Introduction
Healthy ageing and its related concepts such as successful, active, positive and productive ageing have been adopted as policy responses to demographic ageing in many countries. In order to counter the potential ‘burden’ of ageing societies, governments are keen to promote health and independence in old age (Browning and Kendig Reference Browning, Kendig, Moodie and Hulme2004). Like other countries in South-East Asia, the Malaysian government is paying increasing attention to the health and welfare of its older citizens. In 1995, the Malaysian government introduced the National Policy for the Elderly aimed at
… creating a society of elderly people who are contented and possess a high sense of self worth and dignity, by optimizing their self potential and ensuring that they enjoy every opportunity as well as the care and protection of members of their family, society and nation. (Ong Reference Ong, Phillips and Chan2002: 116)
The Health Care Programme for the elderly was introduced in 1996 and aimed to improve and maintain the health and functional ability of older adults, with the ultimate objective of promoting quality of life as well as forging productive ageing among older adults. The Programme stated the following objective: ‘to ensure that the older person has healthy physical, mental and social well-being, is able to care for him/herself and is able to contribute towards social family activity’ (Ministry of Health Malaysia 2006). While policy makers are incorporating healthy ageing concepts into their policies, the question we ask is do older adults have similar perspectives about healthy ageing? We argue that in order to design effective programmes and interventions to assist older people to age well, we need to understand the ageing experience in their own words (Iezzoni Reference Iezzoni2006; Shapiro, Mosqueda and Botros Reference Shapiro, Mosqueda and Botros2003). Furthermore, healthy ageing has tended to be defined by researchers and clinicians who work with predominantly White and Western populations. The aim of this paper is to report on data from a study that sought to explore the concept of healthy ageing in older Malays, and in particular, the role of spirituality which emerged as fundamental.
Spirituality, health and ageing
The role of spirituality and health has been investigated in a number of studies particularly in the United States of America. Much of the debate around the role of spirituality in health has focused on definitions and ways to measure religiosity and spirituality. While most researchers agree that spirituality comprises intrinsic, individual, subjective and emotion entities (Crowther et al. Reference Crowther, Parker, Achenbaum, Larimore and Koenig2002; Hill and Pargament Reference Hill and Pargament2003; Mowat and Ryan Reference Mowat and Ryan2002; Sadler and Biggs Reference Sadler and Biggs2006), it is difficult to measure quantitatively due to the wide individual variation in the expression of spirituality. Themes identified as expressions of spirituality include integrity, humanistic concern, changing relationships with others and concern for younger generations, the relationship with a transcendent being, self-transcendence and coming to terms with death (Dalby Reference Dalby2006). Spirituality can also be seen as a motivational factor or a way of coping in a stressful situation (Hill and Pargament Reference Hill and Pargament2003; Krause Reference Krause2006), even though some studies reported on the negative effects of spiritual or religious coping (Hill and Pargament Reference Hill and Pargament2003; Pargament and Brant Reference Pargament, Brant and Koenig1998).
Many studies have explored the relationship between religiosity/spirituality and mental health. Parker et al. (Reference Parker, Roff, Klemmack, Koenig, Baker and Allman2003) found better general mental health and fewer symptoms of depression among those high in all three measures of religiosity; namely organised, non-organised and intrinsic religiosity. Ardelt and Koenig (Reference Ardelt and Koenig2006) demonstrated that a sense of purpose in life, rather than religiosity, had a direct positive effect on subjective wellbeing. They also reported that shared spiritual activities had an indirect positive effect on subjective wellbeing (Ardelt and Koenig Reference Ardelt and Koenig2006). Addressing religious or spiritual needs may help psychological healing among psychiatric patients (Koenig and Pritchett Reference Koenig, Pritchett and Koenig1998).
Higher spirituality was also positively related to certain health-related behaviours such as being a non-drinker, having never smoked and being a healthy eater but was not related to exercise (Teshuva, Kendig and Stacey Reference Teshuva, Kendig and Stacey1997). The increasing importance of individual spirituality is evidenced by the incorporation of a spiritual component in a range of recent health promotion interventions. These interventions include Spirited Scotland (Mowat and Ryan Reference Mowat and Ryan2002) and an integrative health promotion model within selected communities in the United States of America (Parker et al. Reference Parker, Fuller, Koenig, Bellis, Vaitkus, Barko and Eitzen2001, Reference Parker, Bellis, Bishop, Harper, Allman, Moore and Thompson2002). The long-term impact of these interventions, however, is as yet unclear due to their relatively recent emergence.
