Introduction

Population ageing has become a global policy concern and expected to have a far-reaching effect in developing countries as they have been slower to adopt requisite policy measures (Lloyd-sherlock, 2000; Shrestha, 2000). Despite this demographic transition, there is also a concern of epidemiologic transition, which raises challenges for a healthy and long life (Gage, 2005; McCracken & Phillips, 2017). This combined demographic and epidemiologic transition may significantly challenge the ageing population, especially for older adults who are not healthy and without a proper support system. Compared to developed countries, developing countries are experiencing a faster ageing transition and are noted for inadequate funding, human resources (HR), and lack of healthcare infrastructure. Evidence indicates that adequate interventions from health and non-health sectors are required for a healthy ageing society (Bloom et al., 2015; Lloyd-Sherlock et al., 2012).

The experience of demographic transition is very context-specific in its timing, determinants, and economic considerations, though the transition stages are the same. India added more than thirty years of life expectancy since the 1950s but it has been experiencing an epidemiologic transition (Yadav & Arokiasamy, 2014). The context-specific determinants of demographic and epidemiologic transition also produced internal polarisation within India, with few states leading in these transitions (Dandona et al., 2017). Historically, most of the public health policies in the Indian context were based on maternal and child interventions, while geriatric care is yet to be addressed. India experienced an increasing trend in infectious diseases, non-communicable diseases (NCDs), and cardiovascular diseases (CVDs) in the last few decades, and the prevalence of these diseases, disability, and other health risks were higher among the older ageing adults. It was also observed that these increases were higher among states with a significant proportion of the older ageing population (Paul & Singh, 2017). These were also revealed in studies specific to older ageing population with NCDs (Chinnakali et al., 2012; Tandon et al., 2018). Among Indian states, Kerala experienced a sharp decline in fertility and mortality levels in the last fifty years; now it is in the final stage of demographic transition. The distribution of mortality patterns in the state has shifted from young to older age groups and is further moving towards the oldest-old age cohort (Thomas & James, 2014). Older adults in Kerala are also noted for the highest prevalence of illness, particularly by NCDs (Nair, 2010; Paul & Singh, 2017; Thomas & James, 2014). Even among states with higher older population, Kerala reported a high prevalence of morbidity where the older adults in Kerala were better off in their education and financial status (Paul & Verma, 2016). This raises the concern of healthy ageing, especially with growing geriatric care system.

The World Health Organisation’s (WHO) conceptualisation of healthy ageing emphasises the role of various intrinsic and extrinsic factors as potential contributors of healthy ageing. It reiterates that aging is a random process and is often seen as a consequence of complicated factors related to past living experiences and socio-economic and behavioral influences. Health in the old age is vividly associated with individuals’ intrinsic capacity and functionality, which enable people to be and do what they have reason to value. The intrinsic capacity is the composite of an individual’s physical and mental capacity. Though aging has genetic influences, the pattern of the intrinsic capacity of an individual is determined mainly by the cumulative impact of behaviors and exposures a person had during the lifetime (World Health Organization, 2015).

With the declaration of 2020-30 as the Decade of Healthy Ageing, the United Nations calls for a collective attempt to improve health of the ageing population of today and the future (Dixon, 2021). However, the preparedness of most of the regions for a healthy ageing society is unclear. Past studies conducted in various contexts using population data stressed a multi-dimensional approach for the conceptualisation of healthy ageing (Irshad et al., 2021; Rivadeneira et al., 2021; Urtamo et al., 2019). A review study indicated that the multi-dimensional nature of defining healthy ageing could potentially be influenced by contextual factors, with some dimensions may become irrelevant in certain cultures. The study also observed that the perception of healthy ageing could be potentially different among various population groups, say lay older adults vs. academicians (Hung et al., 2010). A literature search in various scholarly databases indicated that the conceptualisation of healthy ageing from the supply side stakeholders’ perspective is a rarely explored research question and may offer better understanding of healthy ageing and the readiness of various supply side components for a healthy ageing society. In this context, this present study aims to elicit the supply side stakeholders’ view on healthy ageing by considering Kerala as context. We expect that exploring the supply-side factors of Gerontology may offer better understanding of programs, policies, geriatric care services, opportunities, barriers and challenges for building a healthy ageing society. In this study more specifically, the study aims firstly, to understand from stakeholders’ perspective on the meaning of healthy ageing; secondly, it aims to explore the supply side readiness for a healthy ageing society.

