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Impact of Integrating Life Reviews and Cultural Elements to Improve the Indigenous Elderly’s Mental Health in Taiwan’s Community Care System: Evaluation of a Qualitative Study

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07 August 2023

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09 August 2023

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Abstract
In order to cope with the challenges of physical and psychological aging in the indigenous people in Taiwan, most of the tribes in Taiwan set up cultural health stations for indigenous elderly. These community care facilities have practiced many health promotion activities, such as the reminiscence, life review, and arts activity. However, there was little exploration into the benefit of indigenous people’s practice the life review activity in Taiwan—the gap this study aimed to fill. This study adopts life review therapy through a set of innovative life review activity designs in indigenous older adults, including activity planning, and indigenous cultural elements. A qualitative study design using semi-structured interviews was used to obtain data from a purposive sample. Ten participants who assessed to the cultural health stations services and participated in the life review activities of the indigenous older adults in southern Taiwan were interviewed individually. The data were analyzed using Graneheim and Lundman’s qualitative content analysis. The theme—“experiences and benefits of participating”—and two categories with six subcategories emerged. The results demonstrated that the participation of the indigenous elderly in life review activities with cultural elements had obvious benefits for their mental health. Life review therapy can be incorporated as a supplementary LTC treatment for the indigenous people, thereby, promoting the positive emotions of the indigenous elderly.
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Subject: Social Sciences  -   Psychiatry and Mental Health

1. Introduction

Indigenous people around the world have their unique cultural and socioeconomic structures. Notably, the disability rate among indigenous people in some countries is 2‒10% higher than that of the general population [1,2,3,4]. The main reasons are the barriers and inequalities that they often encounter when accessing healthcare services [5,6]. With increasing life expectancies and declining fertility rates, the rapid aging of the population has become a global concern and an issue for Taiwan in particular [7]. The proportion of its population aged 65 and over has increased from 11.53% in 2012 to 17.56% in 2022 [8]. The proportion of its aging indigenous population is similarly rising year by year. Specifically, the proportion of indigenous elderly aged 65 and over has increased rapidly from 26.7% to 41.9% between 2012 and 2022 [9]. The Taiwanese society comprises multiple ethnic groups including the indigenous people, Han Chinese (consisting of the sub-groups of Hoklo, Hakka, and mainlanders), and new immigrants. Taiwan’s indigenous people are the descendants of one of the Austronesian races. As recorded in the official statistics, there are 16 indigenous groups distinguished by their unique cultural customs. The total indigenous population is approximately 569,000, which accounts for 2.38% of the total population. Living on both sides of the Central Mountain Range, the tallest mountains in Taiwan, the indigenous people have their own traditional culture and the habit of group living. They still maintain the tradition of providing communal care for fellow group members until today. Based on their groups’ traditional culture, they also share the responsibility of taking care of their elderly. However, rapid social changes have led to an increasing number of young indigenous adults migrating away from the groups’ mountainous locales to work in the cities. Consequently, the care functions traditionally provided by the group and family members have been disrupted.
Taiwan has one of the fastest-growing elderly populations in the world. According to the official demographic statistics, more than 20% of Taiwan’s population will be over the age of 65 by 2025, making it a super-aged society. The demand for long-term care (LTC) continues to rise steeply with the advent of an aging society. In 2016, the Taiwan government formulated the LTC 2.0 policy and promulgated the LTC Services Act. The focus of the policy is to satisfy the LTC demands of various elderly sub-groups and provide a diversified, widespread, and sustained LTC system centered on the individual [10]. In response to the issue of LTC provision for the indigenous elderly, the National Committee of Indigenous People of the Taiwan Government has established the program of indigenous cultural health stations (CHSs). These stations are dedicated to servicing the indigenous elderly and implementing the policy of aging in place during LTC provision, thereby, enhancing their physical and mental health and quality of life. However, the program is constrained by the environment and existing social structure, including a lack of service resources and inconvenience arising from inadequate transportation infrastructure. Moreover, the services often failed to meet the needs of the indigenous elderly and their families owing to the language and cultural gaps between them and the LTC service providers. To resolve this problem, the government invited indigenous groups and related scholars and experts to discuss and formulate a development plan for the LTC of indigenous people and improve the CHSs’provision of services to them. The need to pay attention to indigenous cultures and respect their native methods of LTC provision have been emphasized in an approach known as cultural care [11].
Despite Taiwan’s implementation of an LTC policy for indigenous people, research topics related to their LTC have yet to be fully explored. Previous research on care for Taiwan’s indigenous people has focused on the existing status of service provided by the CHSs and the difficulties faced, as well as strategies to solve identified issues [12,13]. Several issues remain unclear, including the current status of activities provided by the CHSs to promote physical and mental health and whether these activities are effective at enhancing the mental health of the indigenous elderly.
The theory of psychosocial development, proposed by the renowned developmental psychologist Erikson, divides an individual’s life from infancy to late adulthood into eight stages. There are developmental tasks and crises generated by social interactions corresponding to each stage. Erikson (1998) further proposed a ninth stage, which primarily reviews one’s life cycle. Specifically, the elderly review the tasks of each stage of their life, discover the areas of harmony and discord, and, then, attempt to achieve a balance between the two extremes. Erikson emphasized that the review of one’s life cycle is a developmental task to be completed in late adulthood (from 65 years old to death), with the ultimate goal being the achievement of self-integration [14]. Butler (1963) proposed the concept of life review; he opines that it is a normal and necessary process of aging to be undertaken by the elderly, which helps them review their past experiences with a positive attitude and find the meaning of life [15]. Life review is also a channel through which care is provided to the elderly. It has been widely used and promoted during the application of psychotherapy for the elderly all along and has become an effective teaching and consultation method [16,17]. Holloway and Freshwater (2007) state that life stories allow the elderly to connect their past, present, and future [18].
Subsequently, the researchers, CHS care attendants, and the indigenous elderly jointly discussed the design of the activity program and arrived at the decision of adopting life review as the direction for the program design. An activity program based on a life review suitable for the indigenous elderly was designed in this study. The program consists of seven units, each of which facilitated their review of important experiences at various stages of their lives. They were encouraged to share their own life experiences to improve their mental health. This study aimed to develop a set of activities for a program suitable for Taiwan’s indigenous elderly to make a life review and examine the benefits of participating in this activity program on their mental health.

