Lifestyle Changes and Perception of Elderly: A Study of the Old Age Homes in Pune City, India

The increase in old age homes and its residents mandates attention to the living condition of elderly at these institutions. The study is based on the information collected from 500 residents of 23 old age homes of Pune city in India. A multistage random sampling used for the selection of samples. A semi-structured interview schedule was adopted to gather the information from the respondents, the interview schedule was approved by the research ethical board of the institute. To strengthen the study qualitative insights are also gathered using case studies and key informant interviews. About half of the respondents were having issues while adjusting at old age home and similar percent has reported that their life has considerably changed after joining the old age home. Over half (52%) of these have experienced negative impact, such as homesickness, feeling of left alone (abandoned) by family members, feeling of staying at a hostel, follow certain schedule, elderly have to adjust in their daily life


Introduction
Population ageing is considered to be one of the biggest challenges of demographic transition in the twenty-first century [1][2][3]. Decreasing fertility rates and increasing longevity have resulted in a higher population of elderly people (aged 60 years and above) compared with the younger and adult population than ever before [4][5][6]. Although developed regions were the first to witness the phenomenon of population ageing, now the developing regions are witnessing a rapid growth of aged population [7,8]. The share of persons aged 60 years and above in the world is expected to increase by 56 percent between 2015 and 2030. [9]. As per United Nations Population Division estimates increase the share of old age population from 5.7 percent in 2019 to 7.6 percent in 2030 in lower middle income countries [10]. As per 2011 census [11], India's older population aged 60 years and above is 103 million and it is expected to increase 319 million by 2050 [12].
Increase in the proportion of older population due to shift in the age structure from younger population to older population create various challenges for policy makers and create burden on younger generation and increase demand for social and economic support care for elderly [13]. Before advancement of demographic transition in India, traditional family system was providing care for elderly especially in joint family system. In the past several years, as a result of advanced demographic transition along with socioeconomic development and urbanization, a large chunk of migration has occurred. As skilled professionals have moved to developed countries and from rural to urban areas for better opportunities, leading to reduction in family size and the erosion of traditional families. It led to growth of nuclear families, reduced socioeconomic support and care for elderly, and increased the demand for old-age homes in India [14].
With increased longevity, many of the elderly would require some form of long-term care, the cost of which needs to be borne by their families. This might result in family members withdrawing from school or employment to care for the elderly member. Hence, older people are viewed as a burden [15,16]. Traditionally, within the familial hierarchy elderly people have enjoyed a high status [17][18][19][20][21]. However recently, with the increase in age, several elderly people experience eroding status. In addition to other factors, it contributes to the behaviour of the elderly towards their families and their living arrangement [22,23].
According to BKPAI report [24] marriage of children is and other reasons such as include death of spouse, family conflicts, and migration of children are reasons for elderly to live alone. In addition, the demand for old age homes increased. Some evidences indicate that the increase in old age homes was seen largely in the southern regions of the country, particularly in Kerala and Tamil Nadu, then in the western state of Maharashtra [25][26][27][28], due early demographic transition, urbanization and migration led small family norm compared to other states. There has been changes in the social and family structure which affected the culture and norms of the society. The process of modernization and search for better standards of living and job opportunities forced children to move away leaving their parents behind. In This study we assess the lifestyle of elderly and their perception who live in old-age homes in Pune city of India.

Data Source and Methodology
A list of old age homes was obtained from Help Age India, Pune office [29]. This study was conducted in 23 old age homes of Pune city, India. From these old age homes, a total sample of 500 respondents was selected using the lottery method. The researcher used the purposive sampling technique and limited the sample size to 500 elderly respondents from 23 old age homes. The study includes old age homes which have completed at least 2 years of functioning, avoiding all those old age homes which were established or in function not more than 2 years. The study includes only those elderly who were aged 60 years and above, living in old age homes at least for one year. Elderly persons have experience of living in old age home for less than a year are not considered in this study. Those elderly who was unable to respond to the question or who had any psychological issues (diagnosed by a medical practitioner) are not considered for the study.

Participants
The study population was comprised of 500 elderly people, residents of old age homes. Those elderly who are physically mobile and capable of conducting interviews on their own behalf the respondents should have stayed in the old age home for one year so that they can give a better understanding of the facilities provided in the particular old age home where they are staying. A semi-structured interview schedule was developed for the data collection. This interview schedule received approval for data collection from the ethical board of the institute. Data was coded and analysed with STATA (v.14.0) software.