The role of spirituality in healthy/successful ageing has been increasingly recognised (Kirby, Coleman and Daley Reference Kirby, Coleman and Daley2004; Koenig Reference Koenig2006; McCann Mortimer, Ward and Winefield Reference McCann Mortimer, Ward and Winefield2008; Mowat Reference Mowat2006; Ng Reference Ng2009). For example, Bowling and Dieppe (Reference Bowling and Dieppe2005) and Hsu (Reference Hsu2007) identified spirituality as a minor theme in qualitative studies of older people's perspectives of healthy/successful ageing. In other cases, spirituality has been proposed as the ‘forgotten’ fourth dimension of Rowe and Kahn's model of successful ageing (Crowther et al. Reference Crowther, Parker, Achenbaum, Larimore and Koenig2002; McCann Mortimer, Ward and Winefield Reference McCann Mortimer, Ward and Winefield2008). Despite these developments, spirituality has rarely been included within multidimensional definitions of healthy/successful ageing (Bowling and Iliffe Reference Bowling and Iliffe2006; Phelan et al. Reference Phelan, Anderson, LaCroix and Larson2004).
Erikson's (Reference Erikson1985) model of psychosocial development is one of the most notable psychological development theories in old age. The eighth stage was described as an attempt to achieve spiritual reconciliation towards end of life (Sadler and Biggs Reference Sadler and Biggs2006). The ninth stage, introduced later (Erikson Reference Erikson1997), was seen to incorporate an increasingly spiritual perspective, with the task ‘to develop an attitude of retreat and retirement in relation to the world’ (Dalby Reference Dalby2006: 5). It relates to Tornstam's gerotranscendence theory, which states that living into old age is characterised by ‘a shift in metaperspective from a materialistic and pragmatic view of the world to a more cosmic and transcendent one, normally accompanied by an increase in life satisfaction’ (1997: 143). Although this theory did not specifically address spirituality, the ‘shift’ could mean a shift towards ‘the sacred’ (Dalby Reference Dalby2006: 6). The three manifestations described in gerotranscendence theory are cosmic, self, and social personal relationships. This shift, described as ‘intrinsic and culture free’, also has the potential to be modified by specific cultural patterns (Dalby Reference Dalby2006: 6). Studies among religious and secular Turks and Iranians in Sweden demonstrated increased life satisfaction amongst participants who demonstrated evidence of gerotranscendence (Ahmadi and Thomas Reference Ahmadi and Thomas2000).
Musick et al. (Reference Musick, Traphagan, Koenig and Larson2000) support the role of religion/spirituality in physical health and ageing and proceed to argue the need to better understand spirituality and ageing issues within non-Christian populations. Few studies, however, have explored ageing and spirituality issues within non-Christian populations; and therefore it is an area that needs to be addressed (Coleman Reference Coleman2005). While some studies have investigated concepts of successful ageing across different countries and cultures, including non-Christian populations, the instruments used have not included items related to spirituality (e.g. Fernández-Ballesteros et al. Reference Fernández-Ballesteros, García, Blanc, Efklides, Kornfeld, Lerma, Mendoza, Mendoza, Orosa, Paul and Patricia2008; Litwin Reference Litwin2005).
In relation to the small body of evidence emerging from Asian countries, Mehta (Reference Mehta1997) reported lack of finances, loneliness, illness and other health-related problems as the main issues causing stress among older Malays and Indians in Singapore. In her study, participants used spirituality as an inner resource to cope with stress and ageing and, for both groups religion demonstrated positive influences for adapting to ageing at a personal and social level (Mehta Reference Mehta1997). Another study among Indian Hindus, Christians and minority Muslims in Singapore reported that as one ages, praying to God resulted in peace of mind and better confidence in facing vicissitudes in life (Nagalingam Reference Nagalingam2007).
