spiritual, physical and socialneeds) and 12 sub-themes:thepsychological categorycontainedlosses and emotional loneliness, risk of depression and adaptation to being elderly; thespiritual categorycontained anxiety aboutdeath, and beliefs, values and culture; thesocial category containedchange in roles, change in expectations, family problems and loneliness, and the physical category containedphysical impairment due to elderliness and illnesses. Conclusion:When comprehensive and realistic information is collected regarding the psychosocial needs and problems of elderly individuals, problems that are currently tending to increase, and the expectations of elderly people are properly understood, it is possible to develop new practical models that contribute to the enhancement of services for the elderly.

expectations of elderly people are properly understood, it is possible to develop new practical models that contribute to the enhancement of services for the elderly.

Background
As the quality of life increases, the human life span is extended and the population of elderly people increases [1].Aging is a life-long change and development process. Being elderly is an inevitable and irrevocable period that is comprised of unique biological, physiological and socio-economic characteristics [2].While the periods of infancy, childhood, adolescence and adulthood are considered as growth phases, the period of elderliness is usually considered as a decline. Elderliness is a period where an individual suffers physical impairments with adecrease in abilities, and in which one is more 3 dependent on the environment and faces more mental problems. On the other hand, despite physiological issues, elderliness may notbe a period of decline, but a period in which psychosocial growth continues [3,4].
The World Health Organisation defines aging for those aged 65 and over as "the constant decline of vital functions and efficiency of an individual, and of the ability to adapt to environmental functions" [5,6].Aging is mainly analysedin terms of its chronological, biological, psychological and social dimensions [7,8].It is clear that family structures and society have been affected by the influx of population to urban areas since the early 20 th century, and the concept of the extended family has been replaced with the concept of nuclear family. Parents are left increasingly alone and unable to solve problems after their children start working and move out of the house, which generally makes the elderly individuals feel desperate, defenceless and alone [9].Therefore, the psychological needs of aging individuals have become significant and an important social issue. Elderly individuals with difficulties in adapting to new circumstances, slower mental functions, and who depend on others in order to sustain their daily lives, may start to have emotional problems such as feelings of inadequacy and uselessness, and it may become easier for various psychiatric problems to emerge [10].
Physical changes that occur in aging cause problems in psychosocial domain as well. Together with the social changes, the increase in the number of elderly individuals and life expectancy require that relevant measures be taken and thatthe number of support systems be increased [4].
With regard to the status of elderly and aging as indicated under the National Action Plan, the aim is to ensure successful and independent aging in terms of productivity, and the physical, psychological and social dimensions, while the policies and programs focus on improving the quality of life and general health [11].Assisting and supportingtheindividual, who is in a vulnerable phase as a result of changes intheir roles and responsibilities during aging, or various negative circumstances such as illnesses and disabilities, is thus vital [12]. The basis of elderly services is to ensure that the elderly feel self-efficient and happy individual. Having access to such services is a right for elderly people and it is a responsibility of society to provide them. It is crucial for the elderly to be able to live out their lives in a peaceful way so that younger generations can be hopeful for their own future. Hence, the 4 problems of elderly should be evaluated from every point of view [13].
Within the TRNC, individuals aged 65 and over comprised 7.54%, 8.1% and 10.7% of the total population according to the 2006, 2011 and 2015 data respectively [14].
In the TRNC, elderly services are provided by the state, and there are public care homes, rehabilitation centres, private care homes and nursing homes [15]. Additionally, there are "service for the elderly projects" for elderly individuals in many municipalities.
It is crucial that initiatives be provided for the elderly, who form a considerable proportion of the population of TRNC, to enable them to solve their own problems, live independently, and to support them as much as possible in participating in society. Such initiatives are vital in positively affecting the quality of life of elderly individuals. Healthy aging is not only related to individual characteristics but also closely linked with support services forthe psychosocial, economic and physiological aspects of aging. Since feelings of physical, social, economic and psychic inadequacy are more dominant particularly during this period, the services for elderly must be holistic.
Nurses have a significant responsibility in helping elderly people cope with stress by supporting their adaptation to their level of wellness, illness or the existing environment, and in providing the services they need. Just in any other phase of life, being elderly comes with new changes, experiences and problems.Identifying how to handle reactions to aging, maximizing strength and maintaining the integrity of elderly peoplewould be helpful to the nurses in fulfilling their responsibility [16].