Results
Sample characteristics of elderly population who are living in old-age homes Table 1 presents the sample characteristics of elderly living in old age-homes in Pune city, Maharashtra. Among respondents, over three-fifths (63%) are women and 37 percent are men. Higher proportion (42%) of respondents are aged 70-79 years, followed by aged 80 years and above (31%) and aged 60-69 years (26%). Percentage of elderly living in the old age homes increases with the up to certain education level. For instance, 13 percent of respondents live in the old age homes have never attended school, whereas 24 percent of respondents have completed 8-10 years of schooling. Share of female respondents is higher with no schooling than the male respondents (16% against 9%). According to marital status, higher proportion (62%) of respondents are widowed/widower compared to 23 percent are never married, 8 percent are currently married and 7 percent are divorced/separated. Share of elderly men who are never married is higher than the never married elderly women (28% against 19%). While, share of elderly women who are widowed is higher than the widowed elderly men (67% against 54%). With regard to social groups, majority (79%) of the respondents does not belong to Scheduled Caste (SC), Scheduled Tribes (ST) or Other Backward Caste (OBC). While, 12 percent of respondents are belonging to SC and 7 percent are OBC. According to the type of family, higher larger share (73%) of respondents were living in nuclear family and 26 percent came from joint family. Since, women tend to have lower social status compared to men, they are more likely to depend on the male person of the family either father, husband or son. Hence, women are inclined to have lesser significance in the family. In line with other several factors, women are more likely to join the old age home compared to men.

Lifestyle of the elderly living in old-age homes
Elderly respondents were asked about whether they have experienced any changes in their personal lifestyle and either positive or negative changes after joining the old-age home. The changes in personal lifestyle of the elderly covers various dimensions such as adjusting with the environment of old-age home, feeling loneliness or left alone, home sickness, health issues as chronic and psychological health problems. While, some respondents have experienced positive changes such as improvement in health condition, received good care at old-age home, good social networking as mingling with other old age home residents, peaceful environment, engagement in various activities which is also a part of entertainment for them.  Table 2 shows the percentage distribution of elderly with significant changes in their personal life style. Over half (52%) of the respondents have experienced negative changes after joining the old age home, while about two-fifths (39%) have experienced positive changes and around one-tenth (9%) have neither experienced any positive nor negative changes in their lifestyle at old age home. Share of elderly women with negative changes in higher than the share of elderly men (56% against 35%). Similarly, among widowed elderly more 54 percent have experienced negative changes and 38 percent have positive changes. Whereas, respondents who are from rural areas are more likely to experience negative changes (57%) compared to respondents from urban areas (44%). Share of elderly with experienced negative changes decreases with increase in number of sons (71% elderly with no son to 33% elderly with 3 or more sons). While, percentage of respondents with experienced negative changes increases with increase in number of daughters (48% elderly with no daughter to 81% elderly with 3 or more daughters).

Perception of elderly
The results presented in (Table 3) shows the percentage distribution of elderly's perception who live in old-age homes about the others (elderly who lives at home with their family) are better-off compared to them and they feel lonely or left out at oldage home, which varies with different demographic and social characteristics. Perception among elderly staying at old age home that other elderly (who are not staying at old age home) are betteroff than themselves is higher among widowed/widower elderly (69%) compared to never married elderly (65%) (χ2 p-value <0.05). According to type of family, perception of elderly from joint family who live at old age homes that other elderly (who are not staying at old age home) are feel better-off than themselves is significantly higher (74%) than nuclear family elderly (64%) (χ2 p-value<0.05). Similarly, perception of elderly whose residence is abroad and lives at old age homes that other elderly (who are not staying at old age home) are feel better-off than themselves is significantly higher more (71%) than whose earlier residence is same district at local (64%) (χ2 p-value <0.05).

Mr. Ganpat (named changed) never married respondent said "Many elderlies have children and still they are staying in the old age home with me. After watching them suffering like this, I feel that it's better I am not married and I don't have a family (children).
What is the use of having such children who cannot take care of their parents in their last stage of life? Because, in the end, we (never married and ever married elderlies) are sailing in the same boat." Higher percent of widower / widowed elderly who live at old age homes perceive (60%) that they feel lonely or left out than never-married elderly (55%) (χ2 p-value<0.1). According to type of family, the joint family elderly who live at old age homes perceive (60%) that they feel lonely or left out is significantly higher than nuclear family elderly (55%) (χ2 p-value<0.05). Other demographic and social characteristics of elderly perceiving those other elderly persons are better -off who are not living in the oldage homes and feeling loneliness who are living at old age homes are not shown significantly.  Table 3: Percentage distribution of the elderly perceiving that the other elderly person is better off and the feeling loneliness at old age homes, Pune city.

