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Sociological Narrative of Suicidal Behavior Among Older People

Authors Lyndon N, Azman H, Che Rose RA, Mat Jali MF

Received 14 April 2021

Accepted for publication 21 June 2021

Published 15 July 2021 Volume 2021:16 Pages 1379—1392

DOI https://doi.org/10.2147/CIA.S310405

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Prof. Dr. Nandu Goswami

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Novel Lyndon,1 Hazita Azman,2 Rosniza Aznie Che Rose,3 Mohd Fuad Mat Jali3

1Anthropology and Sociology Programme, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, 43600, Malaysia; 2Centre for Literacy and Sociocultural Transformation, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, 43600, Malaysia; 3Geography Programme, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, 43600, Malaysia

Correspondence: Novel Lyndon
Anthropology and Sociology Programme, Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, Selangor, 43600, Malaysia
Tel +603-89214212
Email [email protected]

Background: Globally, suicide is regarded as an immoral behavior and can be considered a criminal act in some societies. Sociological narrative views suicide not only as a result of mental illness suffered by the individuals but may also be caused by the social environment and other risk factors.
Purpose: The objective of this study is to examine the social risk factors that drive older people to have suicidal feelings or tendencies and the extent to which these factors arise from the changes that occur in their social environment as a result of the process of modernization and industrialization.
Methods: This study employed the phenomenological approach through qualitative data collection technique. A total of 20 informants comprising 10 males and 10 females of Malay, Chinese and Indian ethnicity were selected for the study using purposive sampling technique. In-depth interviews were conducted with the informants. Data were transcribed and subsequently analyzed thematically using the NVivo 11 software.
Results: The findings revealed five conditions that led older people toward suicidal intentions. These include social and cultural changes, lack of social support, conflict in religious belief, influence of economic uncertainty and socio-economic status, and depression as a result of the changes in their social environment.
Conclusion: The implication of this research is that these factors affect older people directly as they struggle to adapt and respond to the major changes that occur in the social structure of the society they live in, stemming from the process of modernization and industrialization. Efforts to enact better policies and services for older people need to be addressed especially in developing countries based on assessment of their needs, weaknesses, strengths, and capabilities by incorporating elements of the worldview of the older people based on their experiences of daily lives.

Keywords: suicide, sociology, modernization, older people, social environment

Introduction

Suicide rates are highest among older adults in developed economies.1 The world’s older population is the fastest growing cohort globally with the trend expected to grow in the future with improved health.2 As a consequence, the number of suicides in this cohort is expected to increase correspondingly. Likewise, as the developing economies experience rapid economic growth and long duration of the industrialization process, it will be interesting to examine the suicide experience among older people in these countries and in Malaysia as well.

Previous literature on suicide in Malaysia suggests prevalence of suicide among people below the age of 40.1 However, an earlier study on suicide conducted in Kuala Lumpur Hospital in 1999 revealed that older persons (above 60 years old) were over-represented and they constituted 18% of the suicide cases.3 Recently, a consultant psychiatrist from the International Medical University (IMU) suggested that suicide rates among older people is high, though the actual data is “not reliable” because of taboo.4 Thus, there is a need to examine the reasons for the emerging rise in suicide trends among older people in Malaysia in view of the country’s prolonged industrialization and middle income trap experience.

Conventional studies from psychological perspective view an individual who commits suicide as someone who has mental illness.5 Such studies which have been mainly conducted in developed countries tend to focus on dispositional, personal and psychological attributes. However, similar studies have also been increasingly carried out in developing economies in recent years. From a sociological perspective, suicide is not solely a result of mental illness suffered by the individual but is also caused by social environmental influence. According to Durkheim,6 suicide is defined as an act that leads to death either directly or indirectly from a positive or negative act perpetrated or committed by the victims themselves. At the same time, the perpetrator consciously knows that their action of committing suicide is a wrongful act in the eyes of the society. Therefore, the social-structural perspective suggests a breakdown or disconnect in the social integration (ie, social ties, bonds) and social regulation (ie, rules and norms) as envisioned by Durkheim. In the West and industrialized countries, sociological accounts of suicide have been prevalent for more than a century.7,8

In the wider literature, social scholars have associated suicidal tendencies among older people with cultural factors, social demographics, family patterns, depression, cognitive style and personality attributes.9–12 However, a sociological focus on social risk factors among older people with suicidal tendencies is somewhat limited. Increasingly, developed countries both in the West and in East Asia13 have also begun to examine the social risk factors amongst older people with suicidal tendencies. Studies on suicide among older persons in Malaysia have also focused on psychological, psychiatric, and physical and demographic factors.14 Few studies have examined social risk factors influencing elders suicide behavior in Malaysia, with the exception of Rahimi et al2 but their scope of social factors was somewhat limited. In addition, most of the field of research is very much descriptive, empirical and remains under theorized.

