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SCOPING STUDY OF OLDER PEOPLE IN RURAL SCOTLAND
CHAPTER 8: QUALITY OF LIFE AND RURAL DIMENSIONS OF AGEING
Introduction
8.1 A priority of the Scottish Executive is to ensure that older people in Scotland are financially secure and that there is an increase in the number of older people who enjoy active, independent and healthy lives. This has been termed 'active ageing'. In other words, the objective is to secure a good quality of life for all older people.
8.2 The five themes framing this report: income, housing, accessibility, health and social care and social and community lives, are all components of the multi-dimensional concept quality of life. Securing a good quality of life involves inputs from these five themes. For older people, quality of life may be encapsulated by three overarching and cross-cutting themes, namely health, wealth and happiness.
8.3 The purpose of this chapter is provide an overview of the main themes discussed in the report, demonstrating the cross-cutting and multi-dimensional nature of quality of life. The chapter also summarises explicitly rural elements of ageing.
Quality of life and older people in rural Scotland
8.4 Quality of life is a multi-dimensional concept that can comprise both subjective and objective assessments. It covers a broad range of issues, and has been measured in many different ways by a wide range of researchers, government departments and voluntary bodies. Quality of life may be self-assessed, be quantified through the use of external, objective assessments or be gauged with reference to both self-assessed and objectively assessed criteria. The quality of life literature rarely identifies older people, or older people in rural areas as a distinct demographic sub-group. However, as noted by Iwarsson et al (1997), subjective elements of older people's quality of life, based on self-perceptions observed in gerontological research, may include self-rated health, life satisfaction, self-esteem and well-being. Objective factors, which rely upon external judgements, include, for example, physical health, cognitive capacity, functional ability, economic status, housing status and environmental factors.
8.5 A number of North American studies have identified what older rural residents themselves are most and least content with in their lives, indicating what issues could be addressed with a view to improving overall quality of life. Michalos (1982) reported findings from the 1976 Rural Development Outreach Project initiated by the University of Guelph. The domains of life studied in the Canadian project were health, financial security, family relations, spouse relations, friendship, housing, area of residence, recreational activities, religion, self-esteem, transportation and government services. These are all issues that have been considered elsewhere in this report. Older rural Canadians recorded high levels of satisfaction with their family life, housing, spouse and friendships and were least satisfied with transportation. Their health status was a source of discontent, with a high goal-achievement gap being noted in that domain of life.
8.6 The domains of life that contribute to quality of life noted above have strong inter-relationships. Financial security means choice, for example in terms of choosing where to live and in what type of accommodation. Good health means that an individual can get out and about, enjoy recreational activities and pursue their social lives. Maintaining a social network of friends and family can promote self-esteem and being mobile, whether through private or public transport, facilitates day-to-day living and facilitates participation in recreational and social activities. Promoting quality of life therefore requires policies, projects and initiatives that address a wide range of issues. To promote quality of life amongst older people in rural areas requires an understanding of quality of life issues in a general sense but also requires an understanding of what is specifically rural about ageing in rural areas.
What is rural about ageing?
8.7 As noted in Chapter 2, " Ageing in rural areas has received less attention in the literature than the proportion of older people living in rural areas might suggest" (Wenger, 2001, p117). The literature review completed for this report confirms this assertion, whether one considers literature about older people in rural Scotland, rural areas within the Nordic countries or rural areas in North America. This could simply imply that there are no differences between ageing in urban or rural areas.
8.8 Wenger (2001, p117) noted that " ageing in rural Britain has advantages and disadvantages but ... it is conclusively neither better nor worse than ageing in urban areas". An elderly person is no less likely to suffer from dementia and require home based or institutional care because they live in a rural area. Neither is an elderly person more or less likely to require personal care in later life simply because they live in a rural area. However, there are specific aspects of rural living that mean that the experience of ageing in rural areas does have some distinctive elements. Existing research about life in rural communities has identified specific features of rural life that older people are not immune from. For example, the Rural Poverty and Inclusion Working Group (2001) observed in their Poverty and Social Exclusion in Rural Scotland report that:
"Generally, older people are affected by the same difficulties as other people living in rural areas. However, lack of mobility, inability to cope through increasing frailty, low incomes and increased social isolation affect older people particularly. Other issues around mobility and care services may affect the lives of older people in rural areas differently to their urban peers or younger rural neighbours. Coupled with these issues, is a lack of access to advice services and a lack of knowledge about help available" ( p41).