Spirituality was identified as a salient factor associated with successful ageing among the community-living older Chinese in Singapore (Ng Reference Ng2009). Spirituality, in this study, was assessed by an item that asked ‘To what extent are your religious or spiritual beliefs a source of support and comfort to you?’ Despite being only a single item, the significant finding justifies further investigation. Another study in Taiwan, that incorporated the perspectives of people aged 65 and above, identified spiritual wellbeing as one of six essential components for an ideal and satisfactory life in old age (Hsu Reference Hsu2007). However, despite the finding and discussion on the role of spiritual happiness and wellbeing (Fu), it was not included in a follow-up survey that sought to investigate the relative importance of 23 successful ageing concepts (Hsu Reference Hsu2007).
In summary, only a few studies have examined healthy ageing from a non-Western perspective. This may explain why the evidence about the role and the link between spirituality and healthy ageing is sparse and under-developed, and mainly based on Christian populations. In this paper, we will explore the role of spirituality in healthy ageing among older Malays in Malaysia. The role of spirituality was not the original focus of the study, but rather spirituality emerged as a significant theme during the analysis and therefore warranted closer examination.
Methodology
Study setting
Malaysia is a country showing rapid demographic ageing. The study was conducted in Selangor, the most populous and more industrialised state in Malaysia. There are three major ethnic groups in Malaysia, namely Malay, Chinese and Indian. Malays form the largest community and are included in the indigenous group identified as bumiputera. The total population in 2007 was 27.7 million with the proportion of Malay, Chinese, other bumiputera and Indian as 50.9, 22.7, 11.2 and 6.9 per cent, respectively (Department of Statistics Malaysia 2008). In terms of religious affiliation, 60.3 per cent of the population is Muslim (incorporating all the Malays), 19.2 per cent Buddhists, 9.1 per cent Christians, 6.3 per cent Hindus, and 5 per cent are from other faiths (Department of Statistics Malaysia 2008).
Older adults in Malaysia are defined as those aged 60 and above. In the year 2000, a total of 1.45 million of the Malaysian population (6.2 per cent) were aged 60 or above. It is estimated that by the year 2020, this figure will rise to 9.5 per cent (Department of Statistics Malaysia 2008). In 2004, the life expectancy at birth was 69 years for men and 74 years for women, with a healthy life expectancy at birth for men and women of 62 and 65 years, respectively (World Health Organization 2006).
The setting provides an opportunity to explore cultural and religious influences on healthy ageing. Given the Malay background of the first author, we specifically concentrated on the Malay group, who are the most populous ethnic group in Malaysia. It was beyond the scope of the study to extend investigation to the other ethnic groups.
Study design
This project is part of a larger cross-national study investigating healthy ageing conceptualisations across Australia, China and Malaysia. The use of focus group methodology allowed us to explore older people's experiences and perceptions of healthy ageing in a group setting, and to yield rich qualitative data in the informants' own words. Ethics approval was received from the Monash University Standing Committee on Ethics on 23 April 2008.
Focus group participants and recruitment
The participants were older Malays aged 60 and above (see Table 1 for participant characteristics). All participants lived in communities located in the east and southern areas of Selangor, within a 10–75 kilometre radius of the capital city, Kuala Lumpur. Data collection took place at three different geographical locations: a traditional Malay village about 75 kilometres from Kuala Lumpur; a mixed housing but more urbanised area about 15 kilometres from Kuala Lumpur; and another mixed housing area but with more traditional houses about 30 kilometres from Kuala Lumpur. Malay traditional villages are usually characterised by single houses built on separate plots of land, whereas the urban or suburban housing areas consist of linked terrace houses or multi-storey buildings from low to high cost or the more expensive semi-detached or single houses.
Purposive sampling (Patton Reference Patton2001) was used to recruit 38 participants through community groups or via personal contact. It was not our intention for this sample to be representative of the community. Rather we aimed to access a variety of perspectives (according to gender, age, education and income). The groups were separated according to gender as advised by community leaders, and given the potentially differing cultural preferences and perspectives or priorities in healthy ageing between the genders (Stewart, Shamdasani and Rook Reference Stewart, Shamdasani and Rook2007).