Thus, there is a vital gap in the literature in relation to the exploration of the social risk factors influencing suicidal tendencies among older people in a transition or developing economies such as in Southeast Asia and particularly Malaysia which has been in a middle- income trap for more than four decades. Though Malaysia has an early onset of industrialization experience in the late 1970s and has currently reached 77% urban population (as of 2020), the impact on the social sphere is understudied. Therefore, there is a need to explore the social risk factors of suicidal tendencies among older people as the older population in Malaysia is expected to reach 15% by the year 2030.15

Additionally, most suicide studies in Malaysia that examined social factors utilize quantitative instruments which lack the contextual and culture specific situation as argued by Sinniah.16 In this regard, there is a need for qualitative studies to explore localized social environmental stressors and resources to capture the essence of social risk factors. This article thus explores the social risk factors that drive older people to have suicidal feelings or tendencies and the extent to which these factors arise from the changes that occur in their social environment as a result of the modernization and industrialization process.

Literature Review

The Concept of Suicide and Older People

According to Durkheim,6 the act of suicide is defined as an act that leads to death either directly or indirectly from a positive or negative act perpetrated by the victims themselves in which they know that their action can result in death. In this case, it can be said that a person who tries to do something or an action with the intent of causing death to themselves with knowledge of the effects is thus committing a suicide. Naturally, humans would strive to survive and would do whatever it takes to ensure their survival and continuity of life. As such, suicide is an act that has a huge impact on a person.

In this study, suicidal behavior entails suicidal thoughts or ideation, suicidal intent and suicidal attempts.17 Capability for suicide and completed suicides are not covered in this study as the focus is on exploring suicidal tendencies among older people. Suicidal ideation is thoughts of serving as the agent of one’s own death. Suicidal intent is the subjective expectation and desire for a self-destructive act to end in death. Suicidal attempt is a self-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended to die.

For the Malaysian society, suicide is considered a deviant act, both from a legal and religious standpoint. Although Malaysia is made up of people from different races such as the Malays, Chinese and Indians, none of the races and their cultural practices permit the act of suicide.18 This is because according to the religions followed by the various races in Malaysia, the act of suicide is a criminal offense and violates the social and religious norms set by the legal provision of the society and their respective religions. The religions adhered by the Malaysian people such as Islam, Hinduism, Buddhism, Christianity and others strictly forbid this act. Due to their adherence to their respective religions, the people of Malaysia therefore subscribe to establish social norms conforming to religious precepts and legal laws which strictly forbid the act of suicide.

According to a research carried out by the National Suicide Registry Malaysia (NSRM)19 in 2011, there are a variety of ways in which a person tries to commit suicide that ultimately leads to death. One of the ways of committing suicide that is most often employed is by hanging oneself. It is assumed that this is because it is the easiest way to commit suicide. Additionally, victims also attempt to commit suicide by consuming pesticides and jumping from a high place. Not only that, but there are also individuals who attempted suicide by exposing themselves to smoke, fire, or by using sharp objects, pistols and chemicals.

An older person is defined as an individual who is over 60 years of age.20 As of 2018, the total number of older people in Malaysia was at 3.23 million compared to 2.8 million for the year 2016.21 The increase is attributed to the lower fertility and adult mortality rate as a result of advancement in the country’s health and medical technology.22

Sociological Narrative of Suicide

Durkheim23 saw the act of suicide as a social integration strain that is a loose bonding of the individual in the society and instability of social relations among the members of the society. The act of suicide is not merely limited to the factors of race, heredity, social support and psychological factors but also refers to the social disconnectedness of the members in the society.24

Based on the definition of suicide stated by Durkheim,6 the main focus of sociological research is therefore to explain the reasons a person commits suicide rather than tying it to psychological factors alone. Based on Durkheim6 work, it can be argued that there is in fact a collective force that exerts coercion on members of the society that may lead to cases of suicide. Even though we sometimes see suicide as more of a personal factor, there is in fact a greater force behind the factor that influences them to take such an action. This is also stated by Durkheim23 in his research which explained that there are three types of suicide, namely egoistic suicide, anomic suicide, and altruistic suicide. All these suicides vary depending on the degree of social integration taking place within a society.

According to Durkheim,6 egoistic suicide occurs when individuals become socially isolated and are no longer integrated within the society and have to rely solely on themselves which eventually leads to individualistic attitudes. In relation to anomic suicide, Durkheim23 saw it as a result of the lack of regulation provided by the society on an individual because of individualistic factors among the members of the society. Therefore, social integration equilibrium and collective consciousness are crucial in helping to prevent suicide. In contrast, altruistic suicide occurs when the society has too strong a bond with one another that they are willing to sacrifice themselves for the sake of their belief or out of deference for their group.25 In our present-day modern world, we can see this altruistic suicide in the military where soldiers are willing to sacrifice their lives in order to defend their country. Additionally, another example is the Suttee ritual practiced by the Hindus in India in the past. Thus, it can be concluded that altruistic suicide is caused by the strong bond within the members of the society that its followers are willing to sacrifice their lives. This is because they believe that suicide in such a manner is their responsibility and a symbol of their obedience toward the government and the society.