2. Materials and Methods

A qualitative research method was adopted in this study to find out the feelings of Taiwan’s indigenous elderly who had participated in life review activities and the benefits that they had gained in terms of improved mental health.

2.1. Participants and recruitment

The participants were screened from an indigenous CHS located in southern Taiwan. The criteria for inclusion were: (i) indigenous elderly over 65 years old, (ii) members who participate in CHS activities, (iii) no severe cognitive impairment and mental illness, (iv) recipients of the CHS’ services for a minimum of one year, and (v) willing to participate in the 7-week life review activity program. Those elderly who met the screening criteria were invited to participate with the assistance of the CHS care attendants. The researchers explained the background and purpose of the study to each participant, and they all signed the research consent form in line with academic ethics. The research intervention period was from October to December 2022.

2.2. Research ethics

This study was approved by the Institutional Review Board (IRB) and was conducted with the consent of the institution. The researcher explained the objective and method of this study to the participants and acquired their written consent. Their anonymity and confidentiality were strictly protected. All research data were encoded to ensure the anonymity of the participants and used only for academic research purposes. The participants were permitted to withdraw from a session or to quit the study altogether during the research procedure for any reason without having their rights to receive care affected.

2.3. Planning of the activity program

A life review program for Taiwan’s indigenous elderly was designed by integrating the life review theory with indigenous cultures. The framework of the program contents was based on Erikson’s psychosocial development theory. Following discussions among the researchers, CHS care attendants, and indigenous elders, the name of the activity program was finalized as the Naruwan Life Review for the Indigenous Elderly (NLRID).“Naruwan” is a Taiwanese indigenous term meaning “hello” and “beautiful home.” It represents a warm greeting and is an important feature of indigenous cultures. The detailed plans for and contents of the activity program are shown in Table 1.

