Cause of Death analysis
Disaggregating cause of death data in Fiji revealed important differences in mortality trends between men and women at the national level, and populations living in rural, urban and maritime areas. A full report of cause of death in Fiji is found in Palagyi et al;(38) here we draw out some salient examples from that analysis which highlight key gender differences.
The top six causes of death in adults aged 55 years and over were the same for men and women in the 10-year period from 2008-2017, however there were important gendered differences in the burden of each disease. Men suffered a higher mortality rate for diseases of the circulatory system; respiratory illness; infectious and parasitic disease: for example, in 2017 the ASMR from respiratory diseases for men aged 55 and over was 230 (95% Confidence Interval [CI] 192-272), almost double that of women of the same age, 120 (95%CI 95-272) . By contrast, women experienced a higher burden of neoplasm deaths in every year of the ten-year period of analysis: with an ASMR of 470 (95%CI 418-536) in 2017, compared to 367 (95%CI 319-419) from men. See supplementary file 1.
Disaggregation of data by geographic area also revealed key gender differences (see Table 1). For example, there was a statistically significant decrease in the average annual percentage change in ASMR for diseases of the circulatory system in maritime areas – a key finding in and of itself – but the annual rate of decline for women (8.9% (95%CI 3.7 – 13.7)) was almost double that for men (4.6% (95%CI 0.1 – 8.8)), between 2008 and 2017. By contrast, in rural areas, the average annual percentage change in ASMR for neoplasms increased at a statistically significant level (p<0.05) by 11.7% (95%CI 6 – 17.7) annually for men, compared to a 6.3% (95% CI -0.1 – 13.1) increase for women, which was not found to be statistically significant.
Focus group discussion results
Table 2 provides an overview of all themes identified during stage one of the analysis, by COM-B component. Sub-themes listed in bold text were those that generated most discussion, on which we carried out comparative analysis to identify gender differences and similarities. A narrative synthesis of findings is presented below, while Table 3 provides illustrative examples of quotes from the FGDs, by sub-theme.
- Capability
Knowledge of health and social support services was a key theme. Both men and women identified community health workers (CHWs) as their main source of information on health service availability. Women appeared better informed about health services availability and cited specific services and clinic times. Women said word of mouth (including from the village headman) was the most common means of receiving information on social welfare support; a number commented that neither government officials nor charitable organizations visited their village. Men appeared to be better informed about government-run social welfare schemes, specific levels of financial support provided, and how to access them.
Men and women said that disability and ill-health, particularly lack of mobility, affected their autonomy, community and family engagement and ability to work. Women also mentioned the impact of disability on earnings, suggesting money was a front-of-mind concern, while men were more likely to comment on their physical capacity to perform work. Men were more likely to discuss the legacy of environmental and occupational health conditions on their health in older age.
Older men were more likely than older women to directly reference their mental or ‘psychological’ health, citing the importance of good diet, exercise and harmonious family relations to stay healthy. Women often expressed concern about the capacity of families to care for older people, the burden this placed on families and resulting in family tensions. Women were more likely to recognize that caring for the elderly was hard work, likely a reflection that women typically perform the carers’ role.
- Motivation
Both men and women spoke about the importance of values and respect for older persons and expressed a range of views on the extent to which these values were upheld. Women reflected on the care of an older person as a responsibility or a duty, while men – recalling their relationship as younger men with the previous generation – worried about the lack of respect they might receive from younger carers.
There was also sadness from both men and women that the older persons do not hold the same place in society as previously. Women feared ageing and were anxious about who would care for them as their health deteriorated, loneliness and financial insecurity. There was an awareness of these issues among women of all ages, with younger women recognizing that older women feared loneliness. Men were also concerned about ailing health and lack of family support but did not express concerns about loneliness or financial insecurity.
Men and women were consistent in expressing dissatisfaction with the process of accessing health care, with similar concerns raised in male, female and mixed focus group discussions. A key issue for both sexes was long wait times to access facility-based health care. Men also perceived that health staff were not sympathetic to their complaints and expressed lack of confidence in local (predominantly female) health workers. Women appeared more comfortable visiting community clinics. Men were more likely to go directly to hospital, despite their frustrations with long wait times.
- Opportunity
All focus group discussions highlighted family and community attitudes towards older adults. The majority (men and women) commented that children and younger relatives were less willing and able to care for older persons, and women also noted families treated them differently as they aged, ‘especially when we don’t have husbands around.’ Changing social norms and loss of traditions were also mentioned, with some viewing their community as less cohesive and caring than in the past.
In relation to the physical environment, both men and women also raised concerns about access to medication – including lack of stock at public pharmacies and the need to purchase from private facilities. Lack of access to transport to visit clinics was also a concern: women were likely to mention the cost of transport, while both noted the challenge of travelling from remote areas to clinics. Women also noted crowded waiting rooms (nowhere to sit), and female carers of older persons commented on how the health system depended on their support. However, women expressed empathy with health staff, noting health centres were understaffed and under-resourced.
Finally, the low level of social welfare support and high costs of living and medication were prominent theme in the female focus groups. As with transport, women often cited the specific costs of items, again suggesting that making ends meet is a front of mind concern. While men did mention concerns over access to financial support and living costs, they did so much less frequently than women, and typically in more general terms.
Policy Analysis Results
We identified 13 Fijian government policies, plans or strategies covering issues potentially relevant to the health and social care needs of older persons (see Box 1). Of these, three included objectives or commitments focussed on older women: National Policy on Ageing (NPoA, 2011-15); Fiji National Gender Policy (2014); and Ministry of Health Corporate Plan (2018-19). Table 4 contains all text from these documents on policy commitments or recommendations relevant to gender and ageing – in all cases this was very limited, with little detail on governance, financing, target setting or monitoring.
When comparing these policy documents against the accepted pillars of policy development – such as problem identification, policy formulation implementation and evaluation(39) – further gaps emerge. Only the NPoA had a clear problem analysis in relation to gender and ageing. It recognized that women made up a larger proportion of the older population and that they were more likely than men to be disadvantaged, particularly in rural areas. It stated: “Older women […] are likely to have lower education, less work experience, lower income and poorer access to assets than men, as well as diminished authority and autonomy within the family. Hence, women are more likely to be dependent, both upon the family and on public welfare programmes, especially at advanced ages and under conditions of illness and disability” (p.6).
The NPoA’s policy formulation related in part to its own problem analysis, focussing on awareness raising of older women’s needs, and older women’s role as carers. However, it did not address the issues it identified of older women’s poverty and vulnerability, and higher burden of ill health and disability. Of four Goals, 10 Objectives and 21 strategies set out in the NPoA, only one Goal and two strategies specifically mention older women. Further, there was no information on the process of policy adoption (how support for the policy will be secured) nor arrangements for implementation or monitoring.
The Fiji National Gender Policy did not articulate a process of problem analysis, policy development, or target setting in relation to older women’s needs. Rather, it mentioned older women in relation to a single issue: security. The Ministry of Health’s Corporate Plan encompassed older women in broad statements on gender equality and tailoring services to the needs of vulnerable groups but did not contain substantive information on how identified problems would be addressed.
Other relevant policies identified recognized either the needs of women, or the needs of older persons, but not older women. For example, the Fiji National Financial Inclusion Policy recognized that women were more likely than men to be excluded from financial services, such as not having a bank account, but the specific financial needs of older women were not mentioned. Similarly, the National Development Plan calls for improved data and evidence on the needs and poverty status of older persons, but not for disaggregated information on older women.