Suicide according to the sociological narrative is caused by various factors.11 Some of these are the result of social changes in the society whether in the social structure, the family function or the social system. According to Delaney,26 there are two types of social change, namely change within the social system, and change of the social system itself as a result of the process of modernization and the impact of industrialization which eventually form three types of society based on social class, namely the elite class, the middle class and the lower class or often referred to as the poor. Change within the social system can be slow and its impact can be so small because its movement only involves adaptation to several things in the system itself.23 In contrast, change of the social system itself involves radical changes and the whole society because this process forces its members to accept such changes. If this situation occurs continuously, it could result in the emergence of a new system such as an economic and political system that is based on the construct of modernization and industrialization to the extent that some people in the system would experience extreme pressure that it could lead to suicidal behaviour.27

A society usually consists of members from various different age groups but sharing the same culture. They consist of children, teenagers, adults and older people. Culture is transmitted within a person starting from the family up to the society itself that forms the numbers of the social system. According to Durkheim,6 the society is a part of the social system. Every part in the social system is closely related and often strives to fulfil each need of the society. When this occurs, equilibrium is achieved, and the system is said to function well because it fulfils the needs and wants of the members in the society. Durkheim6 later saw society as a social system that is constantly changing and not static. Thus, Durkheim6 regarded crime and deviance as having their own function in society in that they actually lead to the unification of the members of the society or the equilibrium factor in the society. For example, when a criminal is punished, it signifies that the legal system has been endorsed or validated by the members of the society. This is also shaped by the collective consciousness in the society including older people who are the members of the society.27

Link of Family Function and Social Support to Suicide Among Older People

According to Ferrante-Wallace and Caldeira,28 the family is a social institution that connects people together through blood, marriage, law and social norms. Typically, a family consists of a mother, father and children. Each of them has their own role to play in society. For example, traditionally, the role of the father is to provide for the family while the role of the mother is to look after the children and manage the household. Sometimes, a family is not only made up of a mother, father and children but also includes older adults.

In the family institution, older people need to be given the best care by the children.5,29 In Sinyor et al11 opinion, the family is the first group that needs to provide support to older people. Ko et al30 recent study on suicide among older people in South Korea reaffirmed the role of social support. The family not only need to assist older people directly, but they also need to provide older people with information and services.29,31

A recent systematic review of social factors and suicidal behavior among older people in industrialized countries in the West (UK, US, Germany and Sweden) and Asia (Japan, Taiwan and Singapore) by Fässberg et al13 found limited social connectedness as associated with suicidal tendencies. Compton’s et al32 study on suicide among poor African Americans across all age-groups found two social factors, namely deficits in family function and social support. In examining the family functioning factor further, they identified lower levels of family adaptability and family cohesion while social support factor identified lower levels of social embeddedness and social support.

Social change resulting from the process of modernization and industrialization5,33,34 has witnessed greater participation of women in the workforce.31 This trend has altered family function34 in caring for older people. The family is no longer seen functioning as a social system and social support for older people. Instead of the traditional expectation of being cared for by the children, institutions such as nursing or old folks’ homes have taken over this role as centers that care for older people. As a consequence, older people who have different value systems and are brought up with traditional family values undergo tremendous pressure in their lives.

As a result, several social scholars view older people as having the tendency to commit deviant behaviors such as suicide if social support from the children is withdrawn and transferred to market functions. Thus, family function which is inherited through the generations has changed based on the modernization narrative to the extent that it sets aside traditional human values.24,27,35 To what extent has these institutional homes socially integrated older people to a more balanced and reordered life?

According to the theory of functionalism, all social institutions such as religion, family, economy, education and others are interconnected like the systems of the human body which complement each other.26 This means that every change in an institution will result in changes in other institutions. Therefore, to function properly, the system needs to find balance or stability so that the system can function well.26 Additionally, the members of the society need to have mutual agreement around shared values. Agreement on the right or wrong values, basic values and issues related to morality will result in a system that functions in an orderly manner.

According to Cumming and Henry,33 there are several stages of suicide that are often faced by older people wishing to commit suicide. Individuals resort to suicide when they are confronted with huge problems that are unexpected, cannot be tackled and cannot be resolved. In addition, the individual may isolate themselves and feel that death is inevitable as they are unable to talk about their problem. When the pressure experienced by the individual overrides the social prohibition, they may resort to suicide. However, when the individual starts to rationalize in committing suicide, it does not mean that they do not value or appreciate life; it may be that they feel death is better than living a life inundated with problems particularly when they do not get adequate social support from the family members. Additionally, the individual may start to feel confident that all the problems faced could not be resolved except by necessarily committing suicide so as to free themselves from the feeling of guilt and responsibility.

Accordingly, Sinyor et al11 and Hassan25 categorized the causes that lead to an older person’s suicide into factors that may originate from their poor physical conditions, extreme changes to the family function and roles to the point that the narrative of capitalism takes over, and the lack of attention or neglect by family members.

Other Social Risk Factors and Its Link to Older Persons’ Suicide

In addition to family function and supportive roles of friends, there are other social risk factors such as social isolation and neglect, lack of religious affiliation, social conflict, economic constraints and depressive states that have bearing on suicide among older people.