As already noted, little specifically rural material on ageing was found during the course of this research, indicating that few research projects have looked specifically at the lives of older people living in rural communities. The observations of the Rural Poverty and Inclusion Working Group quoted above cannot therefore be verified or disproved by this report alone because there is not enough evidence from existing, detailed primary research to base a judgement upon. However, through the review of relevant literature and policies, analysis of data from the Scottish Household Survey, the identification of a variety of projects and initiatives operating across rural Scotland for the benefit of older people, and the brief review of rural older people's issues in the Nordic countries this Scoping Study has identified a number of areas where future research could make a contribution to evidence-based policy making.
Health and Social Care
8.9 The decentralisation of many primary health care activities, including, for example, community mental health, chiropody and physiotherapy, has had clear benefits in rural areas. In-patient services, however, cannot be decentralised in such a manner. Low population densities in rural areas cannot support the specialist hospitals found in densely populated urban areas. For older people who live in rural Scotland, hospital treatment invariably means having to travel some distance from home. This means that appropriate transport is often required to take patients to and from hospital, whether for in-patient or out-patient appointments. The logistics of providing patient transport services (whether through the public, private or voluntary sector) to rural communities are different to those in urban areas. Longer distances can mean that more drivers are required, and the best mode of transport to ensure patient comfort on a long distance journey may be a car rather than an ambulance. The location of in-patient services can make it difficult for friends and relatives to visit, limiting the social contact older people from rural areas can maintain whilst in hospital.
8.10 Mental health is one of three health priorities identified by the Scottish Executive. While decentralisation of mental health services has undoubtedly been to the benefit of many rural communities, the provision of mental health services across rural Scotland is uneven. It can be difficult to attract qualified professionals in gerontological psychiatry, geriatric nursing and gerontological social work, particularly to remote rural communities. Professionals in daily contact with older people may not be aware, or not have received adequate training about mental health issues and thus mental health problems may not be diagnosed. Mobile clinics and tele-psychiatry both bring mental health services closer to people, overcoming mobility constraints, but they can only help individuals who have been referred to the service.
8.11 The provision of community care services to a dispersed older population creates specific challenges. It is costly to provide high quality services at a local level to small populations. In the Scottish Borders, where a third of the population live outwith towns, the rural nature of the region is thought to have the following impacts on the provision of community care:
- people have to travel to services;
- small local services are needed;
- it is challenging to recruit carers in remote areas;
- good communication is required.
(Borders Joint Community Care Plan 2001-2004)
The provision of private sector care services may be uneconomic in rural communities. Older people ineligible for care provided by the state may be unable to purchase home care privately. Whilst many friends and neighbours freely give their time to help older members of the community, many older people do not like to feel they are a 'burden' to other people and prefer to maintain a reciprocal relationship with those who help them. They may thus not receive all the help and support that would improve their quality of life.
Accessibility
8.12 Accessibility is an important facet of quality of life. In rural areas daily life routinely involves having to travel to, for example, shops, recreational facilities, social engagements and medical treatment. In small towns the distances may be small and can be covered on foot. However, for older people living in small settlements and those in the more remote parts of the country, activities of daily life may involve travelling distances that cannot be made on foot. Public and private transport is therefore a significant issue for older people, as it is for all age groups in rural Scotland. Although many over 65s in rural Scotland have access to a car and have high personal mobility, a sizeable minority rely upon various forms of public transport for their mobility. As noted in Chapter 5, service frequency, the distances that must be travelled to bus stops, the routes taken by public transport and the costs of bus and taxi fares can limit older peoples' lives to a far greater extent than is the case in urban areas. Limited public transport and dependence on cars can add to people's isolation and, in extreme cases, can increase the risk of depression and mental ill-health amongst the older rural population.
8.13 The range of goods and services on offer to rural communities is always going to be more limited than that in urban areas. Small populations simply cannot sustain the diversity available in large towns and cities. Where older people have ready access to a supermarket, the cost of groceries is comparable to those in larger urban areas. However, where a small shop is relied upon for food and other grocery items, costs are often higher, stretching the financial resources of many older people.
8.14 Many innovative means of providing services to rural communities have benefited older people as much as they have benefited other age groups. One-stop shops, mobile services and outreach services have been developed across the country and will become more important as the proportion of older people in rural communities grows. The potential of information technology as a means of service delivery in the future is particularly important in rural areas and there is no reason to assume that older generations in the future will not be technologically literate.
