The purpose of this study was to characterize the components required for the implementation of a community-based intervention strategy for mental health prevention in older adults in a poor neighborhood in the city of Temuco. The sample of the qualitative study was composed of 15 older adults, 2 neighborhood leaders, and 2 psychosocial interveners who have been working in the sector. The design corresponds to a case study, and semi-structured interviews guided by a guideline of topics and participant observation in activities carried out with older adults in a mental health and self-care workshop were used in the production of data. The data were interpreted through content analysis. The results show that the form of aging is characterized by loneliness and feelings of sadness, including in some cases tensions derived from family dynamics. There is also economic precariousness and difficulty in accessing health services. During the pandemic, they had to face various situations that increased their feelings of loneliness and helplessness. On the other hand, the results show that neighborhood strategies to support the elderly operate on a contingency basis, and are of an assistance type. On the other hand, there is little presence of services and interventions by professional teams of public policy programs focused on this population group. Among the priority needs of the people interviewed are social contact, breaking the routine, participating in collective recreational activities aimed at sharing with others, and developing workshops with external professionals that allow them to learn. In relation to the strategies that can contribute to a community-based intervention, the need for workshop-type group activities is identified, with a horizontal and close treatment of the professionals who dynamize them. These should be held regularly (weekly), with a personalized call, including the use of participatory and playful strategies and the possibility of developing handicrafts. The workshops are understood by the elderly as a space for socialization, mutual support and learning. According to the findings of the research, these workshops should be complemented with interventions and resources that promote healthy lifestyles and resources to adequately meet the needs of the elderly.

Keywords: Elderly people, mental health promotion, community intervention

Criteria for the implementation of a community strategy for working with the elderly in times of pandemic

The population of older adults has been progressively increasing worldwide, from 1 billion in 2020 to 1.4 billion in 2021.¹ In Chile, meanwhile, the 2017 census revealed that older adults exceed 2 million 800 thousand people, equivalent to 16.2% of the country's inhabitants. Likewise, the population characterization establishes that 55.7% of the population aged 60 years or older corresponds to women, while 44.3% to men. In addition, the study shows that 16.5% of the elderly population corresponds to people over 80 years of age.² Given this, it is estimated that by 2030 the population of older adults will occupy one third of the population at the national level. The Araucanía region is currently the most aged region in Chile with respect to its population, with a rate of 12.2% of people over 65 years of age, and it is also the region with the highest poverty rate at 17.2%.³ In the context of the COVID pandemic, the elderly appear as one of the most affected groups, particularly in the confinement phase (Scholten et al., 2020; Barria-Asenjo, 2021). In addition to the affectation by chronic diseases, many of them have experienced social loneliness and varied mental health disorders.⁴ During old age, there is a progressive decrease in the reserve of functional capacity, which causes greater vulnerability in physical, psychological and social aspects, which can lead to fragility and greater health risks.⁵ This is particularly worrisome in contexts where there is insufficient support and services to properly care for the elderly. Although mental health problems affect the entire population, their effects vary according to the stage in which people find themselves. This is reflected in the study by Martínez and Ramírez⁴ in which they point out that mental health is directly related to quality of life, and that lifestyle risk factors increase the possibility of the appearance of disorders with advancing age. They also state that over 65 years of age, due to the changes caused by aging, there is a greater impact on mental health.

The negative effects associated with old age, such as the gradual reduction of biological, cognitive, and sensory functions that can impact the mental health of older people, can be worsened with the absence of a family group and positive social interactions.⁶ It should be noted that Chile is a very unequal country in the distribution of resources, with significant barriers to access mental health services (Irarrazabal et. al., 2021). Considering the negative impact of the pandemic on mental health and the inequalities in access to mental health, an adverse scenario is observed for its appropriate and timely care (Toro and Leyton, 2023). The work in Community Mental Health implies overcoming the health-illness binomial, considering people's wellbeing as a result of the complex interaction of people with others and with their context. Of course, it integrates the idea that each individual lives experiences in a particular way. Thus, the events in the lives of people and societies are interrelated, as are the psychological and social elements, which combine in such a way that one does not exist without the influence of the other.⁷ In this perspective, community mental health raises the relevance of an intervention situated in the specific sociocultural context, as well as the need to focus on the recognition and valuation of existing collective resources that could and should be implemented to ensure better conditions for people to enjoy wellbeing.