King36 study on adolescent suicides revealed interesting social risk factors such as social isolation and emotional neglect which can have bearing on the suicidal tendencies of older people. In a recent study by Ko et al30 which was carried out in an industrialized South Korea, the researchers found social isolation, experience of neglect, and age discrimination as factors that influenced suicidal tendencies of older adults (ie, for both suicidal ideation and suicidal attempts). Additionally, social isolation resulting from lower social interaction patterns such as poor social network and poor coping skills were found among younger suicide cases in Malaysia16 but these can also be applicable to the older people as well.

Lack of religious affiliation has often been associated with higher suicide rates37 not only because religion provides a sense of purpose and hope but the belief structures and spiritualism are presumed to provide coping mechanism.8 A study on youth’s suicidal tendencies in Malaysia found lack of religious beliefs to play a major role.35 Religious involvement can also provide social support and occasionally facilitate active social networks.8 In fact, older adults involved with organized religion are found to be less likely to complete suicide.8,38

Social conflict and disturbances have also been found to influence suicidal tendencies as revealed in a related adolescent study by Kaslow et al.39 In the study, the researchers identified other social risk factors such as life hassles, partner abuse and partner dissatisfaction. Childhood maltreatment especially sexual abuse among female adolescents was found to make the individuals more vulnerable to suicide attempts.34 Besides traumatic experience, the involvement of sensory perception is implicated in emotional processes of suicidal tendencies.40 These factors can also influence older persons’ suicide. A systematic suicide study across all age groups in Iran by Nazarzadeh41 also found family conflict to be a trigger.

Socioeconomic disadvantage resulting from economic distress influences overall suicide rates.42 Alcohol consumption and marital problems can implicate financial difficulties and can increase risk of suicide.8 Economic and financial constraint was also revealed as a catalyst for all-age groups’ suicide tendencies in Nazarzadeh et al41 study in Iran. In fact, Rahimi et al2 study in Malaysia identified not only financial problem but legal issue as influencing older persons’ suicide.

Depression has been found to have an association with elderly suicidal ideation in several studies in the developed world. Anxiety and depression were found to be strongly associated with not only suicidal ideation but also suicidal attempt in South Korea.40 However, there are several moderating social factors such as socio-economic factor, financial constraint, lack of social support, family relationship and health status that can vary the influence of the depressive symptoms on suicidal tendencies.57 In a study in the US, social inequalities among older people in terms of lower income and financial strain have been associated with higher levels of depression which increase the propensity for suicidal ideation.43 In another study carried out in South Korea, it was found that people who experienced financial difficulties in a depression-suspected group registered the highest rate of suicidal ideation.44 Additionally, having fewer social support resources was also found to be associated with higher levels of depression leading to suicidal ideation.45 Bae44 also asserted that family relationship and health status can vary the influence of depression levels on adult suicidal tendencies.

Methodology

Location and Description of Study Site

The location of this study is in Negeri Sembilan, one of the states in Malaysia. Negeri Sembilan was selected for this study as it has been developing rapidly in recent years as a result of the State’s structural plan which included the Malaysia Vision Valley Development Plan (MVVDP), Rural Roads Plan 2016–2045 and Agropolis Development. The MVVDP which covers the three growth centers in Negeri Sembilan, namely Seremban, Nilai and Port Dickson is established to stimulate the state’s economy. The Rural Roads Plan has transformed villages to new cities and transitioned the economic activities from the agricultural sector to the industrial and labor-based sectors.46 The Agropolis Development is an agriculture-based development which is aimed at developing the state toward becoming a leading food producing state. The rapid modernization process adopted by the state certainly has a direct impact on family functioning, social norms, culture, behaviors and lifestyle especially among the older population. At the same time, the sharp increase in the number of homes for senior citizens in Negeri Sembilan compared to other states was also a major factor for selecting the state as the location of the study.

Negeri Sembilan is renowned for its matrilineal customary “adat perpatih” practice. The state of Negeri Sembilan is to the south of Selangor and Kuala Lumpur. Negeri Sembilan consists of seven districts, namely Seremban, Port Dickson, Jelebu, Kuala Pilah, Jempol, Rembau, Tampin and one smaller sub-district, namely Gemas. Seremban is the capital of Negeri Sembilan. The location of this study is in Port Dickson district. Specifically, Rumah Sejahtera Jimah (Jimah Wellness Home) is located at Batu 3, Jalan Tanah Merah, 71010, Lukut, Port Dickson, Negeri Sembilan. Rumah Sejahtera Jimah (Jimah Wellness Home) is one of a number of non-governmental organizations that provide care and protection for older people who have no shelter or home. Rumah Sejahtera Jimah has 30 older residents of varying ethnic backgrounds such as Chinese, Malay and Indian. From the total, 10 are female residents while the rest are males. All the residents are above 65 years old and have registered to live here as permanent residents. Rumah Sejahtera Jimah is registered under the Department of Social Welfare since 2005. It has three main buildings comprising the male hostel, the female hostel and the office building, and it is also equipped with a hall for sports and recreational activities. All the residents have been sent to this home by their children either voluntarily or to fulfil the request of their family members because of the constraints faced by their own children in an increasingly modernized world.