Methods

Study Setting and Data Collection

The context of the study was conducted in the Indian state of Kerala. Relatively to other states in India, Kerala is noted for the advanced demographic and epidemiologic transition (Nair, 2010; Rajan et al., 2003). Historically, the state has introduced various policies and programs to improve the well-being of older ageing adults. However, the perception of different supply-side players in Gerontology on healthy ageing is an untold narrative. For the present study, the stakeholders’ interview was conducted during early 2022 through telephonic conversation or Google meet, and the data was collected using audio recording. The interview conducted to gather data was open-ended type of questions. The English version of the interview discussion guide is provided in Table 1. We used prompts relating to each main question to collect the data extensively. These prompts were carefully performed as sub-questions to each of the main questions. The interview process was continued until the achievement of data saturation (Moser & Korstjens, 2018). The interviews were conducted either in the local language, i.e., Malayalam or English, whichever is convenient for the respondent. The full information on stakeholders is provided in Table 2. We included various stakeholders representing care providers, practitioners such as non-governmental organisations and geriatrician, policy makers, researchers. The interviews consist of both public and private stakeholders.

Table 1 Interview discussion guide
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Table 2 List of stakeholders and their details
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Data Analysis

The audio-recorded qualitative interviews were transcribed into English from Malayalam, where required. We used a four-step content analysis and themes identification procedure to analyse the interview data (Erlingsson & Brysiewicz, 2017; Williams & Moser, 2019). The first step was translating the audio-recorded conversation into English for further analysis. In the second step, meaningful responses (complete statements) to the relevant questions in the study were identified. By doing this, the data was rearranged into a sequential structure for further comprehensive analysis. In the third step, we assigned common codes to relatable units, which simplified the complexity and quantity of data without losing the essential meaning of units. In the final step, we identified the final theme by grouping the assigned codes with the same concept (Fig. 1).

Fig. 1
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Content analysis framework

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Results

On the meaning of healthy ageing, two main themes were identified, one, “healthy ageing” (constituted by intrinsic and extrinsic factors) and two, “successful ageing” (Fig. 2). On the supply side readiness for a healthy ageing society, four overarching themes emerged, including (i) planning and resources, (ii) leadership, governance and governance, (iii) ageing in place, and (iv) opportunities and challenges (Fig. 3). A detailed summary of the theme identification based on codes and their frequency is provided in Table 3.

Fig. 2
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Conceptualisation of healthy ageing

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Fig. 3
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Supply side readiness for a healthy ageing society

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Table 3 Summary of themes, codes and frequency identified from the stakeholders’ interview
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Meaning of Healthy Ageing

According to the stakeholders the meaning of healthy ageing was a comprehensive one. It was found that both intrinsic and extrinsic factors are inherently contributed to healthy ageing (Fig. 2). It was also revealed that healthy ageing represents a particular component of successful ageing. Successful ageing is a much broader concept that consist various components such as active ageing, freedom and happiness and positive ageing. The complex interaction of these concepts is explained in the remaining “Results” section. The intrinsic factors are internal to each individual and can be contributed by various components, including physiological and metabolic health, psychological wellbeing, and physical capabilities. A practicing geriatrician stated:

“My perception on healthy ageing is that ageing is an inevitable process, and there will be associated physiological changes in all aspects including muscle system, cardio system and neurological system… how these physiological changes can be directed in a healthy way? We screen various outcomes such as frailty, falls and others. We also look at environmental factors. That is… one component is to delay the physiological changes. Similar to physical health, mental health is also equally important. Depression is a symptom among older adults. I also think that being in an idle state is also a factor for progressing many diseases and therefore is an important factor in determining healthy ageing.”

Dr Siju Jose, Geriatrician, Jubilee Mission Medical College and Research Institute (JMMCRI), Thrissur.

It was also observed that most of the stakeholders asserted the importance of psychological well-being and its mediation role with individual physical health, emphasizing the multi-dimensional aspects of healthy ageing. A stakeholder who is part of a community level daycare (Pakal Veedu) facility for older adults expressed:

“I think we are concerned more about physical health when it comes to healthy ageing. But I think we need to also give more attention for mental health as well. We have to accept the fact that we need to spend more for recreational activities. I think both are important and mutually supportive to each other. If one is not there, we may not call it as healthy ageing.”

Ms. Aleena, Project coordinator, Sargakshethra, Senior citizen’s daycare centre.

A different but similar view was expressed by a leading professional of a NGO, with an experience of more than 25 years. His perception of healthy ageing was more oriented with the functional ability of individuals that makes older adults independent to lead their life. He explained:

“Active ageing is important. We should not consider 60s and 70s as older adults. We should plan now by making older adults more productive and active through daycare centres. We will have active elders, active with supports (eg. Medicine) and destitute instead of 60s, 70s, 80 plus years. Destitute are basically bedridden people. There is a possibility of becoming an individual a destitute, say at 55. Therefore, we should not classify individuals on the basis of numbers (age) instead, it should be based on their ability”.

