Beliefs and practices of Chinese adults in Hong Kong toward qualitative study

Asian J Gerontol Geriatr 2014; 9: ?–?
Beliefs and practices of Chinese
adults in Hong Kong toward
preparation for healthy ageing: a
qualitative study
ORIGINAL ARTICLE
Linda YK Lee PhD, RN, Rocky YK Fan PhD
ABSTRACT
Background. This qualitative study describes the beliefs and practices
of Chinese adults in Hong Kong toward preparation for healthy ageing.
Division of Nursing and Health Studies,
The Open University of Hong Kong
Methods. 12 Chinese adults were selected via purposive sampling
to participate in semi-structured interviews. The interview data were
recorded, transcribed, and coded for content analysis.
Results. Significant discrepancies were noted between beliefs and
practices of the participants toward preparation for healthy ageing.
Participants generally believed that preparation for healthy ageing
should be multidimensional and started during adulthood. However,
most of them were unable to prepare because of focal, perceptual, and
contextual constraints.
Conclusion. Health promotion activities should adopt a
multidimensional approach and focus on healthy living and
interdependence of family members in urban areas.
Key words: Adult; Aging; Hong Kong; Qualitative research
INTRODUCTION
Correspondence to: Associate Head and
Associate Professor Linda YK Lee, Division
of Nursing and Health Studies, The Open
University of Hong Kong, 81 Chung Hau
Street, Ho Man Tin, Kowloon, Hong Kong.
Email: [email protected]
The ageing population (>65 years) worldwide is
expected to increase by 35% from 524 million in
2010 to 1.5 billion in 2050, with the greatest increase
in developing countries.1 The proportion of the
ageing population in Hong Kong is projected to
increase from 13% in 2010 to 28% in 2039.2 Healthy
ageing aims to decelerate progression of age-related
disabilities and enhance quality of life.3 Promotion
of healthy ageing can reduce the financial burden
secondary to age-related diseases and disabilities.4
cognitive, social, and spiritual)”.6 There are various
other definitions of healthy ageing.7 An American
study defines healthy ageing as surviving in later life
without experiencing chronic diseases or symptoms.8
A Japanese study defines healthy ageing as survival in
later life without experiencing fatal health problems
physically and mentally.4 In Hong Kong, the Elderly
Commission defines healthy ageing as the total lifecourse approach toward an optimal physical and
psychosocial well-being.9 Most of these definitions
highlight the lifelong and multidimensional nature
of healthy ageing.
According to the World Health Organization,
healthy ageing covers the physical, mental, and
social well-being of the aged population.5 It is
defined as “the process of slowing down, physically
and cognitively, while resiliently adapting and
compensating in order to optimally function
and participate in all areas of one’s life (physical,
Preparation for healthy ageing entails a
multidimensional approach. From the physical
perspective, health preservation and morbidity
compression emphasise the need for devoting more
time to health.10-12 Measures should be taken to
prevent age-related physical problems (such as high
blood pressure, high serum glucose, and obesity).4
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Lee and Fan
From the psychological perspective, healthy ageing
focuses on the attitudes, resilience, and personal
definitions of ageing.6 People should develop
a positive attitude and flexibility to age-related
changes. Religion enables psychological preparation
for later life because it strengthens families and
supports individuals, especially during depression or
when diseases and disabilities are prevalent.13 From
the social perspective, social support plays a key
role in healthy ageing,3,14 by positively influencing
the cognitive function15 and predicting the physical
function of older people.14,16-18 Establishing and
maintaining social connections are important for
healthy ageing.
According to the World Health Organization
policy on healthy ageing, people should prepare for
healthy ageing in early adulthood because healthrelated behaviours are usually established during
this phase.19 Compared with elderly people, younger
adults have more favourable health conditions, more
years of life remaining, extended retirement periods,
and more life opportunities. Therefore, their beliefs
and practices toward preparation for healthy ageing
may differ.
This qualitative study aimed to investigate the
beliefs and practices of Chinese adults in Hong
Kong toward preparation for healthy ageing, and
to propose strategies to foster health in later life.
Preliminary findings of this study have been briefly
reported.20
METHODS
This study was approved by the ethics committee
of our university. Informed consent was obtained
from each participant. A validated interview guide
was used to solicit the beliefs and practices of the
participants toward preparation for healthy ageing
(Table 1). A pilot study of 2 Chinese adults was
conducted to test the interview guide and data
collection method.