In the specific case of the elderly, efforts should be made from an integral perspective, to favor the empowerment of people, so that they can actively and participatively get involved and live a healthy aging.⁴ A key aspect of healthy aging, is participation. This is consistent with the results obtained in research linking community participation and successful aging, evidencing a positive relationship between both variables.⁸ This, since social participation favors integration, social and emotional support, which act as protective resources, preventing isolation and stress. Thus, social participation is a strategy of intervention with older people that contributes to improving the welfare conditions of these people.⁹ In Chile, although the 2017 national health plan incorporates in its approaches the social determinants of health, considering that health is multidimensional transcending the physiological dimension, and that there are social and economic aspects that influence its restoration,¹⁰ it is evident that the social determinants are not modified in practice. Therefore, inequalities continue to be reproduced, and those who age in worse conditions are the people who live in contexts of greater social and economic disadvantage. Therefore, the support, inclusion and resources that can be mobilized by community action in the communities themselves, at least partially, collaborate in improving the living conditions of the elderly. In this task, community organizations and the participation of the elderly themselves can contribute in this direction.⁹      

It should be noted that in the framework of a local research whose focus is the participatory evaluation of community psychosocial dynamics in neighborhoods in vulnerable conditions, it was agreed, together with the community organizations of one of those neighborhoods involved, to implement an initiative to promote mental health with older people in the neighborhood. For this purpose, it was necessary to gather background information that would contribute to build an evidence-based strategy. Therefore, considering that older people who age in conditions of greater disadvantage are more exposed to having a lower quality of life; that they have also faced experiences that have affected their wellbeing and mental health during pandemic periods; that communities can mobilize resources to support aging in better conditions; that community participation has positive effects for older adults, and that there is a need to implement a community-based mental health promotion strategy with older people in a neighborhood of Temuco, we set out the following objectives: As a general objective, to characterize the components of a community-based intervention strategy for mental health promotion for older adults in the vista verde neighborhood of Temuco. Specific objectives: (a) Characterize the ways in which older people in the Vista Verde neighborhood are aging; (b) Identify the main mental health needs of older people in the Vista Verde sector of Temuco; (c) Identify obstacles, resources and challenges in the neighborhood for community-based mental health promotion and prevention; and (d) Analyze elements that contribute to the development of community-based strategies for the promotion of mental health among older people in the Vista Verde sector of Temuco.

Participants

Elderly people between 60 and 80 years of age participated in the study. Some of these people participate in neighborhood senior citizen clubs (12, of which 3 were interviewed individually; while others do not participate in any community organization (4, interviewed individually). In summary, 7 people were interviewed, and participant observation was carried out in the mental health and self-care workshop, in which 12 older adults participated. Also included were two social leaders from the neighborhood, and two professionals involved in the development of a mental health and self-care workshop for older people in the Vista Verde neighborhood. Both men and women participated in the workshop, although women were the main participants. Although the participants appear to be few in number, they structurally represent structurally diverse positions regarding the topic of interest in the 360-degree logic proposed by community psychology Table 1.

Design

The methodology used is qualitative, with a case study design, in order to obtain information that would allow the description and understanding of the topic under study in depth (Enrique and Barrio, 2018). The research has a descriptive nature, in that it aims to "describe the subjective representations that emerge in a human group about a certain phenomenon".¹¹ Based on these representations, it is possible to identify the criteria that should guide the construction of a community-based mental health promotion strategy. In a complementary way, it has a deductive scope in that it seeks to derive from the results elements for the design of an intervention strategy with the elderly.

Instruments

Semi-structured individual and group interviews were used as data production techniques,¹² which were carried out based on a topic guideline constructed ad hoc. This guideline was adapted to the different types of interviewees, while meeting the objectives of the research. In addition, participant observation of a community strategy implemented with elderly people oriented to mental health and self-care was carried out, with a total of 20 sessions (5 in the year 2021 and 15 in the year 2022), led by professional psychologists, and with the participation of guests from other professions (nutritionist and kinesiologist). Observations were recorded in field notes and then analyzed in an emergent way through synthesis memos.