Mr. Biju Mathew, Director, Help Age India.

Stakeholders also pointed out various extrinsic factors that play a detrimental role in healthy ageing. To a great extend, these factors function outside the individual system. A psychologist who is also working as the secretary of an old age daycare facility for more than 20 years inferred:

“Healthy mindset is important even if individuals are physically healthier. Mental health affects physical health as well. Attitude of individuals is important and it transit from the early life of individuals. I also think, individual behaviour such as smoking, alcohol consumption, food intake, type and quality of food, exercise… all determine mental health and physical health. I think sometimes, our medical system also makes people unhealthier. For example, I know one individual who has been suffering from ailments for a long time. But once the person consulted a family doctor. He examined all medical documents and decided to continue with a single medicine (tablet). The major part of the disease was cured. Therefore, our health system, sometimes, makes individuals unhealthier, especially if we prefer high-tech facilities even if we have money”.

Mr. Tito Thomas, Secretary, Smile India-Pakal Veedu (Senior citizen’s daycare centre).

This stakeholder further indicated the role of a robust health system for creating a healthy ageing society. However, a stakeholder who is a practicing geriatrician stated that improved healthcare awareness among the population in Kerala is one of the main drivers of ageing transition.

“I think ageing in Kerala is a social change as well. I think the earlier generation was not much bothered about health. The new generation has better awareness and is likely to seek healthcare. I think it helped to improve life expectancy in Kerala”.

Dr Siju Jose, Geriatrician, Jubilee Mission Medical College and Research Institute (JMMCRI), Thrissur.

From the above statements, it was clear that the higher levels of health consciousness among the population with a significant share of private health care providers in a state like Kerala will be a public policy challenge in terms of controlling and regulation. It emphasises the importance of building a robust healthcare system to create a healthy ageing society. A different subtheme under extrinsic factors were also evolved from the stakeholders’ perspective. It was revealed that supporting components, including social capital/emotional support system and social and recreational activities, may directly or indirectly (through intrinsic factors) determine healthy ageing. A stakeholder from a government old-age home facility shared:

“I think people are happier when they engage with others. They become happy, especially when young people visit them. I think human connection is important. I observed that they become very emotional when they meet their children. I also observed that they become healthier when meeting their children and family. Most inmates here are aged 50 to 70 years. I think that is the best old age time. Generally, after 80, maintaining well-being becomes a challenging issue as it may increase other risks such as falls. I think when we interact and assist them, they become happier. Mental health is very important. They become happier if they feel belongingness. We should not isolate them, and emotional support is very important”.

Ms. Bindhu KV, Superintendent, Thiruvananthapuram Government old age home.

“We provided training programs by combining five old age homes, and provided training to inmates, including simple yoga to improve their health status. We also targeted improving reading ability, we call it assisted readings, assisted TV watching and cognitive health intervention. We stopped the activities as it was a project work. We also advised the government to make older adults in old age homes to engage in activities like gardening, petting (birds)..., which is to make the life, not a worthless one”.

Dr Sobha B Nair, Researcher and chairperson, Centre for Gerontological Studies- Thiruvananthapuram.

Engagement in various social and recreational activities and emotional support may potentially improve the intrinsic capacity of individuals, and their mediated effect may lead to healthy ageing. Economic independence was also identified as a relevant theme under extrinsic factor and it is considered as a means that lead to healthy ageing. A senior policymaker who worked with the government of Kerala under the Social Justice Department observed:

“…economic independence is important. They should have freedom and happiness, and it is possible for those with economic advantage. But people with financial constraints are limited in their free movement. Sometimes, even if they have money, they become malnourished as they neglect the importance of nutritious food since they distribute them to other family members”.

Dr P Prathapan, Centre for Gerontological Studies, Thiruvananthapuram.

A major theme called “successful ageing” was also identified, extending the concept of healthy ageing to a broader dimension. In addition to healthy ageing, we observed that successful ageing requires other components including productive/active ageing, freedom and happiness, and positive ageing. The results also indicated that these components are closely connected with healthy ageing:

“… for a successful ageing, productive ageing and active ageing are important. Generally, in Kerala, we retire at 56 (from government service) though there are exceptional services. Generally, we have a perception that after 60 years, we don’t care much. Since life expectancy is higher, how long will they live after retirement without any productive engagement? Is it healthy living or hell living? People should be productive. I think, even in 60s, people are in at good skills, including teachers, engineers, technocrats and other professions. We may use them to provide further service, either voluntary or paid. Then only we achieve healthy ageing”.

Mr. Biju Mathew, Director, Help Age India.