Income
8.15 Income and overall financial status are very important determinants of quality of life. More pensioners than before are reaping the benefits of private pensions and other investments, and many live their retirement in financial security. However a significant minority live on very low incomes and, as shown in Chapter 3, have a negligible chance of moving out of low income.
8.16 Low income older people in rural Scotland are disadvantaged in many ways. An oft cited example is the higher cost of living in rural areas, particularly the higher costs of day-to-day items. Groceries, petrol and public transport fares, for example, cost more in rural areas, particularly remote rural areas. Heating costs can also be higher, especially in the many areas of rural Scotland without a mains gas supply.
8.17 Low income older people rely upon benefits other than the state pension to boost their income. Benefit uptake rates are known to be particularly low in rural areas, possibly as a result of a culture of 'self-reliance'. As noted in Chapter 3, considerable sums of means-tested benefit income due to pensioners remains unclaimed. Living at a distance from benefits advice centres, one-stop shops and other sources of relevant information may make it difficult for rural older people to find out about their entitlements.
Housing
8.18 Older people in rural Scotland are no more likely than those living in urban areas to require home care or a move into supported accommodation in later life. Tenure patterns amongst older people are different in urban and rural areas of Scotland, with older people in rural areas being more likely to be owner occupiers than their urban counterparts. Home ownership brings maintenance responsibilities, which, as noted in Chapter 4, may be beyond the financial means of some pensioners.
8.19 Providing an intensive home care service to dispersed rural populations is costly although, as show in this report, such support can be provided in remote rural areas. Communities Scotland have expressed concern about the limited availability of supported accommodation in some areas of rural Scotland, a problem that could become more severe as the population ages. As has been the case in Denmark, the future of elder care may lie in boosting intensive home care services rather than developing more supported accommodation. The benefit this service option offers to rural communities is that home care allows older people to remain living within their community.
Social lives
8.20 Most older people have an active social life and participate in a wide range of social, recreational, cultural and learning activities. As long as transportation barriers can be overcome there is no reason to suppose that older people in rural Scotland will be unable to maintain active social lives now and in the future. As demonstrated in Chapter 7, a wide range of activities specifically aimed at older people take place across rural Scotland. Older people, in large numbers, are also involved in many other activities that are open to people of all ages and participation in such activities facilitates inter-generational contact. Older people are likely to be 'visible' within rural communities and as a result may be less likely to suffer from the isolation that befalls too many older people in the increasingly anonymous environment of large urban centres.
8.21 The extent of voluntary activity is a strength of rural communities and the importance of voluntary organisations and voluntary groups has been mentioned throughout this report. Many voluntary organisations rely heavily upon the time older people give to their activities. Indeed many older people are volunteers on projects and initiatives that help other older people. Many older volunteers are likely to have given their time to voluntary activities all their adult lives: to do so in older age is not necessarily a new departure in their lives. A challenge for rural communities in the future will be to encourage and support the involvement of younger generations in voluntary activities to ensure that voluntary organisations supporting older people are staffed in the future and to continue the culture of voluntary activity amongst all age groups in rural Scotland.
General issues arising from this scoping study
8.22 The thematic chapters in this report all conclude with a list of key issues specifically associated with the theme of the chapter in question. This scoping study has also raised some overarching issues worthy of future research which are presented below.
A lack of information about the lives of older people in rural Scotland
8.23 This report has discussed a wide range of issues associated with the lives of older people in rural Scotland. However, although issues of concern to older people in rural areas, including transportation, community care, volunteering and housing have been identified, this scoping study has demonstrated that there is a lack of detailed information about the lives of older people living in rural areas of Scotland in particular and in rural areas of Europe more generally.
8.24 There is considerable scope for detailed research to be conducted amongst older people in rural Scotland investigating issues as diverse as the financial status of older people and how this changes through time, older peoples' views on the provision of supported accommodation and home care services, older people and community transport, the role of older volunteers in rural Scotland and the shopping patterns of older people in remote and accessible rural areas. Without the detailed information such research projects can provide, policy and initiatives cannot follow the principles of evidence-based practice.
Learning from the Nordic experience
8.25 This research was faced with a number of constraints which hindered the ability to explore issues associated with older people in rural parts of the Nordic countries. As is the case in the UK, literature on the rural elderly in Norway, Sweden, Finland, Iceland, Denmark and the Faroe Islands is very limited, particularly material written in English. The language barrier proved to be a considerable constraint to obtaining detailed information about the lives of older people in rural areas of the Nordic countries and as a result only limited use of Nordic examples could be made in this report.
