Older Adults ’ Perception of Their Needs in Tehran : A Cry for Emotional and Social Support

Introduction: Background and purpose: Human’s longevity has increased with advances in health and better management of communicable diseases. Therefore, the number of older adult is increasing in developed and developing countries. A glimpse at studies reveals that identifying elderly’s health needs has been mainly based on the experts’ understanding, while older adult themselves have rarely expressed their own opinions. This study aimed to better understand Tehran, Iran elderly’s perception of their own health needs. Methods: In this qualitative study, with purposeful sampling, data was collected by conducting deep semi-structured interviews with elderlies aged 60-84 years, residing at their private houses. After 19 interviews, the data achieved saturation. The content of the interviews was analyzed through content-analysis approach. Results: Data analyses led to extracting main categories of needs in different domains. The main health needs in physical health domain included: having a healthy lifestyle, independence and safety. Regarding elders’ mental health, coping with their aging, inner tranquility; regarding their spiritual health, the need to have a meaning in life and faithfulness in religion were identified as main groups of needs. And the most important among their main social health needs were the needs for emotional and social support, social involvement and instrumental social support. Conclusion: Although, a wide range of physical, mental and social needs were raised, some were more important. Fulfilling the emotional needs in social health had the highest frequency among the needs expressed by the contributors. Following that with a notable difference were the frequencies of having a healthy lifestyle, independence and inner tranquility. This means that attempts to address elderly health needs should avoid focusing mainly or even only on disease related needs and serious attention should be paid to their emotional and social needs.


Introduction
Humans' longevity has increased with advances in health and better management of communicable diseases, and the number of older adult is increasing in developed and developing countries (World Health Organization (WHO), 2012).According to World Health Organization, the world is aging rapidly, and the ratio of above 60 age group is moving faster than any other age group (WHO, 2012).Population studies in Iran show that the country is ageing, percentage of people aged 60 and above has increased from about 5% in 1956 to about 8.2% in 2011 (the country's last census).According to estimations, by 2025, older adults would have formed over 10% of the country's population (Statistical Centre of Iran (SCI), 2011).With regard to Tehran's elderly population status, the statistics show that the elderly population of Tehran has increased from 3% in 1956 to 6% in 2006 and then has risen swiftly to 8% in 2011.It is estimated that 13.3 of the country's elderly population are residing in Tehran (SCI, 2010;Toohidi, 2011).This indicates the importance of identifying their real health needs and addressing them.
Increased physical and mental chronic diseases, as well as cognitive and functional impairments give rise to the importance of elderly's health issues (Hung, Ross, Boockvar, & Siu, 2011;Marengoni et al., 2011;Prince et al., 2014;Suzman, Beard, Boerma, & Chatterji, 2015) .In addition, reduction of relationships and social networks, losing spouse and relatives have made maintaining a healthy lifestyle a great challenge (World health Organization, 2002).However, there has not been adequate attention on older adult as a vulnerable target population (Adib-Hajbaghery & Aghahoseini, 2007).
An overview of studies reveals that there have been very limited qualitative studies regarding older adult's perception of their own health needs.Most studies have used quantitative approaches mainly based upon the experts' subjective verdict (Adznam et al., 2009;Barati, Soltanian, & Moeini, 2012;Scott & Corley, 2012;Alizadeh, Fakhrzadeh, Shariei, Zanjari, & Ghasemi, 2013;Heidari, Gholizadeh, Asadolahi, & Abedini, 2013;Mcmillan, Mclntyre, Hamilton, & Watts, 2013;Najafi et al., 2013;Motlagh & Taheri, 2014), while elderly perception of their needs is equally important since their perception of their health needs may not necessarily conform to the experts' perception.Therefore, the present study aimed to identify needs from both perspectives.Here, only Tehran older adults' perceptions of their health needs were reported.