All the groups had different characteristics owing to how and where participants were recruited. While this was not our original intention, adhering to cultural norms and the wishes of participants superseded those of us as researchers. Furthermore, employing traditional Western recruitment techniques was considered inappropriate and unfeasible in this context (Feldman et al. Reference Feldman, Radermacher, Browning, Bird and Thomas2008). For example, our original intention was for community leaders to identify interested participants to attend an information session, and a focus group would be organised at a later date. This occurred in groups 3 and 7, where all participants attended a regular group exercise class. However, for those people not involved in an established group, the formation of the focus groups was more spontaneous. For example, in groups 1 and 4, the community leaders, having informed potential participants about the study, found that people wanted to discuss the issues immediately. One community leader requested that once an older person is willing to participate, the interview should be conducted immediately. There are several reasons for this, including: participants wanting to talk about the topic instantly and being worried they may forget their ideas if it was not conveyed straight away. In addition, deferring it to another time might have affected their availability to participate due to other unexpected activities on the planned date as a result of being respected older people in the community.
Participants in focus groups 2, 5 and 8 were recruited by a community leader known to the first author, who was the chairman of the mosque committee. He organised for the regular attendees of the mosque to participate in focus group 2 at the mosque meeting room. Women listed in ‘Asnaf’ were invited to attend focus group 5 at the same place but on a different day. ‘Asnaf’ consisted of mainly poor or destitute people eligible to receive the almsgiving according to Islamic regulations. Focus group 8 consisted of financially comfortable medium-educated women and was conducted in one of the participant's homes.
Group 2 was considered a male faith-based group. It was difficult to recruit women from the community to create a female faith-based group, so the first author was introduced to some women living in a faith-based purpose-built residential community about 60 kilometres from Kuala Lumpur. The characteristics of group 6 therefore consisted of faith-based women from mixed socio-economic backgrounds, with four out of six participants originating from a traditional Malay village.
Participant characteristics
Eight focus groups (see Table 2 for group characteristics) were conducted, with two to six participants per group. The age range for female participants was 60–77 years, and 60–95 years for men. Each participant gave informed consent. Focus groups were conducted until data saturation was reached (Guest, Bunce and Johnson Reference Guest, Bunce and Johnson2006).
Focus group characteristics
Note: RM: Ringgit Malaysia (RM100 is about ₤17).
The first author, whose first language is Malay, facilitated all the focus groups. As part of the larger programme of research, the first author received training in focus group facilitation and used focus group questions that had been previously developed and field-tested as part of this research. The issues explored in the focus groups were (a) how older people understood healthy ageing from their perspective, (b) their definition of the ideal (expected) old age and how they prepared for it, (c) how their life experiences affected their current life situation and (d) what they needed to achieve healthy ageing.
The interviews were audio taped, transcribed, translated and analysed using thematic analysis (Braun and Clarke Reference Braun and Clarke2006; Liamputtong and Ezzy Reference Liamputtong and Ezzy2005; Pope, Ziebland and Mays Reference Pope, Ziebland and Mays2000). The first author transcribed and translated all the eight focus group interviews. In the event where the literal translation did not adequately convey the intended meaning of the participants, contextual meaning was used to produce a meaning-based translation (Esposito Reference Esposito2001). Pseudonyms were used as appropriate.
As healthy ageing is an under-researched area in Malaysia, the thematic analysis was an inductive process which involved coding the entire data set, which were collated to identify themes (Patton Reference Patton2001). It followed six phases as described by Braun and Clarke (Reference Braun and Clarke2006). Two of the authors (NT and HR) read the transcripts and cross-checked the analysis in consultation with the third author (CB).
The findings
In this paper, we report the findings relevant to the role of spirituality in healthy ageing for this Malay sample. Spiritually related concepts were discussed in all eight groups to varying degrees. It was spontaneously discussed in seven groups and was well described when prompted in group 8. Spirituality was coded as such when the informants talked about their relationship with God, self-transcendence, their spiritual activities, and the meaning and purpose of life. As all informants were Muslims, there were some overlaps between religiosity and spirituality. In the Malay language, some specific terms such as amal (general word for charity, practice or habitual action) may or may not indicate spirituality whereas ibadah (more specific word means doing good deeds) usually indicates spirituality, as it is part of the relationship with God).Footnote 1
Role of spirituality in healthy ageing
For the majority of participants as they aged and talked about preparing for the end of their lives, spirituality appeared to become increasingly central to their lifestyle and wellbeing as illustrated by the following discussion between the women in group 8:
Piah: We are more towards that [spirituality], we are already at this age, more towards that, we are inclining more to that, for example we go to any [Quran] learning, religious teaching, Yasin [Quran] recital, we attend more. (aged 65)
Miah: We think of God more than anything else, we are more there [afterlife] now, we know we are going already [going to die], it is already Isya' [night], not Maghrib [dusk], it is Isya'. We have nice friends, today we have this class, so we go, and then you get to know people. I think it [spirituality] comes naturally also. (aged 64)
While the men were more likely to broaden their discussion of spirituality to issues related to the family and the community, the women talked primarily about how spirituality affected them personally and some extended this with reference to their families. This difference may be influenced by the more significant role taken by the man in the community, as compared to women who traditionally concentrate more on their family responsibilities, particularly towards their husband and children.
