Stakeholder consultations

Stakeholder consultations have been used in ageing research to enable improvements in the concepts and measures, and to ensure that they are appropriate and relevant to the research context (Waldegrave, 2006). The aims of the consultations carried out in this study were primarily to gain access to local knowledge on wellbeing in Maldives, to verify the appropriateness of the conceptual model and the research instrument developed for this research, and to facilitate local collaboration at the developmental stage of the research.

Subsequent to the survey, these stakeholders will also provide an avenue to disseminate the research findings and increase the potential of its use by policy makers, service providers and other end users.

The specific objectives of the stakeholder consultations in relation to the survey were to:

(i) verify the appropriateness of the proposed conceptual model of the life domains of wellbeing in the context of Maldives

(ii) identify the relevance of the indicators for the end users in monitoring the wellbeing of people 65+ years in Maldives, and (iii) ensure the appropriateness of the research instrument for a

sample survey of people 65+ years in Maldives (e.g. in the use of language).

A qualitative design using in-depth interviews was chosen for the stakeholder consultations. This method provided for a deeper understanding of the context and

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allowed better insight into what the participants saw as relevant information to be obtained through survey interviews (Bryman, 2001; Creswell, 1994). The selection of stakeholder participants from different areas and spheres of work was expected to be sufficient to provide a good understanding of the research context.

A semi-structured interview guide (see Appendix D) was used to maintain the focus on the study goals while allowing for flexibility in exploring the views of the participants (Bryman, 2001).

The stakeholder consultations were held in Maldives from December 2011 to January 2012. The stakeholders consulted included officials from government institutions responsible for policy, other key individuals in public and private agencies providing services for older people, as well as key professionals and older people themselves. The list of agencies was obtained from published information regarding government and non-governmental organisations. Letters were sent to the agencies informing them about the study and requesting participation, followed up by phone calls. Discussions were held with those agencies and professionals agreeing to participate in the research. Individual older people were also approached through personal contacts. Individual professionals were identified through the stakeholder agencies and personal contacts of the researcher. Interviewees included people with many years of experience in their fields and decision makers at the top level of many organisations. Among the participants were the heads of the organisations, and people working with older people (with work experience ranging from 6-10 years) at programme and service level. A total of 18 people – four older persons and 14 people from nine stakeholder organisations – participated in the consultations (Table 4.1).

Table 4.1: Organisation affiliation, expertise stakeholders and number

Stakeholders No. of people Government policy bodies National Social Protection Agency 2

Ministry of Health 3

Department of Gender and family 1

Service providers Maldives Pension Administration office 1

Male’ Health Service Corporation 1

Non-governmental organisation Aged Care Maldives and Manfaa Centre 3

Professionals Public Health professional 1

Social scientist 1

Developmental economist 1

Older people from the public 4

TOTAL 18

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The participants were from the following organisations and individual groups:

 Government agencies: Ministry of Health and Family, National Social Protection Agency, Department of Family Protection Services and Maldives Pension Administration Office.

 Service providers: Male’ Health Service Corporation.

 Non-Government Organisations: Aged Care Maldives and the Manfaa Centre on Ageing.

 Professionals: key informants from the disciplines of social science, public health and developmental economics.

 Older people: people 65+ residing in islands of different population sizes and development stages.

Prior to the interviews, potential participants were provided with a summary of the research proposal including the proposed conceptual model, indicators, and the questionnaire for their review. The questions were focussed on identifying the key life domains that shape the wellbeing of older people, including those related to the wider socio-cultural, economic and geo-spatial characteristics of Maldives, as a SIDS; the relevant indicators included the individual, family and contextual factors corresponding to the life domains; and several questions relating to the appropriateness of the survey instrument.

Although the stakeholder discussion was very broad, it was closely focussed on the purpose of obtaining information to confirm the conceptual model and the indicators of wellbeing. What follows is a brief review of the insights obtained from these interviews, in particular, how the stakeholder responses guided the finalisation of the life domains and their indicators, the way the impact of geo-spatial differences was considered, and the survey instrument. The responses showed considerable commonality, while also highlighting issues specific to the stakeholder’s area of service, and thus provided a deeper understanding of the social context and insight into what the participants saw as relevant (Bryman, 2001; Creswell, 1994).