A private senior care centre used to engage older adults in various activities that they promote as a method for improving overall health and well-being. A trustee of this care centre has stated:

“We try to utilise their skills. We send some of the inmates, who are retired teachers, to teach at a neighbouring school for tutoring spoken English. We try our best to engage them in activities that they are capable of. We specifically focus on mental health, we offer facilities for Yoga practice, devotion etc., based on their interest, though it is not compulsory. We also engage them in games”.

Philip K John, Trustee, Travancore Foundation, Senior care provider.

Additionally, the study also identified subthemes, namely “freedom and happiness” and “positive ageing” as major components of successful ageing. These subthemes reiterate the importance of quality of life while considering the pattern of successful ageing of individuals. It also indicates the possibility of the heterogeneous nature of successful ageing as a self-experience of older adults. Two of the stakeholders in the study expressed:

“I view healthy ageing as one that individuals should enjoy freedom and happiness. These are very important. We have many daycare centres in Kerala, but people are not utilising their services. There may be many reasons. We need an attitudinal change in their approach to health and happiness. Our society has not approached in that way. Many social norms are causing these constraints”.

Dr P Prathapan, Centre for Gerontological Studies, Thiruvananthapuram.

“Human relations are very important. Even if people prefer solitude, not loneliness, it may bring happiness and peace”.

Mr. Tito Thomas, Secretary, Smile India- Senior citizen’s daycare centre.

Supply Side Readiness for a Healthy Ageing Society

Planning and Resources

Different stakeholders indicate that proper planning and preparation by various resources for a healthy ageing society is required. Kerala has long since initiated different programs and policies where 5% of the total development fund at the local bodies (Panchayaths) is exclusively allotted for various activities for the older ageing adults and disabled. Stakeholders expressed that these financial resources have immense potential and must be utilised in a well-planned manner. A stakeholder has expressed:

“We found that 5% of the local development fund is allotted to older adults and disabled. Generally, the local government bodies build day centre (Pakal Veedu). But we found that many of them are not functioning. Many non-government organisations (NGOs) are also doing similar to Pakal Veedu, but they may face funding problems and may affect its continuity. In a training program with the Kerala Institute for Local Administration (KILA), we emphasised the importance of activating Pakal Veedu. Even a small panchayath will have a 20 Lakh of Rupees, which is enough for the successful functioning of Pakal Veedu. But determination, guidelines, and support are needed. One of the main problems is that even if there are financial resources allotted, they are not utilised effectively. The Pakal Veedu should be a place for activity, it may not become a successful one if there is just infrastructure. They should provide food supply, travel facilities, and more should be there. Proper planning is needed.”

Mr. Biju Mathew, Director, Help Age India.

Similarly, stakeholders also discussed the significance of other resources for creating a healthy ageing society especially trained resource personnel. Two different stakeholders working under a government facility and NGO stated;

“We have mainly different sponsors as a major source of finance. We think HR is also important. We need people to run this system. We try to bring non-working women to take part in these activities. We need more service-oriented people.”

Mr. Tito Thomas, Secretary, Smile India- Senior citizen’s daycare centre.

“We had a social worker who used to engage for the skill improvement of inmates. Since Covid-19 pandemic, we did not continue it. The social worker had done many activities before covid. I think we have to implement it again. Their intervention helped us more. We offer yoga, gardening, and therapy and engage them in various activities. We especially take care of them for all their matters. The social worker was a sponsored post. I think they know much better on how to manage older adults’ matters. We have undertaken few programs. Once Ayurveda medical students visited and taught us the importance of yoga and nutritious food. Weekly they are also conducting medical camps. I think the staff should also be rotated to make them feel more interactive. We don’t have financing issues. The government has allotted Rupees 3000 for each inmate, including their medical support, and we are getting them regularly. We are also receiving finance for other running costs like electricity, and water. It is all coming under various government projects like Vayomithram and various Ayurveda related projects. So respective departments will fund them. Still, I think the lack of social worker is the main challenge for us. We don’t have any trust issues with the inmates. To solve most issues, we have good HR, especially for medical intervention. But I think, without these human resources, there may be many challenges.”

Ms. Bindhu KV, Superintendent, Thiruvananthapuram Government old age home.

Likewise, a stakeholder representing a private service care facility emphasised the relevance of appropriate planning for creating a successful ageing society while stressing the need for individual-oriented planning.

“We have to provide life to years, not years to life. Old age should be fruitful, and they should be engaged in something interesting. At the time of the admission of each inmate, we assess their tastes, background, skills… and we offer appropriate care for each individual based on their needs. We are making them productive by doing this, which may offer a positive ageing experience.”

Philip K John, Trustee, Travancore Foundation, Senior care provider.

A senior policymaker who retired from the government service expressed his hope for better planning and untapping of resources as he witnessed structural changes in the Social Justice Department under the Government of Kerala.