Methods
This qualitative study was conducted using heuristic method (Creswell, 2013) to show Tehran Farsi-speaking elderly's perception of their own health needs.Utilizing purposeful sampling with the highest diversity (Creswell & Clark, 2011) (people aged 60 and above; male and female; educated, literate and illiterate; single, married, and widow; and also of different age groups), participants were selected.Tehran 22 municipal districts were divided into five geographical parts and one district was randomly chosen from each part.Two healthcare centers were chosen as the location of interviews.Before each interview, an Abbreviated Mental Test Score (AMTS) (Bakhtiyari et al., 2014) was used to make sure that none of the participants suffers from cognitive problems (score of seven and more in the test was acceptable).The process of sampling continued until the data was saturated (Creswell, 2014).After conducting 15 interviews, the data became repetitive.Yet, to make sure that the data is saturated, four additional interviews were conducted.Ultimately, 19 participants were interviewed.The interview sessions were tape-recorded with the participants' consent and were transcribed verbatim which formed the study data.
This study was approved by the ethics committee of Shahid Beheshti University of Medicine Sciences with number SBMU.REC.1393.682.All the participants were aware of the purpose of the study and secrecy of their names.Informed consent form was obtained from those who agreed to participate in the study before interview.

Participants' Characteristics
The diversity of participants was good including 10 male and 9 female; 5 with university degrees, 2 with high school graduation degree, one with unfinished high school education, 5 with elementary school education and 6 illiterate; 13 married and 6 widows/widowers.Majority of them were retired or housewives, 5 were active businesspersons or in voluntary activities.

Physical Health Needs
In response to the question regarding their physical health needs, participants referred to different factors directly or indirectly as their needs to achieve, maintain or promote their physical health which is divided into three main classes: healthy lifestyle, independence and safety.

Healthy Lifestyle
Almost all the participants mentioned that to have a physically healthy life, it requires suffering from no diseases.Some of the identified needs for physical health from their perspectives included proper nutrition (with highest repetition in interviews), having health related knowledge, maintaining mobility, avoiding high risk behavior, and self-care to stay away from diseases, all referred to as a "healthy lifestyle".Some participants believed that fulfilling any of the healthy lifestyle prerequisites, itself required some conditions.For example, some interviewees stated that having a proper diet requires good nutrition knowledge, food purchasing knowledge and skills management, and money to cover the costs of a healthy lifestyle: "…we always consider using vegetables, chicken and fish especially fish.….For example my spouse and I put meat in stew for guests but if it is for only us, we put chicken (as meat is more expensive).We pay attention to such things a lot…I am not so into salty or oily food" (68 year-old, male).Or regarding the ability to pay for healthy food a 63-year-old woman stated: "…they always talk about olive oil and stuff.Ok.Can everyone buy it?The only way is to change their propaganda style.Olive oil costs 9 dollars a bottle, right?… I cannot buy it…, what is the best way?I can barbeque my eggplant…" In addition to healthy diet, older adult reiterated that physical activity and exercise were vital for gaining healthy body.Most participants were eager to learn about such issues from the media.
Although, some of the participants noted the responsibility of governments in addressing their health needs, they also stressed on the individual responsibility for self-care and the need to be empowered to attend to their responsibility: "…when I keep myself healthy, I am not a burden on government.If I take care of my body and mind, which is quite expensive, I will not be a burden…but I need to know first and to be helped after that…" (63-year-old woman).

Independence
All the participants remarked that "to be independent" is vital for their physical health.They believed that the ability to do their routine and out-of-the-house activities contributes to maintaining their good health.They repeatedly used words and phrases such as "not being a burden", "not needing others" and similar expressions.They also believed that being aware and capable of monitoring and controlling their own disease symptoms was vital for keeping them independent.To be independent was of so much importance for some participants that they even regarded it to be not only more important than physical health, but also a signal of their health.They believed that an older adult who can manage his own activities despite his physical limitations will definitely live healthy.
Furthermore, most elderly participants expressed the need to be empowered to identify and control their diseases symptoms due to their age and believed it was vital for their independence.
"I suffer from diabetes now…but there is a needle that helps me control my blood glucose level.…. it is important to know the disease better.The more we know and learn, the healthier we will be…" (62-year-old male).
All the participants referred to pain in one or more of their body parts.They stated that they needed pain management skills to keep their independence from their children and others.Most of them demanded to find easy and practical ways to manage their pain on their own.

Safety
Almost all the participants considered safety of house environment as an important health need.From their perspectives, home safety requires safe arrangement of furniture, using safe shoes.
"…look!People of our age must have an order around the house in which everything is not scattered and left around.This is big cost if stuff is everywhere, they will make us fall down...We got to teach our kids not to put anything in an old person's way lest they fall…" (60-year-old man).

Mental Health Needs
According to the data analysis, mental health needs can be categorized in two major categories: coping with aging, and tranquility.