4.3.1.1 Verifying the conceptualisation of the life domains of wellbeing The stakeholders were asked to discuss the areas of life most important for the wellbeing of older people in Maldives. The discussion on the life domains is summarised below.

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 All the participants identified social connections, such as social contact with family and friends and social support, as a critical aspect affecting the wellbeing of older people. Changing family structures and family values were identified by two thirds of the stakeholders as aspects affecting the social support, social relationships and, thereby, wellbeing.

 Health was also identified as a critical aspect, especially those health issues impacting on the functionality of the older people.

 The third most commonly identified area was related to economic and financial issues. This was explained as relating not just to the income of the older person, as a number of their expenses are borne by the family.

The practice of informal remittances and goods from friends and family members who do not co-reside was identified as important for the economic status of the older person.

 About half of the participants noted issues related to the geospatial and living environment such as housing, access to health care and other services. These included access to basic goods, especially commodities for personal care and health, services such as communication, and transport services that would allow the older person to stay in touch with friends and family.

 More than half of the stakeholders noted the relevance of socio-cultural values and voiced concern about the deterioration of the traditional social values in society, and the mismatch between the values of older people and those of the younger generation. They noted that some values are important for the vital functioning of a society. The most commonly noted social values and norms were respect for older people, trust, helpfulness and the traditional norms such as caring for the elderly in the family and community. The level at which this domain should be investigated in the research was also discussed e.g. whether the research should look at the individually held values of the older person or those values held collectively by the community in which the older person resided. The theme emerging from the discussion was that although values begin with the individual and extend to family and community, it is the upholding of these values by the family and community that impacts on the wellbeing of the older person.

85 4.3.1.2 Geo-spatial differences

In considering geo-spatial factors, the stakeholder interviewees suggested that some of the differences in the wellbeing of older people related to living on a bigger urban island or on smaller, more isolated islands.

 They noted that life was socially better for older people on the smaller islands because of the peacefulness and existence of familiar social traditions and values. Some interviewees also suggested that even though adult children often moved to urban islands, social networks with remaining friends and community members often made the older people less lonely. However, the point was made that when older people moved to urban islands to live with their children, they often lost contact with friends and other social network members, and their actual social connectedness with the family members they had followed was poor due to the busy lifestyle on the urban islands. Some stakeholders, however, believed that apart from material goods available in urban islands, living conditions were not very different on bigger islands. In both locations, older people were housebound (mobility was restricted) and dependent on family members due to problems of access and the absence of any social programmes for older people.

 The second major aspect identified was the poor access to services on the smaller islands. Most stakeholders alluded to the limited access to health care and the discontinuity of services and treatment, particularly for older people living on the smaller islands. Even when health care was available, as in most of the bigger islands, stakeholders noted that the older people had difficulty accessing the services without a caregiver to accompany them. They suggested that health care delivery should be more responsive to the needs of older people, by bringing in community-based social services and orienting services to allow older people to be more independent. Limitations in access to transport for those living on smaller islands were also identified as increasing the dependence of otherwise functional older people on family and friends, and thereby increasing the burden on island-bound families.

 The third major issue that was identified related to the housing situation.

In the capital city, which by comparison with smaller islands was highly

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congested, the structure and design of housing was not conducive to older people’s mobility. The stakeholders interviewees noted that many older people in the capital were housebound as almost all housing was in multi-storey buildings (often three or four multi-storeys), many without an elevator.

This made it difficult for older people to engage in social activities outside the household with friends and even with family. Furthermore, a large proportion of people in the more urbanised islands had migrated from other islands and lived in small rented spaces that were expensive. This situation often led to difficulties in social engagement and also to problematic relationships within the family when an older parent lived with adult children. By comparison, in the smaller islands, housing was usually single storey with adequate land for extended families, providing a friendlier environment for older people, despite being away from their children. While these differences existed, all interviewees indicated that they believed social life was better in the smaller islands than the bigger urban islands like Male’.

4.3.1.3 Developing indicators for the survey

The stakeholder interviews confirmed that there was no specific set of existing indicators appropriate for monitoring the wellbeing of older people in Maldives.