Six male and 6 female Chinese aged 19 to 45
years were recruited from an adult educational
institution through purposive sampling. The sample
represented a typical group of Chinese adults of
different age, sex, education level, marital status, and
occupation. Nine participants had completed tertiary
education; 6 were married; and 8 were employed
full-time (Table 2).
Semi-structured interviews were conducted
by one researcher. Each interview lasted for one
hour and was audio-recorded and then transcribed
verbatim. Member checking was performed during
the interviews through deliberate questioning to
ensure that the researcher did not misinterpret the
statements of the participants.21 Notes were taken to
document the reaction of the participants, facilitate
data analysis, and ensure the trustworthiness of
the qualitative inquiry. Key words and phrases
were highlighted, and themes were grouped. Two
researchers coded the data simultaneously to
interpret them from diverse perspectives. Data were
analysed manually as the study progressed.
RESULTS
The participants generally considered healthy ageing
as a multidimensional concept that comprised
physical, psychological, social, and financial
dimensions. They believed that preparation for
healthy ageing should begin before age advanced.
Discrepancies between their beliefs and practices
toward preparation of healthy ageing were noted, as
most participants were unable to prepare because of
focal, perceptual, and contextual constraints.
Physical preparation
The participants identified physical preparation
Table 1
Interview guide
Question
What are your beliefs on the ways for preparing a healthy ageing?
What are the preparatory works that you have actually performed/are currently performing?
Are there any discrepancies between your beliefs and practices? Why?
What is your feeling towards the discrepancies?
2
Asian Journal of Gerontology & Geriatrics Vol 9 No 2 December 2014
Beliefs and practices of Chinese adults in Hong Kong toward preparation for healthy ageing
Table 2
Participants’ characteristics
Participant
Sex/age (years)
Education level
Married
A
F/45
Secondary
Yes
Occupation
Clerk
B
M/27
Tertiary
Yes
Student
C
M/29
Tertiary
No
Engineer
D
F/28
Tertiary
No
Teacher
E
M/36
Tertiary
Yes
Nurse
F
F/30
Tertiary
No
Chinese medicine practitioner
G
F/19
Secondary
No
Student
H
M/42
Tertiary
Yes
Engineer
I
M/24
Tertiary
No
Student
J
F/34
Tertiary
Yes
Housewife
K
M/32
Secondary
No
Salesman
L
F/40
Tertiary
Yes
Small business owner
as the most important aspect of healthy ageing.
Favourable physical health and the absence of
major diseases were essential for healthy ageing.
Participant A mentioned that “Being healthy is very
important among older adults. I do not care whether
I am rich or poor as long as I am healthy.” Practicing
a healthy lifestyle, such as eating a healthy diet,
exercising frequently, regularly performing full-body
check-ups, and avoiding bad habits, is necessary
for physical preparation. According to participant
B, “Adults must quit their bad habits because these
habits are damaging to their health. I have my body
checked up every year. Favourable habits are not
developed overnight; some of these habits may even
take more than 20 years to develop.”
their challenges.”
Psychological preparation
The participants believed that people should develop
positive attitudes toward themselves and their
environment because lives change and unfortunate
events happen. People experience various losses,
such as loss of physical function, income, and loved
ones. Failure to adjust may lead to unfortunate results.
To develop positive self-perception, participant D
suggested that “People, including the aged ones,
must realise that their lives are meaningful. Old
people have valuable life experiences that they can
share with youngsters. Finding the meaning of life is
not only for old people. Everyone must have a sense
of direction, an active life, and the confidence to face
Social preparation
Social preparation provided the participants means
to gain mutual support and social recognition. They
identified family as the most important social tie.
People received physical, psychological, social, and
financial support from their families. The participants
were eager to establish healthy relationships with
their families. Regardless of their age and marital
status, the participants stressed the significance of
having a nice partner, raising their children well,
and maintaining a favourable relationship with their
families. Participant I, a 24-year-old unmarried man,
stated that “Having a wife and children is great. I
would love to see my children marry their partners
Some participants turned to religion for
psychological support. They were aware that external
factors could affect their later lives. Government
policies and resources can be modified through
human means, but fate or fortune cannot be
controlled by people. Religious beliefs could help
them to make sense of their lives, feel comfortable in
later years, and get rid of the fear of death. Participant
D, a Christian, stated that “My religion assures me
that there is no need to be afraid of the changes in
my later life and the uncertainty about death. I do
not worry about death because I know where I will
go after that phase.”