Data Collection and Sampling

The study employed the phenomenological approach based on the interpretive paradigm where the meaning of a concept is understood from the phenomena and from the perspective of the social actors themselves. Therefore, the use of phenomenology in ageing studies is a means to uncover older persons’ consciousness “in the production of social action, social situations and social world”47,48 of suicide experience. Carr and Manning49 concurred that it is an ideal approach in investigating the social reality of older people. In addition, phenomenologists as social constructionists view old age differently based on socio-cultural context which signifies that there is more than one reality of old age and ageing. The main focus of phenomenological research is to describe and interpret or translate the life experiences of the social actors’ reality based on empirical facts.34,50 Schutz has integrated phenomenological approaches in social sciences through the concept of combination between the construct of the person being studied and the researcher with the fundamental aim of capturing the interpretation of reality.34 Phenomenological approach through the technique of qualitative data collection is an approach that proposes for the understanding of a meaning to be obtained and interpreted based on the realities of life of the actors themselves.34

In this research, the primary data were entirely obtained from the older people themselves. The data were collected using in-depth interviews which were carried out face-to-face and in a casual and informal manner. Indirectly, it created a positive rapport between the researchers and the informants and helped made the informants feel comfortable to talk casually and freely. Therefore, all the data in this research were obtained qualitatively in the form of textual data. The transcribed data were interpreted into thematic form. The coded thematic data were then reviewed by two experts from the Centre for Malay Language and Linguistics Studies, Universiti Kebangsaan Malaysia. The main purpose for the review was to ensure that the language, syntax and meaning of each of the themes created are representative of the informants’ understanding and interpretation.

A total of 20 informants were selected for in-depth interviewing in this study. Qualitative research strategies were selected and used in this study. This is due to qualitative research captures the range of diverse subjects in a multicultural context. As such in a qualitative in-depth interview study the intent is to capture the essence of the experience and its meanings inductively for further theorizing. The informants comprised 10 male and 10 female older persons from various ethnicities and backgrounds. The study’s sample was selected based on the nonprobability sampling technique of purposive sampling according to three predefined criteria. The three criteria included the older person must be 60 years old and above, has lived in the home for more than 3 years, and has the tendency or the feeling of wanting to commit suicide.

The interviews were recorded during the interview meeting and were coded on the basis of emerging topics and personal issues. Adopting such an approach in the reviewing and categorization process helped in the formulation of additional questions for the ongoing interviews. All the data were analyzed using the NVivo 11 software.

The researchers used the research ethics provided by the Research Ethics Committee of Universiti Kebangsaan Malaysia (RECUKM). All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional research committee. Informed consent was obtained from all participants according to the Declaration of Helsinki.

Data Analysis

Thematic analysis was used to examine the data generated. Based on Luborsky,51 thematic analysis is suited to this study because it stressed on the informants’ experiences rather than the experts’ and pragmatically, the data could be readily described and coded. Luborsky51 also defined themes “as the manifest generalized statements by informants about beliefs, attitudes, values, or sentiments” which are different from patterns or topics. The transcriptions were coded and analyzed to identify categories, patterns and themes.52 Strauss and Corbin53 categorized coding into three types, namely open, axial and selective. He described open coding as a starting point for which raw data are scrutinized for preliminary and tentative concepts followed by axial coding which involves intense analysis on the categories and themes rather than the raw data themselves. Axial coding runs concurrently with open coding to find linkages for which conceptualizations and links are more sound between the category or categories to finally settle on the “core” category or the major theme. Lastly, selective coding involves the process of “scanning all the data and previous codes”.52 Accordingly, after comparing and contrasting and focusing more on the analytic memos, the major themes or concepts which would guide the research were generated.

Results and Discussion

On the whole, the analyzed findings revealed that there are five main risk factors that drive or induce older people to commit suicide. The five risk factors identified include societal and cultural changes, lack of social support, conflicting religious beliefs, unstable economic influence and socio-economic status, and depression. All these factors have been found to contribute toward the major disruptive changes in the older persons’ social environment.

Changes to Societal and Cultural Factor

Societal and cultural factors in this study can be divided into two aspects, namely traditional culture and modern culture. The former shapes traditions, while the latter has now enforced changes upon the traditions of the family function. Inherently, traditional culture refers to the traditional values and social norms that are usually practiced by members of society in managing and taking care of older people. In this traditional culture, members of the society or family are expected to care for their parents in old age until their last breath. Among the Malays, for example, the filial child is one who believes in the notion that heaven lies beneath the feet of the mother and that the prayers of a mother or father for the success of their children will always be fulfilled by the Almighty. This familial belief is typical of the traditional rural society and is still strongly upheld by many traditional families especially among the older people. However, subtle changes in tradition have begun to seep through into the social system as the wave of modernization and industrialization introduced new social landscapes and shaped new values especially among the younger members of the society. This change in social and cultural values was identified by R1 who stated that he developed suicidal feelings as he grew anxious and desperate when it became more and more apparent that the traditional culture has been abandoned and is no longer practiced by his children. R1 revealed that his children regarded him a burden and were not willing to care for him as their priority is dominated by economic values. RI finds this distressing and is depressively sad as he still believes traditionally it remains the responsibility of the children to take care of their parents as they had cared for them from birth.