2.4. Data collection

Purposive sampling was adopted for this study. The researchers first explained the purpose of the study to the eligible participants. After a participant had provided their consent, the researchers conducted a one-on-one semi-structured interview with them. Each interview session, which lasted 60 to 90 minutes, was duly recorded. The data collection process continued until content saturation was reached. The interview questions focused on the respondents’ feelings and the effects that they felt after having attended the life review activity program.

2.5. Data analysis

The collected data were analyzed using the analytical method for qualitative research contents proposed by Graneheim and Lundman [20]. The research procedure was as follows. First, the researchers read the manuscripts ad verbatim several times to understand the overall contents. Second, we perused the textual data and codes and understood the meaning and relationship between them through continuous side-by-side checks and comparisons. Third, we summarized and analyzed the data and identified common themes, classified those data that had the same meaning, and, then, established the core categories and subcategories. Finally, we analyzed the meanings, rules, and concepts presented by the collected data and finalized the research results.

2.6. Rigor and trustworthiness

We examined the rigor and trustworthiness of this study based on the four criteria proposed by Guba and Lincoln on the precision of qualitative research, as follows: (1) Credibility: One of the researchers is from an indigenous group, familiar with the indigenous cultures in Taiwan, has served in CHSs for a long time and can build a trusting relationship with the indigenous elderly. All the researchers involved have also undergone comprehensive training in qualitative research and possess practical experiences in interviewing and qualitative analysis. Moreover, the researchers held regular discussions with qualitative research experts throughout the research process. (2) Transferability: The descriptions by the indigenous elderly of their experiences and feelings about participating in the activity program provided meaningful insights into the overall life review program and important references for the planning and practice of life review activities in the future. (3) Dependability: Themes were yielded by targeting the textual interpretations, meaning units, coding, and labeling for the categories and subcategories. Multiple rounds of testing were also conducted until a consensus on the research results was reached by the interviewers and two qualitative research experts. (4) Conformability: The researchers immediately sought clarification from the participants whenever they had made vague descriptions. Finally, the participants were requested to review and confirm the research results.

3. Results

A total of 10 participants were enrolled, consisting of 10 females aged 67–79 years who had used services for 1 to 5 years (Table 2).
The findings indicated that one of the main themes was the subjects’ experiences of participating in the NLRID. Another main theme was the impacts and benefits of participating in the NLRID. Three categories were also identified.

3.1. Experience of participating in the NLRID program

3.1.1. Fun was stimulated, and meaning was gained

This study was the first time that Taiwan’s indigenous elderly participated in a series of life review activities. In the past, the majority of the indigenous CHSs had organized monotonous and repetitive activities. The activity program sparked in them the joy of living and the pursuit of the meaning of life.
I was very happy to introduce myself in my indigenous language for the first time. I never had such opportunities in the past, so it was especially significant. I was also able to hear other indigenous people tell their stories in their native language, which was very meaningful.
(PI)
In one of the activities, the instructor asked us to go home and look for old photographs of our life in the past. I find this meaningful because it helps me to realize that the stories of my life and that of my family members happened in the past. Although this realization is sad, god will bless them.
(PH)
The instructor made connections with the indigenous culture during the activity and brewed healthy tea with plants unique to Taiwan’s mountains for everyone to enjoy. This made me very curious. It turns out that plants found in the tribe can also be used to make tea and preserve health, which is highly significant.
(PC)
Several participants stated during the interviews that they were impressed by other participants’ creations and looked forward to each creative process.
The use of mung beans to create self-portraits made the strongest impression on me. At that time, the instructor told us to create a self-portrait, which I found to be most interesting. It was also great to create a life review book, which I really like. I can keep it as a souvenir.
(PB)
I look forward to every opportunity that we get to create something. The instructor was very good at providing guidance. We would start by recollecting and discussing past events before working on these creations.
(PD)