Procedure

After coordinating with the leaders and professionals to carry out their interviews, they were asked to collaborate in contacting older people in order to invite them to participate in the study. The cycle of interviews began with the professionals, then with the leaders and finally with the older adults. Next, the objective of the study was explained to each person who agreed to participate and they were given an informed consent form to read and sign. The confidentiality of their identity was made explicit and that they could withdraw at any time from the study. They were asked for authorization to audio-record the interview. Participant observations for the mental health and self-care workshop sessions were distributed during the last two months of 2021 and between April and November 2022.

Analysis plan

A content analysis was used, combining emerging categories with previous categories derived from the objectives of the study. The information produced in the interviews was transcribed and then analyzed, segmenting the text into units of meaning and assigning conceptual codes that represent or capture a central attribute of the topic under study. In an analytical stage, conceptual categories were elaborated with the codes, establishing conceptual relationship systems around the specific objectives that answer the research question. As indicated above, the participant observations were recorded in field notes and then summarized in memos of the first and second blocks of sessions. Subsequently, the emerging categories were integrated into the overall analysis.

The results will be presented in order to respond to each of the specific objectives, and then in an integrated manner to respond to the general objective.

 Characteristics of the aging process of older persons in the vista verde neighborhood

Most of the older persons interviewed, as well as the participants in the mental health workshop, share difficult life histories marked by economic difficulties and adverse life situations. Some of them also share experiences of family conflicts (domestic violence, alcoholism, some of their children using drugs, among others). Almost all the people interviewed suffer from chronic illnesses, which generates different discomforts, partially limiting their autonomy in some cases. It is observed that due to economic restrictions, as well as lifestyle and culture, there is a predominance of a diet high in carbohydrates and other elements that favor the presence of chronic diseases. A culture of high valuation of food (especially "junk food") as an expression of affection, sociability and enjoyment prevails, so in most of the social events (including the mental health and self-care workshop), conditions are generated to have food. This is managed by them, despite their economic situation. Solitary aging predominates, with older people experiencing feelings of sadness and loneliness, and in some cases a situation of abandonment and discrimination based on their age. Other people, especially women, express situations of overload because they have to take care of grandchildren or partners with health difficulties. They find themselves in unfavorable economic conditions, which is exacerbated by having to take care of a sick family member and/or care for grandchildren, as well as to pay for expenses associated with some of their illnesses, which are not covered by the public health system.

"... because the pension we receive is very little, they put a basic pension, I also receive it, but it is more profitable for me, because I am always working and everything, but there are people who have a small salary, they cannot work because of their health, so the situation is very precarious" (PM-6).

In relation to mental health, there is a predominance of reports that refer to states of discomfort. One of the professionals interviewed pointed out that after the restrictions due to the pandemic, when meeting with the elderly to find out how they were feeling, they were invited to perform an exercise in which elements of their state of mind appeared:

"We asked them to choose which emoticon (image) represented the way they felt, they could choose more than one. In the exercise it came out very regularly that they were feeling, sad, or depressed, or very sad...in fact more than one participant became emotional as he related his experience" (P-1).

Meanwhile, one of the leaders referred to the situation of the elderly:

"For me it is sad, the life of older adults here, they live through many difficulties" (D1).

For his part, an older adult shares what he observes in other older people in the neighborhood:

"The mind is treacherous too, and it works many times well or many times badly; they may have bad thoughts, they may be thinking of doing a serious thing, because, where they see that, how they feel like a nuisance, because I have talked to several, and they tell me: I feel like a nuisance in the house" (AM-S).

However, both in the interviews and in what was observed in the mental health and self-care workshop sessions, there is a great deal of resilience, as well as strong community ties. A sense of community is appreciated, highlighting solidarity and the implementation of collective strategies to face emergencies (e.g., fires, death of a person). This support is especially evident in critical experiences with material and emotional support that is not necessarily sustained over time.