In the same vein, R2 disclosed that she voluntarily chose to be a resident of the old folks’ home Rumah Sejahtera Jimah as she was often left alone at her family home and felt neglected by her children who rarely demonstrated any love or care for her. R2 feels stressed and depressed that the traditional cultural expectation of caring for parents at family homes is not the norm anymore. Instead, alternatives like the old folks’ homes have become an obvious option for children who seek for their parents to be taken care of by someone else while they resume their work and career unhindered. The same feeling was expressed by R10 who stated that she was deeply disappointed and devastated with the attitude of her children who did not respect her as their parent. She revealed that she was mistreated by her own children who had even left her hungry and neglected her needs due to their busy work schedule. For this reason, she mentioned preferring to be in the old folks’ home.

Conversely, modern culture refers to culture that is based on modernization and industrialization where the function of labor and production is placed as priority, above that of the traditional family function. In the case of caring for the elderly parents, children who have embraced or are influenced by the modern culture do not view their parents as their responsibility as they prioritize their own productive and economic needs first and that of their own immediate family. The parents are regarded as old people who are a burden and a stressor to their own problems. Sadly, this view is most often made known to the parents indirectly by the children and this resulted in the older people experiencing a sense of loss of dignity that leads toward tendencies to commit suicide. The aforesaid situation and condition were experienced by R3 and R4 who divulged that their children no longer showed them any respect; additionally, they are no longer seen as the patriarch or matriarch in the hierarchy of the extended family. The loss of their social status as the elders within their extended family led to their sense of loss of respect and dignity.

In sum, R3, R4, R5, R6, R7, R8, R9 and R10, who volunteered to continue to stay as residents at the old folks’ home Rumah Sejahtera Jimah, agreed that modern culture has brought about drastic changes to the traditional culture, where their children no longer feel that caring for their parents at their home is their responsibility anymore. Additionally, they agreed that given their old age, they are made to feel like they are a burden on their children. The informants in this study agreed that in this modern day, their children no longer subscribe to the traditional value of family function where the responsibility of caring for the parents should be shouldered by the children once the parents are older. Here are some of their statements on the matter: I went to this child’s house, stayed at the house for a few weeks, another child will complain. They say I am picky. In the end, I told them find a care center for me. I want to stay in a care center. The views expressed by these informants are consistent with the argument presented by Fassberg et al13 who stated that society and culture play a huge role in determining how people react and view their mental health and suicide. For the informants, culture influenced the way they see themselves in the family and the quality of their interaction with their family members. There appears to be some level of adaptability on the part of some of the older people in this study who made the decision to stay in institutional homes in view of the changing values and the practicality of an increasingly industrial culture and economic situation of their children who are engaged in dual-income households. There appears to be two types of response where one cluster of elders adhered to the traditional culture and the other cluster who formed the majority learnt to adapt to the modern cultural change. The first cluster of elders felt disappointed and depressed as a result of the loss of traditional culture among their children. This was reflected in the children’s lack of respect and responsibility toward their elderly parents, the loss of dignity and social status experienced by the elders as well as the perceived experience of being seen as a burden for their children among the elders. The elders had high expectations that their children would uphold the traditional cultural values and thus felt let down, depressed and disheartened when their children acted differently, leading them to contemplate suicide. The second cluster of elders, though somewhat disappointed with their children’s change in values, were able to rationalize and were aware that their children have their own lives and are unable to carry out their responsibility toward their parents. For this reason, the elders felt the need to learn to adapt to the contemporary situation by moving to the old folks’ home.

Lack of Familial Social Support

Generally, all of the informants in this study identified the lack of social support from their own family members as the main reason they were determined to stay at the old folks’ home. They felt they were at risk if they continued to stay at the family home because their children no longer provided support in terms of financial and health care, emotional well-being and self-worth, opportunities for socializing, and information sharing. This was expressed in detail by R18 and R19 who conveyed that they had become depressed because of the lack of social support shown to them by their family members. They disclosed that they were often left at home alone and the welfare of their health was neglected by their children. This condition led them to feel unappreciated, regressing into a state of low dignity and low self-worth. Additionally, they revealed that they were subjected to verbal abuse as they were constantly scolded by their children even though the mistakes were trivial. The traditional view of filial piety and respect for older people as core values subscribed by the elders are increasingly threatened by social change which is brought about by the process of modernization and industrialization.

R16, R17 and R20 reiterated that they experienced similar situations as R18 and R19 above. They pointed out that their children prioritized earning money at the expense of caring for their parents. Their children even exploited them to obtain financial assistance from the government and yet, neglected them at the same time. Similar to R18 and R19, informants R16, R17 and R20 were also mentally and verbally abused. The combination of a series of abuse and neglect led them into depression and low self-worth, resulting in them contemplating suicide often. R11 and R15 concurred that in these situations, they also experienced weak social support that consequently brought about not only depression but accelerated physical illness that affected their overall psychological health and well-being.