3.1.2. The activities relieved physical and mental stress and improved physical strength

Other than inspiring fun and finding meaning in life, the indigenous elderly also reported that participating in the NLRID program soothed their emotions, helped them recall the past to reconstruct new meaning, and stimulated their brains’ cognition.
Participating in this activity kept my brain active. We have to think because the instructor wanted us to recall the past. Doing so stimulates our memories and brain functions, which is helpful for our brains’ cognition.
(PB)
We can do something meaningful when participating in the program, thereby relieving stress and improving the health of our bodies. This was unlike the past activities organized by the CHSs, which were too monotonous.
(PI)
I think the contents designed for this activity are very helpful for […] exploring the meaning of what happened in the past can relieve stress, exercise our body, and improve our memory […] I also realize that in the future, we can prepare meals using healthy ingredients, which will help us maintain our physical health.
(PE)
It is very beneficial for the elderly to recreate new meanings by recalling the past.
(PD)

3.1.3. Great satisfaction with the NLRID contents and wish for it to continue in the future

I am really happy and hope to continue attending such programs. Otherwise, the indigenous elderly will be bored at home and not know what to do. I hope that the program will continue to be held in the future.
(PH)
I learned a lot about indigenous culture, some of which I did not even know because I left the tribe early on in life to marry my husband. I did not have an in-depth understanding of many aspects of indigenous culture. I hope that there will be programs like this in the future. If so, I will continue to attend.
(PC)
The activity was well-designed and taught us a lot. I wish that this program will continue to be held.
(PG)
If there is a follow-up program, you can continue to teach us about the use of indigenous plants. Looking back on our growing up years, all of us miss cooking with wild plants and flowers as we did in the past. I am very happy to see again the flowers and plants unique to the mountains.
(PJ)

3.2. Impacts and benefits of participating in the NLRID program

3.2.1. Learning about indigenous cultures that they did not know about previously

Unexpectedly, the participants stated that through the activities, they were able to learn certain aspects of indigenous cultures that they were previously unaware of. Some participants recalled their own cultural practices from memory, whereas others recognized the cultures of other indigenous people. The participants also joked that because they married very young, they did not have the opportunity to learn more about indigenous cultures from their parents. Most participants added that they did not have many opportunities to engage with such program content in the past.
We are not familiar with some indigenous cultures and have not learned it […] Indigenous cultures were hardly taught in schools in the past; thus, we rarely had the opportunity to understand the culture of the Taroko people, of which I am a member. During this activity, I was very happy to hear about our Taroko culture, which is different from that of the Atayal people and has its own characteristics.
(PA)
There were limited opportunities to attend courses on indigenous cultures in the past. I can learn a lot about our indigenous cultures through this activity.
(PB)
Although we have lived in the mountains […] and have seen many plants, we do not know what exactly they are nor their significance. Today, we discovered many plants that are beneficial to our bodies, as well as cultural practices that we did not know about.
(PE)
Knowing our own culture is good for us because we can recall what happened when we were young. We can also discuss the cultures of the various tribal groups together.
(PC)

3.2.2. Remembering many past events and generating hope and confidence

The participants indicated that they had not participated in any life review events in the past. The NLRID series of activities allowed them to recall many past events. Through the cognitive transformation process, the participants began to develop hope and confidence in their own lives.
The instructor spoke about our dreams when we were young, and I have always wanted to say about my dreams […] When I was a child, I used to dream about wanting to live a better life in the future. Unfortunately, this dream did not come true because we were relatively poor. I was disappointed that I did not get to enjoy the good lives that other people have […] We have had our ups and downs in our past; so long as we live well now, everything is fine.
(PJ)
Previously, I did not attend any course on reviewing my childhood and growing up. Many events and details have been forgotten. However, participating in this activity allowed us to relive our lives in the mountains, which is the biggest gain […] I feel that life now is much more smooth sailing, and I gradually find it to be less difficult.
(PD)
The instructor guided us through the activity process, which left a deep impression on me. I remember everything that has happened to me from birth to now. I am slowly recalling past moments and am very happy. I feel hopeful and joyful. We learned a lot from this program.
(PH)
The participants’ responses revealed that this special program made their lives more meaningful and fun and allowed them to experience indigenous cultures and their own life journeys.