Spirituality was central to the experience of ageing for participants in this study and, in talking about spirituality, it appeared the role and importance of spirituality was linked to other aspects of participants' ageing experience. Specifically these other aspects include financial security, physical health and function, peace of mind, family, and the living environment. These will be discussed in turn to illustrate the rich and wide-reaching impact and importance of spirituality in these participants' lives.
Spirituality and financial security
Participants indicated that financial security was regarded as important for healthy ageing, and many participants spoke of the hard work they had done in the past, and in some cases still did, just to get by and live comfortably. The importance of being financially prepared for old age was seen by participants to parallel the importance of spiritual enhancement at this stage of life which enabled them to prepare well not only for later life, but also for afterlife as the following participant described:
… as Muslim we can't avoid it, we are aware, at 62, 63 the age of the prophet, one more step to hereafter … we are aware material gains is not priority … no more 8 to 5 for me … to take the meaning of contentment from spiritual perspective, you have an old car, you use it, there is a desire to get a new one, but if you can't, it is okay, that is adequate. Similar to financial, I don't put high expectation towards family financial support by our children, not that I don't want it nor look forward to it nor look down at them … (Mat, aged 62, man, group 3)
In this case, it seems that Mat's spirituality has assisted him to lower his expectations, change his priorities and accept his material and financial circumstances. Thus, while participants emphasised that having enough money was important to fulfil material needs in life, spiritual endeavour was seen to balance this material desire and assist participants to experience a more peaceful life journey.
While it was agreed that concentrating on spiritual activities was a priority in later life, the extent to which participants were able to devote themselves to these activities may be determined by their financial circumstances. As the following conversation amongst the women in group 6 indicates, having higher educational attainment (and consequently the potential for higher financial security) was perceived to impact on the spiritual activities:
Facilitator: How do you prepare for old age?
Ana: Looking for a place where we can concentrate for ibadah [good deeds] (aged 60).
Lia: I did not really prepare myself much earlier, with increasing age many of my friends attended religious classes, and I used to follow them when I had free time. At the same time I ran a small business, direct selling, I am not highly educated, those highly educated are different … gradually I went to the mosque more frequently …, then I decided to stay here [spiritual retreat]. (aged 65)
While it was not stated explicitly in this extract, it was the perception of the interviewer that a better education leads to greater financial security, and therefore a greater capacity to dedicate more time to spiritual endeavours.
Spirituality and physical health and function
When asked what they needed to achieve healthy ageing, participants highlighted the importance of good physical health which allowed them to fulfil their spiritual and religious obligations without hindrance: ‘Once we retired, we should strive to prepare for afterlife. So, one is health and another thing is strong religious faith, good health so you can do good deeds (ibadah), strong faith motivates you to do that’ (Aji, aged 61, man, group 2).
Being physically independent appeared to be very important for participants, particularly for enabling them to carry out their religious activities such as attending religious classes or congregation and going to the mosque. As illustrated by the following conversation by the women in group 7, poor physical health has the capacity to limit spiritual activities:
Hani: Firstly, health. (aged 60)
Ida: If you have knee pain it is difficult for you to meet others, it is difficult to go for prayer congregation, have to do it at home, have to find the end row in the mosque, it is difficult to get around. Once you are bed ridden you will be unhappy, be it older people or anybody. (aged 60)
Ros: Even not older people. (aged 63)
Ida: But older people like us, we are alone, on our own.