These findings are consistent with Allan et al5 who argued that good social support is imperative to improve the quality of life of older people. Moreover, they remarked that the process of adequate care improves self-efficacy as well as reduces suicidal behavior. Hence, a strong social support from close family members in providing moral support and building a positive image of the older person is imperative for this group of people to develop and sustain better physical health and psychological well-being.

Conflict in Religious Beliefs

Interestingly, the informants in this study agreed that conflicting beliefs in religion is one of the main factors that influenced older people to contemplate committing suicide. Belief in religion according to the informants refers to the daily rituals, level of understanding and application of their understanding of the religion that is followed in daily life especially in going through life as an older person. This was explained in detail by R11, R12 and R13 who stated that their understanding of the religion they followed has influenced their thinking and emotion when having problems with their family members, particularly those that touch on their welfare and health. Through their religion, the informants have also come to accept that death is a definite eventuality that everyone will encounter. However, according to R11, R12, and R13, as older people start to feel more disconnected from the society and their family, they simultaneously begin to experience physical and mental isolation. As they experience thinning social ties, they prefer to withdraw from the norms of the society as they feel too exhausted to change and conform to the modern culture. This state of the social disengagement was further elaborated by R1, R2 and R6 who vouched that their conflicting beliefs in religion helped to prepare their state of mind to focus on the impending death and made them delve deeper into searching for spiritual fulfilment that the social realities have deprived them of. However, this conflict in trying to balance the spiritual and worldly needs have caused much anxiety and confusion among the informants interviewed and caused them to harbor suicidal thoughts as they feel they have lost control of their purpose and roles over both spiritual and worldly matters. This finding is consistent with the views of Cumming and Henry33 who maintained that older people need to find new roles in the society to substitute the lost roles in old age. Losing their social status and affection from the family and society could lead them toward feelings of disengagement or isolation from the social ties in the society. Therefore, it is vital that older people be continuously engaged in social and religious activities to help them build social relationships with new members of the society such as peer groups as this is one of the keys to happiness that would simultaneously lift them from extreme depression.

Influence of Economic Instability and Socio-Economic Status

Influence of continuous economic instability and socio-economic status was commonly identified by the informants in this study as a major risk factor that impacted the state of their health care and security. This is because the instability of income and the fluctuating economic situation put the income of their children at constant risk. This risk is a stressor for their children as they have to deal with the burden of debt, the possibility of losing their jobs, and earnings or income which may not be enough to cover the household needs because of the high cost of living. As a consequence, the elders themselves may be experiencing food shortages and be unable to receive good quality healthcare services and facilities.

Undoubtedly, these conditions would exacerbate the problematic situation already experienced by these older people when living with their children as they are already viewed as a burden by the children. This was confirmed by R5, R6, R7, R8 and R13 who stated that economic hardship faced by their children greatly affected their lives. Their worries heightened when their children could not afford to meet their healthcare needs particularly in terms of the costs of treatment and medications. They experienced extreme depression when they could not afford health care and their children could not afford to assist them with the costs. Their desperation eventually led them to harbor suicidal thoughts as death will end their own as well as that of their children’s sufferings. All of them vehemently mentioned that they did not want to burden their children financially especially when their main concern as grandparents was more on the wellbeing of their school going grandchildren.

The same concern was also expressed by R14, R15, R16 and R17 who echoed that a stable and strong socio-economic status is necessary for their children to be able to afford to provide for their daily needs such as food, accommodation and healthcare. However, as their children’s socioeconomic status is unstable and not sufficient enough for the family, they have to rely on government assistance and make the old folks’ home as their alternative home. Thus, it is important to note here that the traditional culture of family values is still prevalent among the older people at this old folks’ home as their priority is still on their children and their grandchildren’s happiness and wellbeing before their own. As a consequence of their unconditional love for their family’s wellbeing, the informants were willing to move into the old folks’ home to lighten their children’s financial burden. They also justified their children’s abusive treatment and neglect toward them to their children’s financial strain and stress level. Thus, in keeping with the traditional cultural understanding, these informants demonstrate that for them, the happiness of their children is more important than their own happiness. Ironically, this very act of sacrifice for their children that results from their children’s socio-economic problems inadvertently draws them into a state of desperation and depression. This can be attributed to the dilemma of being adaptable to the children’s needs on the one hand and having high expectations of the children fulfilling the traditional norms, on the other. Thus, suicide rate linked to socio-economic dissatisfaction and socio-economic insecurity is high among older people who are unable to cope with this dilemma. Research carried out by Serafini et al54 and Rushing et al55 also found that economic factors such as total income and type of employment to some extent influence mental health and suicidal behavior among older people. Their study also found that mental illness and the variable of employment mutually influence one another, and unemployment sometimes further exacerbates mental illness. However, continuous social support from the government particularly in providing basic necessities such as accommodation, food, healthcare and security to some degree helped alleviate them from committing suicide.

Depression as a Result of the Changes in Their Social Environment

The majority of the informants in this study agreed that depression is the catalyst for suicidal ideation, intention and attempt. They said that they were told their depression came about from their inability to adapt to or accept the drastic changes occurring in their social environment. The social environment interpreted by the informants refers to the physical and social environment where the person lives, and it develops in a social structure that is dynamic. This includes the culture in which the individual is educated or lives and interacts, formally or informally within a social system. Equally, depression according to the informants is when something bad happens and the person becomes clinically stressed and dissatisfied not only with the people around them but also the entire organization and system. Hence, as soon as a person has experienced depression, their social and material world changes drastically and it would subsequently disturb their mind to the point that they experience mental illness and contemplate committing suicide.