The available indicators for people 65+ years from routinely collected data included age-specific mortality, morbidity indicators, cohort life expectancy, health insurance coverage and pension coverage, but there was no recent data on income, work status, social conditions or the social relationships of older people.

Although the 2006 Census had collected information on the living arrangements of older people, this information was not a consistent feature of the censuses in Maldives and was not collected in the 2014 Census.

Most interviewees were not aware of any measures used in research for monitoring wellbeing. However, they emphasised that international measures and indicators needed to be adapted to the country context and additional measures should be included for the research to be useful for policy planning. It was suggested that indicators that allowed for international comparison, as well as indicators specific to the Maldives context, should be used to provide an evidence base for programmes and policies to enhance wellbeing.

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The stakeholder interviews, therefore, informed the development of the core indicators for the wellbeing of older people in Maldives. The indicators were also informed by the conceptual model of wellbeing described in Chapter 3. The resulting survey instrument was designed to collect information on respondent characteristics, the subjective and objective measures relevant to the conceptual model, and questions relevant to the policy options. The questionnaire drew on validated measures used in previous research as well as measures constructed by adapting some of these items to increase their relevance to SIDS contexts.

Specifically, the indicators were compiled taking into consideration the World Health Organisation (1997), Quality of Life (WHO QOL) instrument, the New Zealand General Social Survey, and a study on Enhancing Wellbeing in an Ageing Society in New Zealand, (Koopman-Boyden & Waldegrave, 2009;

Ministry of Social Development, 2007; World Health Organization, 1997). The majority of the stakeholder participants (13 out of 18) identified the proposed indicators (listed in Table 4.2) as appropriate for monitoring the wellbeing of older people in Maldives.

In addition to these indicators, the interviewees from stakeholder organisations noted some aspects where information would be useful for them to plan future programmes. These included comparative information on:

 The relationship between wellbeing and social connectedness with separate indicators for family and friends, e.g. social activities with family and friends, social support

 The sources of social support

 Information on the constraints older people face in socialising with family and friends in bigger urban islands compared to smaller islands, and

 The affordability of health care, especially the instances where older people had to pay for their health care, despite the existence of social health insurance.

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Table 4.2: Indicators for monitoring the wellbeing of older people identified by the stakeholders in Maldives

LIFE DOMAINS INDICATORS OF WELLBEING WELLBEING Overall satisfaction with life HEALTH Life expectancy at age 65 years

Self-rated level of health Access to health care (utilisation)

Health care financial cover (population coverage by health insurance) Out-of pocket expenditure on health care

Access to social support (family and others) Satisfaction with health status

SOCIAL

CONNECTEDNESS

Living arrangement (with family or other arrangement) Satisfaction with living arrangement

Social engagement (with family, friends and community)

Level of social connectedness (with family and others and overall ) Satisfaction with the social connectedness (family, friends and overall) ECONOMIC

STATUS

Level of economic standard (adequacy of money) Old age pension coverage

Satisfaction with economic standard of living ACCESS TO

GOODS &

SERVCES

Affordability of essential goods (food, housing, personal goods, health care goods)

Access to communication (telephone, internet) Access to transport (land, sea)

Level of access to goods and services (in general overall) Satisfaction with access to goods and services

SOCIAL VALUES

& NORMS

Safety, trust, helpfulness/voluntarism, respect and care for older people Level of conformity to social values and norms (in the community) Satisfaction with community’s conformity to social values and norms.

Overall, the detail of the discussion and the range of concepts generated during the stakeholder interviews was extremely valuable. All interviewees subsequently noted that the proposed survey instrument was relevant to the socio-cultural, economic and geo-spatial context of Maldives. The need for appropriate phrasing in the translation of the survey instrument to the local language, Dhivehi, was emphasised. A few stakeholders proposed additional question items in areas related to their service area and suggested paraphrasing some questions for ease of translation to Dhivehi.

The survey instrument was amended to ensure the appropriateness of the language and to enable adequate information on the indicators for end-user applications.

Drawing on these insights, the indicators for the conceptual model were developed. What follows is a description of the indicators and the measures that were subsequently operationalised in this research.

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