Methods
The research was conducted as a qualitative studyusing focus group interviews to identify the needs and problems of elderly individuals living in the town of Dikmen, TRNC.The population of research consisted of elderly people aged 65 and over, who applied to the health centre in Dikmen. There were two nurses working at the municipal health centre, which was located in the centre of Dikmen. The villages in the municipality are provided with elderly care services once a month by home visits. Data saturation was reached when the sample had a total number of 20 elderly individualsaged 65 and over who had applied to the health centre and volunteered to participate. Three focus group interviews were conducted with each group of 6-8 people.

Data collection
The research data are collected through focus group interview method. The open-ended questions used in the focus group interviews were about perceptions of aging, perceptions about their own lives, opinions/ideas about aging, changes caused by aging, their needs and how they fulfilled their needs, situations that required support and the situations that affect them at the most.Additionally, there were also questions about characteristics, such as age, gender, marital status, having a child and social security, that are considered to have a possible effect on the needs and problems of the elderly.The focus groups were formed from among the elderly individuals living in Dikmen who met the inclusion criteria between 6 and20 July 2018, and the needs and problems of these elderly individuals were determined accordingly. The size of each focus group was recommended to be between 4 and 9 people [17].For this study, each focus group interviewwas conducted with 6-8 people.
In addition to the 6-8 elderly people, there were also the researcher and rapporteur. The data were recorded in writing through the rapporteur. The rapporteur was informed in advance about the aim of research, the interview questions and how the answers would be written. Before the interview, the researcher introduced himself/herself and provided information aboutthe research, and then the group members were requested to introduce themselves.The rapporteur recorded the answers given by the elderly individuals, and their needs, feelings and opinions were also recorded. Interviews were conducted with a total of 20 individuals from three groups on the 6, 13 and 20 July 2018. A meeting room at Dikmen Health Centre meeting room was used as the location for the focus groups. Each meeting took between 90 and 120 minutes. After each group meeting, the notes taken by the researcher and rapporteur were documented.

Data analysis
The research data were evaluated in two phases: log development (documentation) and content analysis. With regard to the log development, each focus group meeting was documented in writing.
Each participant was given a participation code in advance based on his or her residence and gender, and the log development form was converted into a written format. Following the log development, data coding, identification of sub-themes, organisation and interpretation of codes and themes were 6 performed during content analysis. Four experts were consulted with regard to this process in order to ensure the reliability of the categories and sub-themes. The categories and sub-themes were identified in accordance with the expert opinion.

Results
In terms of thebasic characteristics of the participants, 75% were 65-75 years-old, and 25% were 75 or over. 30% were female and 70% male. 75% of the participants were married while 25% were widowed. 65% were retired while 10% were employed. All the participants had children.
Following the focus group interviews, the psychosocial needs of elderly were placed into four categories: psychological, spiritual, social and physical needs (Table 1) "My spouse's health problemsmake me very sad.He/she can't walk yet he/she wants to go out for a picnic but he/she can only sit in one place when we go."(13M) Loneliness: "My husband is sick and can't walk. He doesn't leave home, it is difficult for him to leave. He uses a walking stick. He doesn't leave the house even though I want to."(1M) "Yes, I know that he doesn't want anybody to see him using a walking stick, that's why he stays at