R1, R2, R3, R4 and R5 explained that they became depressed when they experienced extreme changes in their social environment which included factors such as drastic changes in their family function, lack of social support, social isolation, death of someone dear, financial difficulties, chronic illness and reduced social interaction. The uncertainties and anxieties surrounding these social conditions that led to stress created depressive symptoms.

The informants suggested that depression as a result of changes in the social environment requires intervention from the government. Among the interventions that can be provided by the government include providing old people friendly nursing homes, offering healthcare schemes for the older population and carrying out various different recreational activities for older people as well as encouraging children to provide strong social support for their ageing parents. This is consistent with the findings obtained by Rushing et al55 and Wyart et al56 in their study where they argued that long-term stress at home as a result of traumatic events experienced by older people should be followed by government interventions to reduce and balance the stress so that symptoms of suicide among older people can be managed and controlled.

Conclusion

It can be concluded that there are five primary risk factors that drive or push older people toward suicidal intentions or wanting to commit suicide. These include risks of societal and cultural changes, lack of social support, conflict in religious beliefs, influence of economic instability and socio-economic status, and state of depression that comes about as a result of the changes in their social environment. However, the overarching risk factor that can result in the other four related risks is the impact of socio-economic status on the family as this factor appears to be directly influenced by the process of modernization and industrialization. At the same time, these factors are due to the response of the older people to the changes that occur in the social structure of society as a result of modernization and industrialization. However, from a sociological standpoint, suicide is not solely attributed to the mental illness experienced by the individual as it is also due to the influence of the social environment.

Previous studies have suggested that in transition economies like Malaysia, older people are vulnerable to suicide tendencies and are more inclined to depend on the role of family function to provide care services for the ageing person as the idea of institutional care is somewhat remote. However, due to modernization and industrialization, traditional values of children’s filial responsibilities are weakening, and the inter-personal and inter-generational relations are also getting strained. Family function is undergoing stresses and strains as witnessed in the informants’ accounts of thinning out of social ties, social disconnect, neglect, perceived burden and many others. The process of adaptation by some of the older generation appears to show signs that moving into institutional homes is a practical and better option in view of the acceptable health care services provided as well as opportunities for social engagement with peer groups. In this study, the majority of the old people are adaptable to institutional care as it is seen as a social support to fulfill their needs especially in terms of opportunities for social engagement and a sense of togetherness with peers, which they found lacking while with their children.

In fact, some of the elders are utilizing the traditional value of unconditional love for their children as a reason for moving into these modern institutional homes so as to reduce their children’s burden. This hybrid approach of incorporating traditional values in modern social institutions by the older people can also be reciprocated by the children in sustaining traditional values, especially filial piety in terms of providing time for emotional and moral support while their parents are at the institutional homes. Alternatively, the children can also utilize modern market institutions such as social insurance and other investment schemes to care for their ageing parents. This is also a reminder for the current generation to have adequate social protection for their future retirement age so as to have adequate savings and investments to sustain their aging life in a healthy and socially engaged manner. Otherwise, they too will fall into the trap of social dependence and vulnerable mental state.

From a theoretical perspective, this study provides insights in enhancing the utility of macro level role theory by combining social integration theory and disengagement theory and then integrating it with a micro-level interpersonal theory. Durkheim6 social integration theory suggests that fragmentation, rupture and disruption to the family function will impact older people’s social ties and bonds. Cumming and Henry33 disengagement theory suggests that the aging process which is witnessing an increasing withdrawal of older people from the social world will potentially lead to social isolation. As a result of the modernization process, both macro structural and micro processes will potentially lead to suicidal behavior. For this reason, theoretical intervention measures for suicide can be thwarted by increasing the social connectedness and social engagement of older people. The interpersonal theory at the micro level suggests that suicidal tendencies of older persons result from the feelings of thwarted belongingness and perceived burdensomeness, precipitating a sense of hopelessness and depression. Future research can thus validate this macro-micro theory link.

The process of modernization and industrialization merely acts as a key agent in driving such change to ensure that there is a balance in rationalizing the values and social structure of society. Efforts to enact better policies and services for older people especially in developing countries need to be addressed based on the assessment of their needs, weaknesses, strengths, and capabilities by incorporating elements of the older people’s worldview through the experiences of their daily lives. Guidelines for incorporating the needs and wants of older people in human development, policies and practices are necessary to ensure that they are not discriminated against by the social systems of society and social institutions that are based on free market thinking.

Acknowledgments

The authors are grateful to the participants for spending their time and sharing their perspectives and experiences.

Funding

This research was supported by the Research Grant from UKM with the Grant Code SK-2017-002.

Disclosure

The authors reported no conflicts of interest for this work and declare that there is no potential conflict of interest with respect to the research, authorship, or publication of this article.

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