“When I was working, the social justice department was one. Now it has two; one for women and child development, and the other for old age, probation, and disabled. That means they have a new ministry and secretary, and hence they can do much more than before. I think they will have more funds and time for older adults.”

Dr P Prathapan, Centre for Gerontological Studies, Thiruvananthapuram.

However, an interesting observation was made by a senior demographer who also worked with the state government for policy and advocacy. He stipulated that for creating a healthy ageing society, there should be more geriatric healthcare intervention though the overall economic condition of older adults in Kerala is comparable:

“I think, economically, older adults are doing well. In Kerala, there is a universal pension, all older adults are getting some money. Economic security is probably good. But on the health, I think they are doing, but they are not reflected in our surveys. For, healthy ageing you should not talk from the old age, it should start early. For example, when we speak of education, to have a good productive life, you spend more years for education, say 25 years. You are investing a lot to have benefits for another more years. When you want to have healthy ageing after 40 years, you have to prepare at an early age. In Kerala, I don’t think we are preparing for healthy ageing. We speak about out-of-pocket spending, treatment and other things, still there is no systematic policy to start healthy ageing at 60. When you reach 60 in Kerala, you have almost all health problems. Most of them are taking medicine by the age 60, and they are taking medicines for multiple diseases, and the trend goes as age increases. It indicates that we are not prepared. Some issues will be coming during old age, but many issues can be postponed. The political will is not going beyond pension. There should be more health policies. To start, they may just do a full medical check-up for all older adults. It is not very costly. You will get more data so you can better plan for healthy ageing. I think more research is needed, and also, we need the right people. There is scope for a lot to research on ageing in Kerala.”

Dr Irudaya Rajan S; Demographer, Chairman, IIMAD, Thiruvananthapuram.

Leadership, Governance, and Implementation

Stakeholders also stressed the importance of leadership, governance, and effective implementation of various interventions for creating a healthy ageing society. A stakeholder representing a private senior care facility has stated:

“I think there are changes in Kerala in gerontology-related policies. We are a private team, and I think we need more such facilities under government control so that the benefits may be reached to larger sections of the society. Overall we need more interventions.”

Philip K John, Trustee, Travancore Foundation, Senior care provider.

It indicates that the government has the potential to expand various interventions for older ageing adults’ wellbeing. The government might maximise the beneficiaries through the day-care facilities that have been functioning at the local government level. A stakeholder stressed the role of local bodies to lead various interventions at the local level as it may help to benefit a large section of older ageing adults:

“I also observe that most of the program has no continuity. New people try to introduce new policies. We have funds and infrastructure at the local bodies, and we should implement policies properly. Our organisation (Help Age India) runs various models called Swayamprabha day centres in different districts. We have shown evidence that the programme is doable. We have elder self-group program that we experimented with after Tsunami in 2005. There we focused on promoting group activities and the employability of older adults. For example, in Cuddalore and Bihar (two regions in two different states in India), these groups are now making masks. It is like federations. We supported them initially, then the federations took their own and proceeded. Pakal Veedu, should have yoga, physical activity, recreational facilities… all should be provided through day centres. It is not a costly one. Further, there shall be training for employment to make them productive. In our cases, there are examples of older adults producing soap, candles, tailoring, painting, embroidery… It may be a source of income. They become more active and productive. We should provide them all the opportunities. I think we should also try to integrate all stakeholders. The benefits will be for society at large. We need vision…”

Mr. Biju Mathew, Director, Help Age India.

The stakeholder further indicated the importance of better governance and implementation of various interventions. A conducive governance mechanism with capacity of program implementing institutions may help achieve a healthy ageing society.

“We received funds from the government. We find that the inconsistency of bureaucracy is a challenging factor to continue various projects. We don’t have a problem of HR. Once we find the funding, HR is not a problem for us. We don’t face any problems in communication/trust with older adults. We use the local HR at the bottom (from the place of work) to communicate various programs successfully. Moreover, we have more than 40 years of experience. We are now functioning at the national level. We adapt to changes in technology and system. It makes the decision-making process faster and is faster to implement various programs.”

Mr. Biju Mathew, Director, Help Age India.

An important observation was shared by the senior retired government official who was part of the committee that drafted the Maintenance and Welfare of Parents and Senior Citizens Act. He stated that the rights and dignity of older adults might be protected through legislation. The stakeholder observed that implementing appropriate legislative measures is also a decisive step towards creating a healthy ageing society. It was also observed that the continuity of various interventions was also detrimental:

“In my perception, older adults had many concerns, including their living matters. In 2007, the Maintenance and Welfare of Parents and Senior Citizens was introduced and in 2009, their rules came in to effect. It largely changed the social approach to ageing. I think this law helped to improve the status of older adults in society. Older adults also need to accept their role in society. We do involve in most government policy formation or consultancy activities. We also send petitions to the government on various issues. I think there is political will in the state. There are modest variations and discontinuity in a few schemes over time. But most of them will not change even if the government change. Pension and all are consistent and are regularly increasing.”