 Needs in the area of mental health in individuals

The main discomforts affecting mental health are related, on the one hand, to loneliness, emotional overload associated with the children's problems (separations, economic difficulties or drug use), as well as the helplessness experienced for not being able to help them anymore. Another central aspect is linked to the economic situation, which constitutes a permanent stress. In addition, the presence of chronic illnesses has an important impact, especially because of the restrictions on autonomy that they entail, as well as the expenses associated with their treatment. They say that they used to do a lot of things, and now they get tired or feel sick, which limits them from doing what they would like to do.

One of the professionals interviewed expressed the following regarding loneliness and lack of support: "In other words, the multidimensional perspective of perceived social support is very low, and therefore, the feeling of loneliness is very great" (P2).

Regarding the concern generated by the economic situation and the demands arising from their illnesses, one of the interviewees said:

"I have a pension. But my pension is not enough for me either. Before it was enough, but now it's not, I have to buy... I buy medicine for myself, for my pains. All that because the doctor gives me, but he gives me very little." (PM-2).

It should be noted that the understanding of mental health is associated with the absence of mental health, especially associating it with problems of greater complexity that are not easily solved. They point out that when they suffer emotionally and their mood is very affected, they have asked for help at the family mental health center, but the experience is that they are given medication. In addition, they usually have to wait a long time to be seen.

 The idea that being and feeling well is associated with relationships with other people, with the possibility of being part of a space in which they can participate, and with activities that break the routine, that allow them to learn and recreate. Playful activities, such as workshops, where they can share with others and meet on a stable and regular basis, are valued. This space should also include training in the field of health.

One of the leaders indicates: "I think they would like that, to get them out of the routine that is here, in the town, to get them out of the loneliness...I think that would be the way to go, to have a little workshop, we are going to play dominoes, another group is going to play cards" (D1).

For his part, an older adult emphasizes the varied learning, exercise and conversation activities: "I am always asking them to do activities, knitting, crochet, drawing or if we have to do gymnastics, listen to a radio, move around, not sit all the time, and talk" (PM-1).

Therefore, mental health as such, is situated in the experience of discomfort and suffering, while well-being lies in relationships, the establishment of bonds, participation, learning, in the possibility of feeling useful, being able to support other people and having a space where they can share their experiences in confidence and carry out activities that allow them to be active.

 Obstacles, resources and challenges in the neighborhood for community-based mental health promotion and prevention

It is identified that the neighborhood has obstacles such as internal conflicts, lack of external support (Municipality, state institutions, NGOs), stigmatization of the neighborhood due to the prevalence of alcoholism and drug addiction in some people, poor access to health care, in addition to the little response received from the municipality to the structural demands of the neighborhood. Therefore, living conditions are a central aspect in the background of the mental health status of the residents, especially among older people. With respect to resources, it is recognized that, despite all the difficulties mentioned, there is community organization and participation, which has made it possible to gradually improve neighborhood conditions. One of the older people interviewed said:

"Because before, the street was pure mud, there was no paving, there was no multi-pitch, there was no headquarters, there was nothing...it was a global change where there was paving, a headquarters, a multi-pitch, and sports clubs and clubs of this and this and that began to be formed." (PM-5).

In addition, a strong sense of community appears recurrently in the workshops, highlighting a shared history of mutual support, a social identity that was built on a daily basis and the feeling of being part of a larger whole (the neighborhood).

Solidarity and concern for the most disadvantaged people also stand out. The role of the president of the Neighborhood Council (territorial organization) is especially highlighted.

 "... she, as president, always visits the houses, sees the need, and sometimes she comes to talk to us or sometimes she organizes a special meeting... and there we agree to make a little food box. I think we do the right thing... as we formed it here, because since we arrived we have been like that, concerned about one neighbor, the other, or to see our street painted, pretty and all that" (PM-6).

There are neighborhood strategies oriented to neighborhood assistance in emergencies, but not specifically focused on the elderly and their problems, such as loneliness and abandonment. Action is taken according to the emergency, but a permanent and stable community strategy is not generated. Regarding the strategies implemented from the institutional point of view, they only recognize the workshops that emerged from the Universidad de La Frontera (Workshop on mental health and self-care), and do not identify any other type of external help for the promotion of mental health. Although there has been material state support during the pandemic, it is a response to the national contingency and does not respond to a sustained strategy to support the situation of the elderly.