Coping with Aging
From older adults' viewpoint, older adults face a lot of individual and family problems and they have no choice but to accept or adapt to their aging problems.
"…anyway, I give myself energy.Those problems that are mine, I solve them myself.I don't need others.Even if there is a problem, I don't say it to my kids because they have their own issues.I even solve their problems…" (64-year-old woman) Therefore, from their perspectives, they need to be mentally empowered and have the ability and skills to adjust themselves to imposed situations.They considered this as one of their mental health needs.

Tranquility
Tranquility and its required skills and conditions were among the most repeated mental health needs.From older adults' viewpoint, keeping one's tranquility needs "anger and anxiety management" and gaining "happiness".Most participants referred to issues such as "proper and emotional relationship with spouse and family members", "being forgiving", "not getting angry in problems", "thinking positively", "gaining happiness" as influential on gaining tranquility to be mentally healthy.Acquiring emotion control especially anger and anxiety were among the important mental health needs with the highest frequency in their statements.
"…we need calmness, calmness, calmness at home, at work, in the society…... I've always tried to keep myself calm, to calm myself first in these situations…" (68-year-old man)

Spiritual Health Needs
The stated spiritual health needs identified in the data analysis are mostly in two groups: "the need to have a meaning in life" and "being bound to religion principles".

The Need to Have a Meaning in Life
Some of the participants stated that having spiritual health requires having a purpose and also some commitments in life.All older adults stated religious beliefs including belief in the afterlife, belief in the purpose of life and an omnipotent power, and being mortal as their main spiritual needs.In addition, in their view, belief in God as the omnipotent in life is a vital need for being healthy as they would tolerate the problems of aging easier.Furthermore, the belief in afterlife would make them ready for journey to the other world.Some even believe that an older adult is healthy if he has a strong relationship with God and rely on Him in his/her problems.

Being Bound to Religious Principles
Many older adults stated that achieving spiritual health resides in having religious faith, saying prayers, performing religious rituals such as going to the mosque, visiting holy places, taking part in religious meetings and sessions and going to pilgrimages and abandoning sins.They also stated that performing religious acts helps them deal with aging problems and pains.They believe that praying affects all dimensions of their lives.They also referred to reading of the Holy Quran as a way to gain peace and calmness, and to help them tolerate life problems.Some participants stated that due to problems like their disease, they are unable to fulfill their spiritual health needs.
"…it is also important religiously and I want it.I like to go to the mosque but I can't.They're building a new mosque.It is closer but it was left without being completed…" (69-year-old woman)

Social Health Needs
Numerous social health needs were stated and can be categorized into three groups: the need to get emotional social support, the need to get instrumental social support and the need to actively take part in social activities.

The Need to Get Emotional Social Support
This need was the almost unanimously noted need by the elderly both in social health and in comparison with other needs.Many older adults stated that loosing social interactions due to loss of spouse, independence of children from the family and lack of emotional support from children, has led to impaired social support, loneliness, social isolation and ultimately, a dwindle in social health.They believe that lack of family members' attention not only leads to reduction of interactions, but also deprives them of emotional and mental support; hence, making them feels lonely.An elderly stated that: "…lady!They must assign the weekend to their parents and talk to them.Dear!My son!My daughter!It is hard for you.It is hard for me, too.I have worked the whole week with your dad, I have cooked cleaned, bought things; now, devote two hours of your weekend to me, for your grandma, your grandpa.You make them happy.You cheer them up.It works."(64-year-old woman) Data analysis showed that the need for emotional support was the most repeated need both in social needs class and also in all the stated needs.Older adults stated the need for having a satisfactory marriage, need for respect and attention, the need to overcome social isolation, the need to tackle relationship problems with children as their social needs.
Older adults often stated that solitude has led to their depression and low spirit.Some people believe that older adults' bad mood leads to their loneliness.
"…even this is in your own hand, since I see an old pal who cannot hold his tongue (has a bitter tongue).You have to force his/her children to come and stop by.Look!When one gets old and has bad mood, he has lonely senility.Aging is loneliness.It is also bad to be lonely.Loneliness brings nightmares, depression, Alzheimer and other stuffs" (64-year-old woman).
An elderly person talked about respecting old people as a social health need: "…old people need respect, they need dignity and they need to have their children around them, to stop by.Loneliness bring Alzheimer, it increases one's pain and grief" (64-year-old woman).