3.2.3. Instructors were activity-led to adopt instructional methods with positive encouragement, thereby, inspiring the participants’motivations to change

The answers of most participants indicated that they highly and positively evaluated the instructors. They appreciated the many materials prepared by the instructors and their frequent use of positive encouragement during the activities, which not only encouraged the participants to alter their motivation but also strengthened their sense of cohesion. Therefore, the positive teaching methods adopted by the instructors are the key to initiating change in the indigenous elderly.
The instructors gave very good descriptions and connected indigenous cultures with our lives in the past. I hope that they will continue to teach us next time.
(PE)
The instructors’ sessions were very lively and conducted in a positive and encouraging way, which left a deep impression on us.
(PH)
The instructors taught us a lot of information on the unique plants and healthcare used by the indigenous people and guided us positively to share our knowledge. I used to be too shy to speak in the past but this process helped me substantially.
(PF)

4. Discussions

This study found that conducting a life review was effective at enhancing the mental health of the indigenous elderly. The findings were consistent with those of other studies on the elderly from non-indigenous ethnic groups [21,22,23]. Several previous studies have confirmed the positive impacts of life review therapy on various aspects of the elderly’s lives. Our findings have also verified Butler’s theory that conducting a life review is a modified form of cognitive therapy [24]. The findings further demonstrated that life review therapy effectively enhanced the mental health of the indigenous elderly, especially those in the CHSs. In the past, the indigenous people of Taiwan encountered severe social discrimination in society in terms of language and culture; we established during the research process that the indigenous people need care, encouragement, affirmation, and a platform on which to heal their pain and share their stories. Gibson (2019) emphasized that conducting a life review embodies therapeutic significance, maintains the self-integrity of individuals, and endows them with the ability to communicate with others [25]. Therefore, life review therapy can better integrate the lives of the elderly and give them the belief that their lives are meaningful. This process promotes self-affirmation and makes them realize the positive meaning of successful aging. The needs of the indigenous elderly in their later years go beyond receiving care itself. Of greater importance is the affirmation of the meaning of their lives and gaining a sense of value.
Life review therapy has been widely accepted and applied to help the elderly improve their sense of well-being and reduce their psychological load [26]. The results of a recent meta-analysis study concluded that life review therapy has a huge impact on reducing depressive symptoms among the elderly [27]. The majority of the indigenous elderly in the CHSs are mild to moderately physically incapacitated. However, many of the research participants were depressed not because of their current physical state but their early experiences of war, poverty, and social discrimination. Life review therapy can successfully improve mental health through well-designed life review activities that help the indigenous elderly consolidate their life experiences. For example, after reviewing and reevaluating her own life, a group member said she realized that she currently had a happy family and successful children. These are achievements that she can be proud of. Consequently, she now sees her children’s success as her own and has adjusted her own criteria for defining success and failure. Relevant studies point to the life review process as a therapeutic method that enables the elderly to reinterpret the past, thereby, giving them a different perspective of, and ascribing positive meanings to, past events. This enables them to review and reexamine the difficulties and shortcomings in their lives [28,29]. In the process, the elderly identify unresolved problems from past failures, rekindle hope and generate new perspectives, and consolidate the meaning of life, thereby, developing a new self-concept. This study provided the participants with the opportunities to reflect on each stage of their lives and deal with past regrets or traumas. Such interventions can improve the mental health of the indigenous elderly by helping them move beyond grief, reduce regrets, and increase their feelings of satisfaction. Moreover, life review therapy is a pleasant and meaningful process. The fun lies in the meaningful exchanges throughout the process, during which the participants share stories from their past with other group members, thus, reminding them that pleasant events are gradually happening.
In addition, this study found that the program design of integrating life review therapy with indigenous cultures sparked cognitive stimulation and maintained the cognitive abilities of the brains of the indigenous elderly; it also enabled them to view their own cultures more positively and stimulated their sense of identity with their indigenous groups. Communicating in their indigenous languages and recalling their cultural practices not only helped them to understand the cultural values of their indigenous groups but also enhanced their identity and self-confidence in their indigenous identities. In addition, this study found that the positive and encouraging guidance of activity leaders was one of the keys to strengthening the process of change in the indigenous elderly. The participants’feedbacks indicate that the instructors must create an atmosphere that is highly receptive and supportive to guide the participants’in-depth exploration of the topic. Finally, planners of activity programs should pay attention to the cultures of the indigenous people and incorporate large amounts of indigenous cultural elements into the contents of the life review activities. These are important elements for increasing the motivation of the indigenous elderly to participate and undertake changes.
However, there were several research limitations. First, timing and funding limitations meant that the research participants only included the indigenous elderly in one CHS in southern Taiwan. Their experiences may differ from those of the elderly from other Taiwanese indigenous groups. Therefore, the scope of future studies should be expanded to include different CHSs. Second, because the life review program was conducted at an indigenous CHS, great care should be taken before generalizing these results to other LTC facilities for indigenous people. Third, this study applied the qualitative research method to evaluate the effectiveness of the program. The findings were based solely on the data acquired after one intervention program; thus, the duration of the program’s effects cannot be predicted. Future studies can consider designing a series of studies to test the relationship between the frequency of intervention and the duration of the life review program.