8.26 Notwithstanding the limitations identified above, there remains considerable scope to investigate and compare the Nordic and Scottish experience of rural ageing. This would, however, require translation of a wide range of material, and ideally, the development of a research programme involving Nordic partners. Funding that would allow research visits to the Nordic countries to be made would also be useful.
The diversity of older people's lives
8.27 It is important to recognise that older people do not constitute a homogenous population. Whilst issues associated with the elderly, or old-old, are well covered in this report, there is a lack of published material about the young-old, including those who have taken early retirement and those whose health and financial position has allowed them to remain active.
8.28 The experiences and needs of older people will vary depending on their age (e.g. young-old versus the elderly), their physical and mental health, whether they are locals or in-migrants, the extent and support of their family and social networks, their housing situation, their level of wealth and income, etc. Their experiences may also vary depending on the type of rural community within which they are living, and its particular geographical, structural, economic and social characteristics. Such variations among older people, and among rural communities, are likely to have a significant influence on quality of life as well as the extent to which the older population can contribute to, and be involved in, their rural community.
8.29 A sensitivity to heterogeneity should inform future research. The diverse lifestyles and needs of older people may thus be recognised. In particular, issues associated with the old-old and the young-old need to be highlighted, as do the effects of living in different types of rural area.
Using the Scottish Household Survey to understand the lives of older people in rural Scotland
8.30 This Scoping Study has demonstrated the potential of the Scottish Household Survey to provide information about the lives of older people across rural Scotland. There are currently two years worth of data available from the Scottish Household Survey, 1999 and 2000, and as further years of data are added the usefulness of this data set will increase. There is considerable scope for further analysis of Scottish Household Survey data to be undertaken in the future.
8.31 Detailed analysis of Scottish Household Survey data relating to older people in rural Scotland could be conducted. Analysis based on the six-fold typology of rural areas ( see Annex 1), by health board area and by local authority area could be contemplated. A more detailed age-breakdown of data presented in this report could also be considered.
Community activities and services for older people
8.32 Within the scope of this report it has only been possible to provide a brief illustration of the range of services and activities involving older people in rural Scotland and the Nordic countries. Formal and informal projects and initiatives, ranging from patient transport, befriending and handyperson schemes and lunch-clubs to name a few take place across the country. The importance of the voluntary sector in Scotland, both in promoting and providing activities and services for older people and in involving older people as volunteers themselves has been highlighted.
8.33 A comprehensive review of projects and initiatives involving older people across rural Scotland could usefully be completed. Information about, for example, who uses the services, who provides them, who funds them, how long they have been running for, how important users and providers consider them to be etc. could be put to many uses by policy makers, service providers and local communities themselves. Amassing information about community activities in one place is beneficial for rural communities in that they can easily find out what is happening in their local areas. The Community Directory prepared in Caithness is an initiative that could usefully be copied across rural Scotland ( http://www.caithness.org/community/index.htm).
CONCLUSION
8.34 This chapter has provided an overview of the five themes discussed in the report (income, housing, accessibility, health and social care and community lives), framed within an overarching context of quality of life. Quality of life is a cross-cutting, multi-dimensional concept. Many older people living in rural Scotland experience a good quality of life. However, a sizeable minority are not as fortunate and would benefit from intervention in areas identified elsewhere in this report.
8.35 Whilst living in a rural community per se does not necessarily create specific problems for older people, rurality exacerbates problems commonly associated with ageing. In particular, older people in rural Scotland can face difficulties associated with personal mobility, the accessibility of goods and services, isolation and low incomes.
8.36 The Scottish population is ageing, a trend expected to continue for the foreseeable future. Population ageing is most evident in rural districts, placing increased demands upon services such as health and social care and housing. Delivering high quality services to growing number of older people who live in dispersed communities across rural Scotland will be challenging. The task of improving existing, and developing new services and facilities for an ageing population could be informed by future research. Issues for future research include the following:
- detailed research in the thematic areas identified in this report;
- an analysis of the cross-cutting nature of these issues;
- developing a more detailed understanding of how the public, private and voluntary sectors contribute to the quality of older people's lives in rural communities;
- identifying best practice through studying older people's issues in rural communities outwith Scotland, notably the Nordic countries, North America and Australasia.
8.37 In conclusion, this report has identified a range of positive and negative aspects of older people's lives. While a sizeable minority of older people in rural Scotland experience multiple disadvantages many older people living in rural Scotland today live active, independent and healthy lives: they are enjoying 'active ageing'.
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