Dr P Prathapan, Centre for Gerontological Studies, Thiruvananthapuram.

Ageing in Place

As people age, “ageing in place” is relevant as it may help them to live with full autonomy. This is especially important as social changes happen, including urbanization and cultural changes. A representative from a government old age home has stated:

“I think there is relevance for healthy life expectancy. I think there should be fulfilling environmental factors to achieve healthy ageing. They need a good environment, fresh air and there should be more space for them. I think, we should not restrict them, rather, we need to give them the opportunity to engage in something or recreational activities. Happiness and a free mind are very important. In my short duration of service, I observed that to make them healthy we need to provide wide facilities, including gardening and other facilities. I think it will improve their mental health and will be enough to cure most diseases. I think being idle is a sign of an unhealthy pattern.”

Ms Shyny LK, Superintendent, Government old age home, Kollam.

The stakeholders’ statement clearly indicate multiple factors’ role in creating a conducive “ageing in place” atmosphere which may significantly determine older ageing adults’ overall wellbeing. A senior demographer explained the importance of ageing in place with evidence from his past interview experience:

“…mental health is also important. There are many suicide cases among older adults in Kerala. We have data on people who committed suicide, but we don’t have data on people who attempted suicide, it must be much more. The social environment is also matters. Money is not everything. During our surveys, I used to ask older adults, what is important? money or health? Living arrangements should be looked at. Around 5% of the older adults in Kerala are living alone, and around 15% of older adults may be living with a spouse only, both are likely older adults. The intergeneration connection is important for mental well-being. In Kerala, there are socio-cultural factors, like migration. Losing their spouse is also a problem. Their replacement is also a problem even if they move to a better condition. You need love, care, and assistance. A trusted one is also important. Older adults do not trust everybody...”

Dr Irudaya Rajan S; Demographer, Chairman, IIMAD, Tiruvananthapuram.

Opportunities and Challenges

Different stakeholders expressed concerns for creating a healthy ageing society. We identified major challenges, including the social perception of healthy ageing and inequity in opportunities. A medical practitioner has stated:

“One of the main limitations is that some people think that when they become close to 80 years old, they cannot be healthy, people may not cooperate with appropriate intervention. People do not see the scope of healthcare. I am not talking about bedridden patients. This perception limits the intervention scope for healthy aging.”

Dr Siju Jose, Geriatrician, Jubilee Mission Medical College and Research Institute (JMMCRI), Thrissur.

Similarly, it was revealed that inequity in health-seeking practices and inequality in health status among different population remain a challenging factor for creating a healthy ageing society, as different stakeholders have stated:

“I think the demographic changes and related transitions (increasing nuclear family, migration, etc.) in Kerala is a natural phenomenon. Society is trying to adapt it. I think proper health-seeking should be there. There is a greater level of inequity in health-seeking practices based on haves and have-nots. Our study has revealed that there are issues with proper care-seeking practices among older adults, including delayed care due to economic constraints, lack of support to seek care, etc. Though there are many health facilities, lack of proper healthcare-seeking lead to poor health outcomes.”

Dr Sobha B Nair, Researcher and chairperson, Centre for Gerontological Studies- Thiruvananthapuram.

“I think there is a change in the perception of our generation. We prefer a use and throw culture. The same is true in the case of older adults, in most cases. I am worried about this perception. People also think, why should we invest in people with less productivity? I think increment in pension is also a politically motivated thing. I doubt whether they do it for their health improvement. We have many famous people who are active in their oldest-old days. But at large, most of the oldest old do not have a comparable level of health status.”

Mr. Tito Thomas, Secretary, Smile India-Pakal Veedu (Senior citizen’s daycare centre).

“I think the social changes (migration of children and loneliness among older adults) happening in Kerala are contextual factors. We have to address it. We need to also address the aspects of Non-resident Indians (NRI) returnees as well. Their replacement after retirement may require more supporting systems, especially social and mental support. We have to consider the inequity part in terms of well-being and opportunities during late life. Sometimes, people below the poverty level may have a social capital advantage. But for the most middle class, I think there is a need to address their supporting system as they may not have the same social networks.”

Ms. Aleena, Project coordinator, Sargakshethra - Pakal Veedu (Senior citizen’s daycare centre).