The Need for Instrumental Social Support
Besides the need for emotional social support, some older adults referred to the need for instrumental social support.They believe that social support from different local, non-profit, charity and state organizations are necessary to achieve social health.They referred to the need for government's financial support, equal distribution of services in the society by authorities, and granting help to the needy elderly.
"…there must be organizations to defend the old.What is the use of holding assemblies, spending a lot,….theyjust show off….anddo nothing for the old.A rightful person's right must be granted to him/her…" (64-year-old-woman).

The Need for Active Social Involvement
Besides other's roles in social health, older adults believe that action from their own side can be helpful as well.The participants referred to developing community-based programs using older adults' capabilities in the society and facilitating their presence in the society, and their interaction with people for active involvement and gaining social health.They stated that older adults' capabilities can be used in bailout and resolving the neighborhood problems.Therefore, not only is their experience useful in social activities, it also helps in boosting their social health.
"…now, the elderly are responsible.As approved by the people in city council, Tehran is the lover of old people.We must use them more, use their ideas more, and use them in different ways…" (62-year-old man).Some older adults referred to obstacles that hinder their involvement.
"…about our being social, have a look!The elderly go to assemblies, resolve issues in the neighborhood, yet when it is about taking part in social activities, people say: oh they are too old, they can't…this makes the elderly have some problems in this situation…" (68-year-old man).Some older adults stated that voluntary group activity is important for being healthy.
"…when it is voluntary work, I go happily.We work for child laborers if they need shoes, clothes and other stuffs.They are not under good hands…and as soon as something happens you take them money and do things for them…we get money from the benefactors and they only know me.We do it fast and give money.Working for child laborers gives me energy and good feeling…I was not like this.I really felt lonely and absurd at home (68-year-old woman).