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Lee and Fan
and have their own children. I would love to see
and play with my grandchildren. I consider that as
healthy ageing.” Participant C, an unmarried young
man, concurred that “Having my own family and
children is very important because I can rely on them
when I become old. I cannot rely on my parents and
my friends because they may face the same problem
when they approach the same age. The most plausible
source of support will be my spouse and children. If I
cannot have my own child, I will adopt one.”
Relationship with close friends has a unique
nature that cannot be fulfilled by families. According
to participant B, “Everyone has a secret. I have some
secrets that I cannot share with my wife. Instead, I
trust my friends with these secrets.”The participants
believed that everyone should have close friends.
Common hobbies and frequent contact with others
are essential for establishing a social network.
Financial preparation
A satisfactory financial status is associated with
financial independence and a sense of security. The
participants wanted to be financially independent and
reduce their dependence on either the government
or their families. They anticipated that they would
not receive sufficient government support and their
children might not be able to take care of them. They
believed everyone should have a stable job, have
well-planned savings, practise lifelong learning,
own a house, have an insurance plan, and have
an investment. The savings need not be large, but
should be sufficient to support a decent living. An
amount of HKD 3 million to HKD 7 million (USD 1
= HKD 7.8) could support an individual for 20 years
after retirement. Participant K, who was earning
a low salary, explained the need for developing a
sense of financial security: “When I become old, I
will have a low earning ability. My situation will be
similar to that of old ladies who collect and sell old
newspapers. They cannot anticipate how much they
can earn each day and may not be able to maintain
their expected standard of living.”
Living up to the beliefs of healthy ageing
The participants admitted that they should begin
preparing for their later life during their adulthood,
but their practice was incongruent with their beliefs.
According to participant D, “I only exercise during
holidays. I do not have enough time to exercise when
I return home from work on weekdays.”
4
The participants primarily focused on financial
preparation, despite identifying physical preparation
as the most essential aspect of healthy ageing.
Participant L, a 40-year-old small business owner,
argued that “Young people use their health to earn
money. When they become old, they use their money
to cure their diseases. I drink and stay very late at
night with my business partners. I know that I am
compromising my health. Given that I have enough
money, I would consult a famous doctor and buy
expensive drugs when I encounter health problems.”
Constraints on engaging in health behaviours
Focal, perceptual, and contextual constraints
hindered the participants from preparing for their
later life. Focal constraints refer to the limitations
that immediately confront the participants. These
constraints include exhaustion, busy lifestyle, and
unsatisfactory income. Unsatisfactory income affects
the preparatory activities that require a large amount
of money. According to participant C, “I really want
to own a flat, but they are very expensive. Moreover,
my salary is very low.”
Perceptual constraints refer to interpretation of a
situation. The participants generally perceived that
“the preparation for healthy ageing only requires few
years” and considered that “preparing for later life
at their age was too early.” They identified a certain
age when they would begin to prepare for their later
life. Participant B, a 27-year old student, said that, “I
will start to have my body regularly checked when
I reach 30 years because my health would begin to
deteriorate after that age.”
Contextual constraints refer to circumstances
that contribute to the effect of focal factors. High
demands in the workplace were identified as the
most important contextual constraints among
working adults. These adults were busy throughout
the week and required to work during evenings and
weekends. Consequently, they became exhausted
and ran out of energy to exercise or attend social
gatherings. According to participant A, “I am busy
throughout the day. How can I pursue any hobby?”
Inability to prepare for healthy ageing
The participants generally felt that they were unable
to prepare for healthy ageing. Participant C, a selfproclaimed aggressive person, stated that “I have
worked aggressively, eaten irregularly, and walked
Asian Journal of Gerontology & Geriatrics Vol 9 No 2 December 2014
Beliefs and practices of Chinese adults in Hong Kong toward preparation for healthy ageing
excessively over the past years. I anticipate that I will
suffer from muscle pain and arthritis when I become
old. I am now experiencing the symptoms of these
diseases, but I cannot do anything to revert them.”
With regard to maintaining a close relationship
with her family, participant A said that “My sons
return home late every day. I do not even have a
chance to see them. How can I talk to them? I have
no choice but to wait for them until they return
home.”