Discussion
Where the statements on psychological needs were analysed, losses, loneliness, the risk of depression, and adapting to being elderly were all found. Losses occur as people start to age. The loss of spouse, friends, and status due to retirement and ill-health create a feeling that life is Risk factors for depression are complex and multifactorial [18].During aging, the change in the quality of life, and physical health problems and losses might cause loneliness to arise, and such feelings might threatenthe mental healthof elderly individuals.Decline in the trust towards other people, decline in financial support, anger, stress and fear of being exposed to violence might cause alienation and loneliness in an elderly individual [19].
Considering the statements, the fact that the participants felt regret, inadequacy due to physical illnesses, lack of hope, sadness and low energysuggest a risk of depression. The most frequent mental illness encountered in the elderly is depression [20,21]. According to a study bySucuoğlu conducted in 2012 in urban Nicosia to identify how individuals aged 65 and over maintained their daily life activities and their incidence of depression, the frequency of depression in elderly individuals was 30.9% [22]. The individual's assumptions about their future health can be analysed with by identifying their level of satisfaction about their existing age and their adaptation to changes [24]. Aközerassessedaging and the perceptions of elderly individuals, and foundthe perceptions of the elderly towards aging to benegative (13.3%), positive (84.0%) and very positive (2.7%) [25]. With regard to the statements made, those that reflect anxiety about death, including regrets about the past and losing their loved ones, stand out.
Spirituality, or theworld-views and beliefs of individuals, affects their attitudes, beliefs, values and health across their lives. It can addmeaning to the life, and help people to find the meaning in their pain by influencing their capacity to trust, love and forgive. Spiritual difficulties may arise in different ways. Such difficulties occur when a person loses a sense of meaning in their lives, believes they have no purpose or experiences feelings of hopelessness [16].In the related literature, anxiety about death is one of the factors that causes psychological illnesses among elderly individuals. The idea of death gives rise to anxiety in individuals but this may serve to reconcile the individual to life and provide meaning to their existence. It is possible to live a meaningful life when the reality of death is acknowledged [25]. Regrets about the past are considered as one of the factors that cause anxiety about death [26].In a number of studies regarding the elderly, it has been suggested that psychological services are provided to enable the aging population to acceptand be prepared for death, and not to be afraid [13].
All of the participants had negative opinions about care homes. Research has shown that elderly individuals prefer to receive care in their own homes. For these reasons, the provision of home care services has become significant. Home care services are provided by the professional organisations and include a number of domains such as health, economic and social services for elderly people who cannot receive such care fromtheir relatives [27]. On the other hand, studies about the care homes indicate that they are preferred by elderly individuals who are in need of services such as physical care, companionship and therapy and who are financially insecure [28].
The focus group members showed a tendency to tell stories about the past during the focus group interviews. Elderly people often have clear memories about their past lives and they enjoy remembering their past and sharing these memories with people who will listen to them. The "reminiscence method", first used during a group study conducted by Ebersole in 1976, has become part of psychological services for older individuals in European countries [29].
When the statements about social needs were analysed, issues such as a change in roles, change in expectations, family problems and loneliness were found. Family and society play a fundamental role in the protection, care and support of elderly. Although it seems that the spouse has the biggest role in the care of theelderlyindividual, the children are often expected to fulfil such a role due to the infirmities caused by aging; hence children become major source of support and communication.
The loss of roles or having fewer roles during the retirement negatively affects the elderly person's senseof belonging to their occupation, family and society. New and enjoyable activities need to be introduced toreplace past activities during the adaptation to elderliness, otherwise feelings of alienation from the society may be experienced and the elderly individual maybe left to themselves and feel alone. When the retirement occurs in an expected and desired way, this does not cause any mental difficulties and one can enjoy being a retired person. The opposite of this situation might 13 cause psychosocial stress. It should be taken into consideration that people who have been forced to retired or whose retirement has not been planned may be at risk of alcoholism and depression. Therefore, it is important that an elderly individual who can work and be more or less productive is able to benefit from this; this could help that person to feel useful [30].
Difficulties experienced in the social environment affect individuals in a negative way. Loneliness is caused by qualitative and quantitative deficiencies in a network of social relations. According toPeplauand Perlman (1984), loneliness is an unpleasant psychological situation due to the difference between the existing and desired social relations.Such an unpleasant situation might be considered to be related tosituations such as dissatisfaction, unhappiness, anxiety and shame [31].
With regard to physical needs, there are physical impairments related to being elderly and illnesses experienced. According toErci etal. elderly peoplewho had a better ability to care for themselveshad betterlife satisfaction and levels of hope [32].The identification of behaviours showing psychosocial problems, and the development of effective management skills,improve the chance that the patient will get better and minimize the frustration of nurses. Individualsfaced with illnesses and difficult situationsreact differentlybased on their past life experiences, coping strategies and characteristics; hence nursing should use a holistic structure that defines an individual and their own surroundings as a whole [16].
The health of elderly people should be considered in a holistic way. In elderly services a nurse should be aware of being a member of a multi-disciplinary team, know how to handle the psychosocial, emotional, environmental and physical skills, problems and needs of elderly individuals in order to provide effective and quality care, and should focus on providing psychological support to maintain and develop health.

Conclusion
There is a need to develop practices and methods to minimize the impacts of problems of aging on the daily lives of elderly, and to diversify services accordingly. Nurses havea pioneer role in establishing social environments to care for elderly adults, performing psychosocial interventions based on their needs and being aware of better methods and models that provide a scientific basis to nursing practices.New, comprehensive, practical models should be developed in order to reduce the psychosocial care needs of elderly individuals. Hence, nurses should have a full and realistic knowledge ofthe psychosocial needs and problems experienced in, and be able to evaluate the factors that affect the mental health of elderly individuals.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. interpretation of data.SM and FO contributed to the drafting of the manuscript. SM and FO read and approved the final manuscript.