 Elements that contribute to the development of community-based strategies for the promotion of the mental health of the elderly

The elements that contribute to the development of community-based strategies for the promotion of mental health that have been identified are: the participation in the neighborhood, such as the neighborhood council and the senior citizens' club. On the other hand, accompaniment can contribute positively to the construction of community-based strategies and the creation of collective spaces oriented to activities where the elderly can share with each other and learn how to take better care of themselves. The people interviewed stated that it should be guaranteed that these activities are stable over time, that they are horizontal in their treatment with those who promote them, as well as a personalized call so that people feel included and considered. Strategies should promote relationships by creating a positive social climate for the exchange of experiences. They should include a variety of activities that integrate music, movement (protecting the difficulties that some people present), work around a vegetable garden, make manual works that rescue their tastes, skills and knowledge. It should also incorporate the participation of professionals from different areas that provide them with concrete information to take care of themselves and understand the processes they are going through. Based on what was observed in the workshop sessions, group activities with the elderly along the lines described above should be complemented with other services related to quality of life. A support network should be built, which in addition to strengthening mutual support, stable community care from other members of the community, integrates the responses of state services from a participatory logic and promoting resources and capabilities.

The study shows that the elderly in the neighborhood studied live in conditions that restrict their mental health. In addition to the precarious economic conditions, there are other conditions related to family relationships, loneliness and those of old age associated with chronic diseases. Economic restrictions impose permanent stress; illnesses begin to limit autonomy, cause suffering and overburden expenses. In terms of health deterioration, it has been established that the progressive decrease in functional capacity significantly limits the elderly, making them more vulnerable in physical, psychological and social aspects.⁵ This appears clearly in the accounts of the interviewed older adults. In this study, social loneliness has a relevant impact on mental health and overall health, which is consistent with what has been reported in previous studies.^13–16 This situation has been intensified during the pandemic, as has been widely reported. The presence of social determinants of health, particularly mental health, is also evident. From this, the need for a comprehensive approach to improve the living conditions of the elderly is evident, as a relevant condition to promote the mental health of this population group. This justifies the need for a community-based approach, which understands mental health as a complex outcome in which living conditions play a preponderant role.

It should also be noted that there are resources in the community that operate as mechanisms for the care of the elderly. They have a feeling of union, empathy, value participation in community spaces and wish to carry out more activities that allow them to interact, learn and get out of the routine. There is solidarity and people who are especially concerned about the elderly in difficulty. Consequently, the construction of complementary spaces to community life that offer opportunities for participation, sociability, recreation, bond building and learning, appears as a relevant element in a community strategy to promote mental health (in a wellbeing perspective) in the group studied. This is a space that should integrate the experience lived by the elderly with the contribution of health professionals, in order to promote healthy lifestyles, self-care and mutual care. This coincides with what has been raised from community mental health.^17,7 As pointed out by different authors, community mental health requires a work methodology that implies sharing objectives and tasks with other resources of the territory itself (health, educational, social and institutions of various kinds, among others) based on the recognition of the resources that the communities and groups themselves have. In this perspective, the results obtained allow us to outline the components and criteria that should be considered in community-based interventions to address mental health in this group. The first is participation, where older adults should be accessed in a collaborative manner with the neighborhood's own entities, promoting motivation to participate in the spaces created. Participatory processes should be generated that bring creativity into play from the collective, enhancing and expanding community support networks,¹⁸ which, according to this experience, start in the group or organization (in addition to the family).

Secondly, interdisciplinary work should be generated in which it is possible to work together with various professionals from different areas of public policy that have an influence on improving different aspects of the lives of the elderly. And, finally, to provide spaces for meeting, participation in an experiential logic, which allows, in addition to the exchange of experiences, learning associated with self-care and mutual care. The aim is to build and strengthen intersubjectivity and mutual support networks based on everyday life (the workshop experience is projected to everyday life). A mental health and self-care workshop appears to be a successful strategy, fulfilling the conditions previously mentioned, but it can also be a resource that helps to connect the elderly with other spaces in the neighborhood that allow the strengthening of networks, showing the contribution of the elderly to the rest of the community, as well as with institutions that can contribute to improve their living conditions.^19–29

Thanks to the members of the Vista Verde neighborhood, especially the elderly.

The author declares there is no conflict of interest.

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