Spiritual determination seemed to motivate some participants towards continuous engagement with life, as illustrated by the following informant who considered himself as ageing well despite his sub-optimal health and functional status:
I am not strong enough to work, so religious activity is more important. Wake up at night for tahajud [optional late night] prayer; we are encouraged to do the night prayers, if we cannot stand until the dawn, just for two to three hours would be enough. Recite the Kursi verses, the one easier to remember, I cannot see much to read the Quran, so just recite what I can recall, the Yasin verses … that is my priority now. (Daud, aged 79, man, group 1)
In these instances, therefore, it appears that physical health is important to participants particularly in relation to them being able to fulfil their spiritually related desires. However, if they do find that health impedes their capacity to do things they might have done in the past, then their spirituality can assist them to adapt to and cope with these changes.
Spirituality and peace of mind
The participants talked about the importance of achieving peace of mind in later life. Many informants believed that to attain this, one needs spiritual guidance, ‘Doing good deeds according to spiritual guidance, you get a more peaceful and organised life at this age’ (Jak, aged 73, man, group 4).
Participants spontaneously shared some of their spiritually related activities that gave them peace of mind, as evidenced in the conversation that occurred amongst the women in group 8:
Zie: I start my day with subuh [dawn] prayer followed by supplication. (aged 77)
Piah: I recite ‘Yaa Sin’ on Friday night. (aged 65)
Miah: That's Friday night, for me I do it twice a day, since my husband passed away, Insya Allah [with Allah's will] every morning and after maghrib [dusk prayer] I read again, Insya Allah you have peace of mind. (aged 64)
Piah: After maghrib, I am yet to finish reading the Quran, You read [the Quran] Alhamdulillah [thankful to Allah] you feel such relief.
Others saw a peaceful life as a prerequisite to pursue a spiritual life: ‘I want a peaceful life, be able to do my prayer and ibadah [good deeds] without disturbance’ (Ara, aged 70, woman, group 6).
Closely associated with participants discussion about peace of mind was the notion of good cognitive function and its important role in healthy ageing. Some informants practicsed spiritually related practices that they believed were helpful in protecting and maintaining their cognitive health or delaying the emergence of cognitive impairment, as indicated by the following participant:
Forgetfulness is not necessarily related to age, there is a supplication (you need to regularly do) to avoid this … I was being interviewed by one officer from the Selangor state religious affairs department last month. He was so amazed, that at this age I can speak really well, most people at my age, nineties, mostly demented. I told him, God gives us the wisdom, pray for it. (Bidin, aged 95, man, group 1)
Spirituality and family
Family, particularly family wellbeing, was perceived by participants to be intricately related to their healthy ageing experience. Participants regarded their responsibility towards their children and grandchildren as a lifelong commitment. Despite feeling less responsible for their children once they are happily married, participants still continued with regular prayers for the happiness and wellbeing of their descendants:
For me, at this old age, Alhamdulillah [thankful to Allah], God gives me sustenance, God give me longer life to be with my children and grandchildren, that is my priority. The second thing, if God has decided that my time has come, I am ready. My priority, healthy kin and kith, no bad luck for them that is what I have been praying for. (Daud, aged 79, man, group 1)
During the discussions, participants talked about how the current younger generation is lacking in humanity and a respectful attitude towards older people. Many participants worried about the attitudes of younger generations. In response, they used prayer as a way of coping with it: ‘We supplicate to Allah after each prayer, [we] even wake up for tahajud [late night] prayer and continue with supplication, it is really a test, to test our patience…’ (Seha, aged 70, woman, group 5).
Prayer appeared to be a common practice, with many participants advocating regular supplication to pray for their own wellbeing and the future generation:
Yes there is a specific supplication for that, wasallimna wasallim diinana wasallim iimanana wasallim tauhiidana wasallim i'tiqadana wasallim arwahana wasallim ajsaadana wasallim aulaadana wasallim zurriyatana. Ha … that is important, that supplication, the old people must recite it, everyday … [it means] security, peace for the children, grandchildren, your wife, your own self, everything, for other Muslims men and women, all others. (Bidin, aged 95, man, group 1)
In summary, the importance of having happy and healthy family members was illustrated by participants making references to the contents of their regular prayers. Interestingly, while family was clearly important, some participants (predominantly female) expressed a desire to concentrate more on their spiritual enhancement in later life, now that they felt they had fulfilled their obligations to family.