Discussion
Having a healthy lifestyle is well documented to reduce older adults' chances of suffering from diseases, reduce early mortality, increase recovery, deal with life's stressful factors, and increase the quality of life nowadays (Sadana et al., 2016;Rizzuto, Orsini, Qiu, Wang, & Fratiglioni, 2012).WHO has stressed on lifestyle boosting behaviors as a key strategy for maintaining the health conditions of the elderly and helping them maintain high quality and independent life (WHO, 2015).However, health and quality of life of the elderly is affected by some external factors and to a large extent by environmental situations and conditions (WHO, 2015).In other words, having a healthy lifestyle requires fulfillment of different needs which is in many situations beyond the older adults' ability.
The analysis of the data revealed that although the elderly referred to many needs such as physical, mental, social and service, some of these factors are more influential and therefore referred to more frequently.Fulfillment of emotional needs was the need stated with the highest frequency and following that with a great difference were healthy lifestyle, independence and tranquility.
The findings showed that one of the concepts that were concurrently stated in the older adults' points of view was independence.The participants referred to doing routine activities, doing the out-of-the-house activities, continuing one's treatment and pain management as their functional independence and as a basic aging need.They even thought a healthy older adult is the one who is not a burden on somebody else's shoulders.This perception of independence and its importance has been referred to in other studies as well (Thanakwang, Soonthorndhada, & Mongkolprasoet, 2012).Losing one's independence was among the fears frequently stated by the participants.There have been similar concerns in other studies too (Kakhki, Saeedi, Delavar, & Saee-O-Zakerin, 2010).Losing one's independence which in itself arises from physical problems leads not only to deterioration of physical health, but also to dissatisfaction with life (Holm & Severinson, 2013) and social relations which in itself leads to decreased mental and social health.Like the current study, other studies has shown that the elderly need to have control over their own lives (Ravanipour, Salehi, Taleghani, & Abedi, 2010) and enjoy their friends, family, government and organizations marginally for some activities (Ravanipour et al., 2013).
Among important mental health needs that were stated in this study was aging process; in other words, adjustment to aging is an inevitable problem.However, many older adults have either conformed to their situation or are bound to conform (Caldas & Berterö, 2007;Birkeland & Natvig, 2009).Accepting the process of aging has been mentioned as a mental health need (Birkeland & Natvig, 2009) and as one of the most important adaptation strategies (Tohit, Browning, & Radermache, 2012;Bagheri-Nesami, Rafii, & Oskouie, 2010).People with different cultures have different strategies towards it.In this study, older adult have usually managed the problems of aging by performing favorite activities, keeping themselves entertained, and being thankful to God.
Regarding spiritual health needs, beliefs and religious conducts was considered necessary by participants.Numerous studies have supported the positive effects of spiritual health on humans' health (Rahimi et al., 2013;Yehya & Dutta, 2010) .In a systematic review of papers from 1872-2010 regarding religion, spirituality, physical and mental health, Koenig (2012) showed that religion and spirituality have positive effects on adaptation, positive feeling, feeling good, happiness, hope, self-esteem, emotion control, social support and social capital, and reduces suicide, depression, anxiety, psychotic disorders, drug abuse, personality disorder, social problems, crime and marriage instability.It also has clear positive effects on physical health, hygienic behaviors, cardiovascular diseases, high blood pressure, brain problems, immunity system improvement, Alzheimer, cancer, pain and mortality.Numerous studies have also proved the positive effects of the role of religious beliefs and religious conduct and taking part in religious rituals on improving physical and mental health of the elderly and reducing their mortality (Stanley et al., 2011;Zeng, Gu, & George, 2011).
But among the stated needs by both male and female older adults in all ages and even social classes and living conditions, the need for emotional social support was stated more than other needs in other subclasses of physical, mental, spiritual and social needs.As shown in Table1, it has the highest frequency.This need is stated with factors including, having a satisfactory matrimony, respecting the elderly in the society, reducing their solitude and emotional problems with children.Among these, reducing older adults' solitude was the most frequently stated issue.It is predicted that this feeling will be stronger in the future.The WHO report states that while family and especially older children of the family are the primary source of older adults' support and care, the decrease in population trend shows the elderly will be deprived of family support even more in the future (WHO, 2011).Other studies have proven that older adult are very vulnerable to the effects of social isolation (Stephens, Alpass, Towers, & Stevenson, 2011).Evidences show that social isolation leads to higher mortality and increase in physical and mental problems (Saito, Kai, & Takizawa, 2012).Social support helps in fulfilling real and emotional needs.Belonging to a social network in the society makes someone feel valuable, respected, emotional and having friends.Having social relations is stated as a subclass of healthy aging by older adult themselves (Thanakwang et al., 2012).
In addition to emotional and instrumental support by the family and society, active social involvement is an important factor noted by many older adult.Among the interesting and important points, was insistence of many participants on the elderly's own responsibility to involve them in the society more actively?In this regard, the older adults stated that the grounds for their participation must be set so that they can have more opportunities to involve themselves with family, friends, neighborhood and society.Many studies have concluded that there is a correlation between social relation and mortality, cognitive ability, depression reduction and feeling good mentally (Nguyen, chatters, Taylor, & Mouzon, 2016).
Active involvement of the elderly in social activities and their participation in favorite, local and voluntary activities was a determinant of healty aging in other studies (Register & Scharer, 2010;Thanakwang & Soonthorndhada, 2011).
The study's limitation was the failure to investigate older adults' needs from family members' or attendants' point of view.Despite the limitation, the authors tried to consider maximum diversity in participants regarding their age, sex, literacy, social class and lifestyle to gain a wide range of the understood needs in depth.

Conclusion
This study investigated the health needs of older adult from their own point of view.The study findings offered a clear picture of older adults' health needs in physical, mental, spiritual and social dimensions.These findings set light on concepts which can be helpful for many health workers, attendants, decision-makers and even older adult to fulfill their health needs.The analysis of the data shows that although a wide range of physical, mental, spiritual, social and services was raised by the participants, some were more important and therefore used more frequently during the interviews.Fulfilling emotional needs with the social isolation subcategory had the highest frequency in the social needs.Therefore, policy-makers, decision-makers and senility planners need to develop and plan to help reduce the elderly's social isolation.A part of such plans can be educational policies to enrich the culture of respect for the elderly by the young population.Governmental as well as non-governmental organizations, volunteer bodies and charity organizations can provide educational programs regarding dealing with the elderly, interaction among family members, communication and family counseling courses for the elderly and the younger family members.There should also be provisions to facilitate community-based participatory programs for the elderly in the society and promotion of their social and emotional health.
However, it seems that the elderly needs as regarded by researchers is more lenient towards diagnosis and treatment while the elderly themselves regarded it to be more about self-care and filling emotional voids.

Table 1 .
Summarized physical, mental, spiritual and social health needs of Tehran elderly