The study further reveals that unexpected health shocks like Covid-19 could have a detrimental effect on healthy ageing as it may limit the functioning of various stakeholders, increase premature mortality, and other losses in health and wellbeing. Stakeholders have expressed their concerns:

“Kerala is in a stage of second demographic dividend, whereas India is in a first demographic dividend. If I look at Kerala, …. I know that general health is okay, but for older adults, they live to close to 20 years after 60. But they are living with more diseases and disabilities. People are living with high morbidity. That was very clear during Covid. Kerala has more aged people, and the mortality was higher, partly because they live with more morbidities.”

Dr Irudaya Rajan S; Demographer, Chairman, IIMAD, Tiruvananthapuram.

“We have challenges like financing. We may do much better services if we get more funding and grants. I think we have to invest more in recreational activities, and we (the society) have not accepted that. We have more beneficiaries from our local area…Particularly after covid, finance has become a big challenge. I think now more of the Corporate Social Responsibility (CSR) activities, which are the major source of our finance, are diverted to Covid related activities. Now the general activities are getting less priority.”

Ms. Aleena, Project coordinator, Sargakshethra - Pakal Veedu (Senior citizen’s daycare centre).

“I think we are not giving much priority to geriatric care. I think it is because older adults have no common platform to raise their voices. There are many senior citizens forums. But most are not very active. The covid scenario made it worse.”

Philip K John, Trustee, Travancore Foundation, Senior care centre (private).

Discussion

The present study elicited the conceptualisation and readiness for a healthy ageing society with a stakeholders perspective in the context of Kerala, which is one of the demographically advanced states in India. The study results reiterated that healthy ageing is a composite of various intrinsic and extrinsic factors and is consistent with the healthy ageing framework proposed by WHO (World Health Organization, 2015). However, the stakeholders’ perception extended the notion of healthy ageing to a much broader domain, “successful ageing”. Successful ageing is a wider concept that is made up of productive ageing, active ageing, freedom, happiness, and positive ageing. Though the definition of successful ageing is different across studies, a common concurrence is visible that considers multiple dimensions beyond health. It consists of more of a qualitative life dimension and offers a meaningful life even at the oldest-old age (Bowling & Dieppe, 2005; Rowe & Kahn, 1997; Urtamo et al., 2019). The thematic analysis also indicated that the interaction of factors within healthy ageing (intrinsic and extrinsic factors) and the interaction between healthy ageing and successful ageing plays a significant role for a meaningful ageing experience.

Consistent with the WHO conceptualization of healthy ageing (World Health Organization, 2015), we identified three major subfactors - physiological and metabolic health, psychological wellbeing, and physical capabilities - that contributed to the intrinsic capacity of individuals. Available evidence from the literature accounted for these factors for measuring healthy ageing (Irshad et al., 2021; Rivadeneira et al., 2021). It was also found that the intrinsic capacity of individuals largely represents the functional ability that enables wellbeing in old age (Beard et al., 2022; Lu et al., 2021). On the other hand, the extrinsic factors are outside the individuals’ internal mechanism but could have a significant direct or indirect role in determining healthy ageing. Consistent with literature evidence, the identified themes under extrinsic factors comprise lifestyle risks, health system and intervention, health consciousness, social capital or support system, social or recreational activities, and economic independence (Lu et al., 2019; Sowa et al., 2016).

The study observed that healthy ageing offers only a partial attainment of a meaningful ageing transition. In order to attain successful ageing, individuals should be active. In the literature, active engagement in paid or unpaid activities including employment, social participation, independent health, secure living, and a capacity enabling environment, is considered as driving factors for a healthy ageing (United Nations Economic Commission for Europe (UNECE), 2018; World Health Organization, 2002). The results also indicate that successful ageing is inherited from positive ageing, freedom, and happiness of individuals which is based on subjective judgment (Stoncikaite, 2019). The contribution of healthy ageing as an aid to successful ageing is imperative since health is essential for making individuals productive, active and attain coping strategies. Therefore, the study indicates that a holistic approach that is required to assess successful ageing.

On the supply side readiness of a healthy ageing society, the study reiterated existing literature that the role of multiple players at various levels, including the government and non-government partners is inevitable (Gorman, 2002; Paul & Asirvatham, 2016). One of the major concerns of the supply side readiness is the accumulation of various forms of resources and appropriate planning. Studies indicate that by preparing an inclusive system for healthy ageing, it is likely to pose a challenge in emerging economies especially due to resource constraints (Gutiérrez-robledo, 2002). From the stakeholders’ perspective, in the case of Kerala, there is immense potential with the local governments as they have exclusive development funds for older ageing adults. Financial resources at the decentralised government level may help attain an inclusive healthy ageing society through well planned implementation and targeted interventions (Valkama & Oulasvirta, 2021). As many stakeholders expressed, training and utilisation of resource personnel for the wellbeing of older ageing adults, it is a challenging task in Kerala as it is well-known for producing more care providers who prefer to work outside the country (Kodoth & Jacob, 2013). There are also models experimented in Kerala through the daycare centers (Pakal Veedu) by utilizing resource personnel from the self-help groups (e.g., Kudumbashree). However, trained resource personnel could produce better results in geriatric care (Banoob, 1992; Rudnicka et al., 2020).