Spirituality and the living environment
The living environment included the house that participants lived in, the people they lived with and their neighbourhood area. The importance of spirituality to healthy ageing appeared to be enhanced in later life and this was confirmed by participants expressing their eagerness to live in an environment which supports their spiritual needs. Being able to safely and easily access the mosque was most important, as illustrated by the following participant:
I never married … After my mother died; I started to feel too insecure to go to the mosque at night. I hoped to find a place where I can feel closer [to God], nearer to the mosque without worrying about my security. (Ana, aged 60, woman, group 6)
The mosque is the community centre for Muslims. It is not necessarily meant only for religious activities, but it serves a multipurpose role, such as a place for them to learn and meet friends as described by this participant when asked about the need for friends or new friends: ‘don't really need because we go to the mosque every day, in the mosque all are friends, friends are all those in the mosque’ (Atan, aged 71, man, group 2).
The following man purposely chose to live near to a mosque and tolerates what he perceives to be challenging behaviours in the neighbourhood. Aware of his responsibility towards others, the practices of neighbours not attending the mosque was a concern for him:
For us, we regularly go to the mosque, I always live near to a mosque, but the neighbours, the people living in the surrounding area, wherever it is, there is always more people who do not go to the mosque, this is worrying … we can accept if their kids make noise, when we want to sleep, they work on their noisy bikes, that is still acceptable, but [the neighbours] not going to the mosque is a burden [for us]. (Aki, aged 74, man, group 2)
In the following example, a participant describes how she has been able to continue her spiritual duties by moving into a specially designed community for the purpose of pursuing spiritual development. She expresses her concerns about not being able to easily get to the mosque: ‘My son did not know about this place before. I want to live here to prepare for afterlife. If I stay at home, who is going to bring me to the mosque?’ (Lia, aged 65, woman, group 6).
In a society where the children are expected to look after the older family members, a few informants had to make a difficult decision to leave their grown-up children to live in a place to fulfil their spiritual quest:
The children feel bad as we leave the house, as though we are being neglected by the family members. They said to me, you have gone through all the difficulties caring for us but once you are older we are not capable to care for you. I told them it is not that, if I live in this house, I cannot be consistent in my spiritual obligations, it is difficult to go to religious classes, the mosque is far from the house, when there is a call for zuhr [noon] prayer, I may still be in the garden, during maghrib [dusk] time, I may still watch the television … In here we wait for the time but out there, the time has to wait for us. I want to live here till the end of my life. (Rima, aged 66, woman, group 6)
Some participants readily informed their children regarding their wish to live in a place where they can concentrate on their spiritual development, as illustrated by the following woman:
I have told my children about my wish when I am older, I am not old yet now. When your mum is older, your mum and dad want to live in [spiritual retreat]. Living in [spiritual retreat] is like living in Medina, there is a lot of teaching sessions in the mosque, you do not have to take care of us. (Ima, aged 62, woman, group 7)
In summary, spiritual needs seemed to affect participants' decisions significantly about where they chose to live, clearly illustrating the importance of the living environment for these participants.
The findings reported here were not homogenous across all eight groups. We have reported the general sense of the findings, but there are significant differences in the experience of the role of spirituality for healthy ageing relating to gender, age, income and education. For example, for older participants who may be less mobile and in poorer physical health, spiritual activities may take up more of their time, have more priority in their lives and have more influence over decisions about where they choose to live. Furthermore, it appears that those participants who enjoyed a better education, and were able to get better jobs and gain more financial stability, were those who are now able to dedicate more time to their spiritual endeavours. And for women, access to ongoing learning opportunities and spiritual development appear to be of great importance, while for the men regular attendance at the mosque is a priority. These different emphases in participants' experiences provide important insights into our understanding of how older Malays experience growing older.
Conclusion
In this Malay community, conceptualisations of healthy ageing appear to be broader than the definition originally proposed by Rowe and Kahn (Reference Rowe and Kahn1997). The role of spirituality identified in this study supports the proposal of Crowther et al. (Reference Crowther, Parker, Achenbaum, Larimore and Koenig2002) of spirituality as the fourth component in Rowe and Kahn's model. Crowther et al. (Reference Crowther, Parker, Achenbaum, Larimore and Koenig2002) argued that spirituality be included in a multifaceted definition of successful ageing, in addition to the interdependent role of biological, psychological and social elements.