Future intention of elderly to length of stay in the old-age homes
( Table 4) presents percentage of elderly and their future intention to length of stay in the old-age homes in Pune city, Maharashtra with different demographic and social characteristics. Percentage of elderly and their future intention to length of stay in the old-age homes is significantly associated with educational level. Length of stay in the old-age homes till death is decreases with increasing educational level. More than half of elderly population with no-schooling (55%) have future intention to length of stay in the old-age homes till death compared to graduation and above educational level (46%). The 44% of elderly have no idea about their future intention to length of stay in the old-age homes with no-schooling compared to graduation and above educational level (47%) (χ2 p-value <0.1) The higher percentage of elderly population whose childhood residence is rural and their future intention to length of stay in the old-age homes till death (58%) compared to others (51%) and lower percentage of elderly population whose childhood residence is rural and they did not have idea about their length of stay in the old-age homes (35%) compared to others (45%) (χ2 p-value<0.1). Percentage of elderly people who had no children with them with length of stay in the old-age homes till death is significantly lower (72%) than others who were having children (44.2%) and percentage of elderly who had no idea about their length of stay in the old-age homes is significantly lower (50%) compared to other who were having children (24%) (χ2 p-value<0.001). Other demographic and social characteristics of elderly such as age, sex, martial-status, religion, social groups (SC, ST, and OBC), family type (nuclear and joint family), having sons and daughters have not shown significant association with their length of stay in the old-age homes in Pune city.

Discussion and Conclusion
The gender difference is quite prevalent in living in oldage homes as elderly women are more likely to live in the oldage homes than elderly men. Majority of widowed/widower elderly and elderly who came from nuclear family live in the oldhomes due to lack of care and support and death of their partners, especially women have prolonged widowhood due to longer life expectancy than men [38]. Previous evidence shows that increasing urbanization and globalization lead toward nuclear family and migration of children for their job leads to unable to care for their aged parents [30]. For elderly persons, without support of their children, caring themselves is very difficult [30,31].
Most of the elderly have experienced negative change in their life after entry in the old age home as they felt home sickness, health issues as chronic and psychological problems, feeling lonely or left alone, need to adjust with environment of old-age homes and responded that neutral as neither satisfied nor felt bad living at old age homes. Many of previous studies have shown similar evidence that elderly who live olde-age homes suffer from Socio-psychological health problem such chronic health issues as stress, loneliness, depression, anxiety and other health and social issues as loneliness and lack of familial relationship. Especially staff of old-age homes lack caring for elderly, empathy, insufficient understanding of aging issue and skill to take care of elderly in old-age home led to worsen the lifestyle of elderly [32][33][34][35][36]. Among these elderly persons, widowed/widower and elderly from rural areas have not satisfied much about their life compared to their counterparts. Widowed/widower elderly are forced to join in the old-age homes due to lack care and socioeconomic support, death their partners, and for being from nuclear family. Majority of the women respondents have spent most of their time with family members and taking care of the household chores. While men have played part in both indoor and outdoor activities. As a result, compared to men, women while staying away from home or family members have shown more disappointment [37].
Important emerging finding of this study is that share of elderly who have experienced negative changes decreases with increase in number of their sons, whereas it increases with increase in their number of daughters. Only few of the elderly have experienced positive changes after joining the old age home such as improvement in their health, received good care at old-age homes, good social networks as mingling with other friends and peaceful environment. Old age brings several issues, and health problems and lack of care and support are the key issues for the elderly. At the old age home, elderly receive health services, care and support which are important needs of the elderly. Hence, several respondents stated that their health condition has improved or they received appropriate health services at the old age homes. While many respondents have unpleasant experiences with their family members and old age home avoids such unpleasant events.
Majority of elderly's perception who live in old-age homes about the others (elderly who lives at home with their family) are better-off compared to them and they feel lonely or left out at old-age home. Of these, perception of widowed/widower elderly and elderly from joint family about other elderly is that they are better-off and they also feel lonely or left out at old age home is significantly higher than their counterparts as never married and nuclear family. A large part of the respondents covers never married elderly or those who never intended to join the old age home. So, this group considers other elderly who are living with their family members having better life than themselves. Majority of elderly's intend to stay at old-age home till death and some have no idea that how long they will stay at old age home. Of these, the elderly who have no children have more likely to stay at old-age home till death compared to those who have children.
The study mainly suggests that situation of elderly living in old age homes need attention, as several elderly are experiencing homesickness, unable to cope up at old age home, and feel lonely or left out, irrespective of availability of all required facilities at old age home.