A key challenge for healthy ageing will be the skill assessment of the older adults to utilise them in a potential way. As one of the stakeholders stated the state’s Social Justice Department could play a pivotal role as their function is now exclusively restricted to old age, probation, and disabled. This change at the administrative department level may aid in drafting more focused planning, resource diversification, and implementation. One of the elementary areas of policy intervention that has been neglected so far in the state is the geriatric healthcare intervention. The stakeholders’ view indicated insufficient geriatric care intervention in the state, and a comprehensive health package may be a potential tool for appropriate planning for creating a healthy ageing society. Evidence indicated that a population-centered comprehensive health intervention is a cost-effective and competent tool for improving population health (Merchant et al., 2021; Zingmark et al., 2019). In line with literature evidence, the stakeholders’ views reiterated the need for efficient leadership, governance, and effective implementation of various interventions to create a healthy ageing society (Ye et al., 2021).

The stakeholders’ view further emphasised that ageing in place is an inevitable mediating factor for achieving healthy ageing. The results indicated that the interaction between ageing in place and healthy ageing could be directed by various factors including social environment and emotional well-being. A qualitative study conducted in the Spanish context indicated that there are enablers and barriers for the interaction between healthy ageing and ageing in place (Bosch-Farré et al., 2020). The study emphasised that ageing experience is subjective, and it becomes successful only when people benefit from autonomy and well-being along with the creation of opportunities for an active engagement (Bosch-Farré et al., 2020; Wiles et al., 2011). The stakeholders’ perspectives further indicate various forms of challenges to a healthy ageing experience. It was observed that the inequity in opportunities (healthcare seeking, health status, and social activities) hinders the attainment of healthy ageing. The study results, therefore, testify that for a healthy ageing society, policy intervention at the macro (policy and programs), meso (family, informal community, and society at large), and micro (individual health behaviour, predisposing factors) levels are needed (Stolk et al., 2009).

The results also indicated the potential interaction between various factors of supply-side readiness for a healthy ageing society and healthy ageing (intrinsic and extrinsic factors). These supply-side readiness factors for a healthy ageing society is inevitable to achieve successful ageing by improving health, delaying retirement, improved social and community participation, improved healthy life styles (Oxley, 2009). A study conducted in Ecuador based on the WHO’s conceptual framework of healthy ageing concluded that there is a potential interaction between healthy ageing components (intrinsic and extrinsic factors) with the supply-side readiness factors. The study urges for public policies and programs (Rivadeneira et al., 2021). The declaration of UN Decade of Healthy Ageing also emphasises the need for a collective global action in working towards healthy ageing (Dixon, 2021).

The present study has many strengths. It is one of the earlier studies conducted in the Low and Middle Income Country contexts to bring the stakeholders’ perspective on healthy ageing and readiness for a healthy ageing society using a qualitative in-depth exploratory approach. A significant share of the available literature on healthy ageing foccussed on older adults’ perspective of healthy ageing using secondary data. Therefore the study offers a rarely explored narrative of healthy ageing from a global south context. The study is not free from potential limitations. Firstly, due to the Covid-19 pandemic, the study was conducted through telephonic or google meet conversation. There might be a possibility of effective conversation engagement if it was a face-to-face interview. Secondly, even though the interview discussion was guided by targeted questions with more prompts as a technique to enrich the data, yet, there may be a possibility of respondents’ bias in various forms (Novick, 2008). Thirdly, the present study only represents the stakeholders’ view on healthy ageing, and a better interpretation of healthy ageing may be possible if we consider the views of older adults on healthy ageing as well. Finally, the present study may be extended to emerging areas of healthy ageing research including role of technology and healthy ageing, medical intervention for healthy ageing, living environment and healthy ageing, urban design and healthy ageing and more (Black & Street, 2014; Friedman, 2020; Koch, 2010; Michel & Ecarnot, 2022).

Conclusion

The findings of the study indicated that healthy ageing represents only partial achievement of a successful ageing experience. Productive or active ageing, positive ageing, happiness, freedom and wellbeing are required for successful aging. The stakeholders’ view emphasised on the importance of acquiring more resources, a well planned draft, and an effective flawless implementation which will work towards a healthy ageing society. Further to this view, the stakeholders’ indicated that integrating both health and non-health sectorplayers in gerontology, this composition would enable and createa healthy ageing society.