In our study, it seems that spirituality is a core factor for healthy ageing in this community. For example, even though physical health and function is a primary concern for the participants in this study, a strong motivation to maintain physical health appears to be derived from the desire and commitment to fulfil their spiritual obligations. Moreover, in the event of deteriorating physical health and function, participants demonstrated yet stronger determination towards spiritual fulfilment. This adaptation to biological and environmental changes reflects the general principle of selective optimisation with compensation, a prototype adaptation strategy as proposed by Baltes and Baltes (Reference Baltes, Baltes, Baltes and Baltes1990). Our study indicates that most participants do use this strategy to achieve healthy ageing. They select to concentrate more on their spiritual identity, optimising it by doing as many good deeds (ibadah) as possible, thereby achieving peace of mind despite all vicissitudes in life. That spirituality emerged as being such a key resource for these participants, particularly in assisting them to adapt and respond to the ageing process, also supports Mehta's (Reference Mehta1997) findings in her study of Malays in Singapore. The new knowledge that this study offers is a deeper understanding as to how spirituality guides older people to appreciate or feel contented with what they have, in the face of various challenges, and yet at the same time motivates them to continue to learn and pursue their own personal development.
The changes that participants spoke about in relation to their social and personal relationships demonstrated evidence of gerotranscendence as described by Tornstam (Reference Tornstam1997). While Tornstam did not specifically discuss the role of spirituality, the three dimensions in his gerotranscendence theory, namely cosmic, self and social personal relationships, do seem applicable to some extent, particularly the broadmindedness, tolerance, positive solitude, being more selective and redefinition of social relations (Tornstam Reference Tornstam1997). As this study was not specifically designed to investigate evidence of gerotranscendence, further exploration of this phenomena and its impact in this community may be warranted.
For this Malay community, spirituality was fundamental to healthy ageing. Other factors were identified to be important for healthy ageing, and often their expression was influenced by spirituality. Using a tree as the analogy for healthy ageing, in this community, spirituality and peace of mind represents the roots and trunk, whilst the other factors represent the main branches. For a strong and healthy tree, the roots need to be well grounded in the earth. For each individual, the branches may look different or consist of different entities, but the tree still requires the well-supported roots and trunk (i.e. spirituality and peace of mind) to supply the necessary nutrients for a good life, and more specifically, healthy ageing. Figure 1 provides a pictorial representation of the fundamental role of spirituality for healthy ageing, as identified by participants in this study.
The fundamental role of spirituality in healthy ageing.
In returning to our opening question, it seems that the older adults in this study do share similar perspectives to policy makers about healthy ageing – particularly around maintaining ‘healthy physical, mental and social wellbeing’, the ability ‘to care for him/herself’ and ‘to contribute towards social family activity’ (Ministry of Health Malaysia 2006). However, spirituality was not included in the stated objectives; perhaps it may have been considered unnecessary to mention due to spirituality being so engrained within everyday life.
While the findings of this study are not generalisable to the whole population of older Malays in Malaysia, purposeful sampling has provided access to information-rich cases (Patton Reference Patton2001) to increase our depth of understanding of some important issues to consider in the promotion of healthy ageing within the population studied. Given the important role of spirituality as a resource for healthy ageing, it may be in policy makers' and practitioners' best interests to be more explicit about its role – by stating that older people, in addition to the other key elements, require opportunities to enhance their spirituality. Whilst awareness of the importance of older peoples' spiritual needs was demonstrated by its inclusion in Malaysia's Ministry of Health action plan, there may be a need for more integration and inter-departmental collaboration to ensure a more holistic and comprehensive approach towards older people that incorporates their spiritual needs. These findings also have implications for policy and practice in other countries, such as Australia, where older Malays have chosen to migrate to and grow old.
This study was conducted in the most urbanised state in Malaysia and involved older people living in primarily suburban areas. It would be interesting to do a similar study in the less developed states to access the views of older people living in more rural and remote areas. As Inglehart and Baker (2000: 19) have demonstrated, ‘the differences between values held by different religions within given societies are much smaller than the cross-national differences’, this renders further exploration of the perspectives of non-Malay communities in Malaysia and Muslim communities in different countries, particularly to examine whether the expression of spirituality seen in this study is influenced more by culture or by religious tradition.
Acknowledgement
The authors warmly thank all the participants for their time and involvement in the study, and particularly those who helped organise the groups.