5. Conclusions

To the best of our knowledge, this study was the first life review program implemented at an indigenous CHS in Taiwan that combined life review therapy and indigenous cultural elements. The results demonstrated that the participation of the indigenous elderly in life review activities with cultural elements had obvious benefits for their mental health. Therefore, this study has provided positive evidence of the impact of life review therapy on the overall mental health of the indigenous elderly. Additionally, healthcare professionals serving the indigenous elderly should consider implementing life review programs to improve the mental health of their clients. Simultaneously, life review therapy can be incorporated as a supplementary LTC treatment for the indigenous people, thereby, promoting the positive emotions of the indigenous elderly.

Author Contributions

Conceptualization, Y.-C.T.; Data curation, H.-H.; Formal analysis, H.-H.; Investigation, Y.-C.T.; Methodology, Y.-C.T.; Project administration, H.-H.; Resources, H.-H.; Software, Y.-C.T.; Supervision, Y.-C.T. and H.-H.; Visualization, Y-C.T.; Writing original draft, Y.-C.T.; Writing review and editing, Y.-C.T. and H.-H. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was approved by the Human Research Ethics of National Cheng Kung University (Approval No. NCKU 110-203).

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Acknowledgments

The authors would like to express their deepest gratitude to all participants of this research.

Conflicts of Interest

The authors declare no conflict of interest.

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Table 1. Contents of the Taiwan Indigenous Older Adults Life Review Therapy Sessions.
Table 1. Contents of the Taiwan Indigenous Older Adults Life Review Therapy Sessions.
Number Erikson’s stages of psychosocial development Theme Related to
indigenous culture
1 Early childhood About myself Indigenous languages
2 Late childhood My family Indigenous Sacrifices
3 Adolescence My lifeline Indigenous Totem
4 Early adulthood My dream Indigenous craftsmanship
5 Middle adulthood Meaning of my life Indigenous music and dance
6 Late adulthood My healthcare Indigenous Plants
7 Review life Blessings for life Making life review book
Table 2. Demographic characteristics of participants (n = 10).
Table 2. Demographic characteristics of participants (n = 10).
Participants
No.		 Gender Ethnic Group Age Education Marriage
A Female Truku 79 Elementary school Widowed
B Female Paiwan 75 Elementary school Widowed
C Female Bunun 69 Elementary school Widowed
D Female Paiwan 67 Senior high school Widowed
E Female Bunun 74 Elementary school Widowed
F Female Puyuma 70 Elementary school Married
G Female Ami 77 Elementary school Widowed
H Female Atayal 67 Senior high school Widowed
I Female Lukai 75 Elementary school Married
J Female Paiwan 71 Elementary school Widowed
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
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