Salutogenic by design

Ageing studies focus on health and well-being of senior-only households.

In Singapore, ageing is a key demographic challenge. Currently, about 14 per cent of the local population are aged 65 and above. By 2030, this demographic is expected to increase to 25 per cent.

Given the significant impact ageing has on future economic prospects, societal structures and policy-making, it is no wonder then that Singapore, as with many other countries worldwide, sees healthy ageing as a key plank in maintaining the health of its older citizens.

“Healthy ageing includes engaging in health-promoting behaviours and preventive actions. It is keeping older people active, functioning well and independently to prevent them from being institutionalised,” said Dr Seah Betsy, research fellow at the National University of Singapore’s Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine.

Dr Seah has been studying health-promoting and risk-preventing interventions for older people since she started her PhD project in 2016. Guided by her PhD supervisor Associate Professor Wang Wenru, the principal investigator of the project, Dr Seah sought to develop and evaluate the feasibility of a multi-dimensional, community-based health promotion and risk prevention programme for senior-only households in Singapore.

The number of households with seniors aged 65 years and above, and who live alone, has increased from 27,900 in 2010 to 67,600 in 2019. “Older people residing in senior-only households experience declining health and have diminishing resources. They are at higher risk for poorer health outcomes and engage in lesser health-promoting and risk-preventive actions,” Dr Seah said.

Her PhD project, known as SHAPE (Salutogenic Healthy Ageing Programme Embracement), is based on the salutogenic concept, first proposed by Aaron Antonovsky in his 1979 book Health, Stress and Coping.

The number of households with seniors aged 65 years and above, and who live alone, has increased from 27,900 in 2010 to 67,600 in 2019.

“The salutogenic concept posits that life experiences help shape one’s sense of coherence, and the approach focuses on factors that support health and wellbeing, beyond a more traditional, ‘pathogenic’ focus on risk and problems,” said Dr Seah. Sense of coherence, a key construct of the salutogenic approach, refers to a coping capacity of people to deal with everyday life stressors.

SHAPE was conceived as a health resource programme focusing on positive well-being and optimising health outcomes. The 12-week intervention programme includes both weekly group-based activity sessions and home visits. In a randomised controlled trial, eligible participants were allocated either into the SHAPE intervention or the control group, after which outcomes such as sense of coherence, quality of life, health-promoting behaviours, self-efficacy, among others, were measured after evaluation.

Dr Seah’s study protocol, “Salutogenic Healthy Ageing Programme Embracement (SHAPE) for senior-only households: A study protocol”, was published in the Journal of Advanced Nursing in 2018.

Sense of coherence

To find out how older adults residing in senior-only households perceive health and ageing in relation to the salutogenic model, Dr Seah conducted focus group discussions with 27 older adults who either lived alone or with their spouses only, to draw out responses.

An analysis of the data showed that most of these seniors had minimal education, worked hard to make a living for themselves and their families, and picked up essential survival and street-smart skills. “They developed their individual life and health orientations through the socio-cultural exchanges of vicissitudes in life, shaped by their limited pre-understandings of health knowledge and the ageing process, as well as their personal competence on the utilisation of surrounding resources to address these life encounters,” said Dr Seah.

“Our data found that as the vicissitudes of growing old independently strike them, ageing experiences become unpredictable, unexpected and less comprehensible for them. This played a part to their short outlook towards old age. Consequently, this could limit their will and abilities to seek meaningful pursuits or valued aspirations and movement towards the salutogenic health pole,” she elaborated.

Greater support is thus needed by the seniors to adopt positive health actions and improve their knowledge and competence for self-care, beyond their survival and street-smart skills. Dr Seah said that the pursuit of healthy ageing could be achieved using Antonovsky’s three elements to measure sense of coherence — comprehensibility (reducing the unpredictability of ageing-related processes and vulnerabilities); manageability (supporting active adoption of actions that promote physical, mental and social health); and meaningfulness (individual reflection in making sense of old age to seek motivation in living each day purposefully).

Her paper, “Achieving healthy ageing through the perspective of sense of coherence among senior-only households: a qualitative study”, was published in Aging and Mental Health in 2020.

Mobilisation of health assets

Dr Seah built on her research using the salutogenic approach to explore how health resources are used among the 27 older adults who either lived alone or with their respective spouses in an elderly-populated residential estate in Singapore.

The older adults were “generally resourceful” in navigating their resource-rich environments to cope with everyday life stressors and promote health, the descriptive study found. “However, they were occasionally limited by individual factors, such as negative dispositions, poor health knowledge, and inaccurate perceived usage of ageing assets, which affected their comprehension, access to and utilisation of the resources,” said Dr Seah.

To overcome these barriers, community health practitioners could facilitate resource integration via salutogenic pathways, said Dr Seah. These could include cognitive (eg increasing older adults’ awareness, comprehension and discernment of the types of available resource), behavioural (supporting them in adopting know-how knowledge on initiating and maintaining the resource), and motivational (helping them make sense of the intended purpose of using a specific resource).

“For example, a minimally educated older adult who is interested in learning how to use social media platforms to interact with his or her loved ones but is unsure how to do so can be guided by a community health practitioner who introduces available courses in the vicinity and provides some basic technical knowledge (cognitive), initiating online interactions with him or her through these communication platforms (behavioural), and commending his or her efforts in learning to maintain contact with loved ones (motivational),” she explained.

“Such an approach contrasts with traditional health promotion that focuses on risk minimisation, early detection and management of diseases and shifts the attention to more wellness-oriented and person-centred health goals such as relationship building,” she added.

“The salutogenic approach focuses on factors that support health and wellbeing, beyond a more traditional, ‘pathogenic’ focus on risk and problems.”

To embrace the salutogenic way of care provision, Dr Seah highlighted the need for the roles of community health practitioners to be altered and expanded to empower older adults’ personal capacities to mobilise surrounding resources in the community.

Her study recommended that community health practitioners use an “eco-map” of ageing assets — an overview of the external and internal resources available to the elderly’s resource-rich living environment — as an assessment framework to recognise, consider, and build a repertoire of resources among older adults residing in senior-only households, to develop “strength-based approaches in health management”.

“In other words, taking on the role of a resource facilitator requires a community health practitioner to have knowledge about the older adults’ internal and external resources before being able to provide useful personalised support in resource navigation,” Dr Seah said.

The descriptive qualitative study, “Supporting the mobilization of health assets among older community dwellers residing in senior-only households in Singapore: a qualitative study”, was published in BMC Geriatrics in 2020.

SHAPE was funded by the Ministry of Education’s Social Science Research Thematic Grant.