DISCUSSION
The findings of this study highlight the
multidimensional nature of healthy ageing and are
consistent with other studies.22,23 Practising various
preparatory activities ensures a healthy later life.
Good health at a later age cannot be achieved
through a single measure.
The participants emphasised the importance
of maintaining favourable physical health and
adopting a healthy lifestyle. However, studies on
the perceptions of older individuals toward ageing
have highlighted the concept of ‘living with chronic
diseases/illnesses.’24-28 The discrepancy in perceptions
may be due to the fact that diseases are uncommon
among adults, but are frequent among older people.
The absence of disease is considered a blessing
among older people, and the presence of disease
does not necessarily impede a healthy life.13 The
younger population is not aware of the prevalence
and effect of disease on the older population.
Therefore, the younger generation must be oriented
about the realities of old age for preparing for later
life.
The
participants
defined
psychological
preparation as acknowledgment of changes,
limitations, and unfavourable situations that they
may encounter in the future. Preparing for later life
enables people to adjust and face challenges. The
participants also resorted to religions to prepare
themselves psychologically for healthy ageing. They
considered religion as a source of support, especially
when they were sick or near death.13
Social support from friends and neighbours
partially compensates for the loss of a spouse,
child, or relative.13,14 Close friends and relatives also
encourage cultivation of health-related behaviours,
provide direct material support, guide the use of
medicines, and inspire community involvement.18
Studies of the older population demonstrate that
families help reduce the risk for functional decline,17
promote personal feelings of well-being,29 and
relieve chronic diseases among older people.13
Nonetheless, the psychological well-being of older
people is associated with the quality rather than the
quantity of their relationships with their families.29
The participants emphasised the importance of
establishing favourable relationships with family
members. Given their inexperience or young age,
the participants were unaware that marital problems
(such as affairs and divorces) could affect their family
lives. This topic warrants further investigation.
Financial stability provides older adults with
financial independence and a sense of security. The
participants were satisfied with being financially
stable, instead of very rich. The participants worked
very hard and sacrificed their health in the process.
This phenomenon also warrants further study.
Reality of preparation for healthy ageing
Well-educated, middle-class participants work hard
to earn money to achieve healthy ageing. However,
the demanding and competitive nature of their
professions requires them to devote much of their
time and energy to their work. Thus, they have
limited amount of time for health-related activities.
The lack of a comprehensive retirement scheme
further contributes to this phenomenon. Given the
belief that a better financial standing can lead to an
improved lifestyle, they work long hours without
rest, work several jobs, refrain from leisure activities,
distance themselves from their friends, and smoke or
drink alcohol for business reasons, despite knowing
the damaging effects of these practices. Adults who
are fairly healthy may think that money can help
them recover from their diseases, but older adults
only begin to appreciate the benefits of having
favourable health when they begin to experience a
significant decline in their health. They feel thankful
for being healthy.25 Favourable health is difficult
to achieve in later life regardless of wealth. The
interviews revealed a reality that deserves immediate
attention.
Implications and recommendations
Findings of this study shed light on the planning of
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Lee and Fan
health promotion strategies. First, the orientation
of these strategies should shift from a single
aspect to multidimensional aspects. Second, rather
than emphasising disease management, health
promotion strategies should focus on behavioural
modification, such as exercise, social engagement,
and stress management. These strategies teach
individuals to maintain their health in a busy and
demanding environment. Third, promoting healthrelated behaviours among adults and young people
is necessary to drive them away from unhealthy
behaviours that are easily acquired but difficult to
relinquish.10 Underlying diseases usually begin at
a young age rather than in later life.4 Fourth, the
positive attitudes of adults toward ageing should be
fostered.
Limitations of this study were its small sample
size and sampling method. Therefore, the findings
should be interpreted in consideration of the study
context. All participants belonged to the middle
class. Future studies on other social classes are
needed for comparison. Moreover, people associated
with unconventional family structures, such as
cohabitation, divorced couples, absence of children,
or existence of children outside of marriage, should
be investigated to understand the relevance of these
family structures in later life.
CONCLUSION
Preparation for healthy ageing must commence as
early as possible. Physical, psychological, social,
and financial preparation is necessary for healthy
ageing. Nonetheless, our participants could not
actively prepare for their later lives because of
focal, perceptual, and contextual constraints. A
multidimensional approach for healthy ageing
should be adopted.
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Asian Journal of Gerontology & Geriatrics Vol 9 No 2 December 2014