Introduction
This research commentary is based on my two studies. The first assessed the quality of life of older adults from diverse socioeconomic backgrounds in Karachi, Pakistan using CASP (control, autonomy, self-realisation, pleasure). The second study assessed women's needs and quality of life in a rural village in Sindh, Pakistan. These studies comprehensively explored all four domains of CASP, providing a nuanced understanding of the quality of life of these older adults.
CASP is a theory-based measure based on the theories of Abraham Maslow (1968), Doyal and Gough (1991) and Peter Laslett (1996) on the Third Age. The framework posits that all human beings, regardless of cultural background, share a standard set of needs. Such universality allows researchers to measure the extent to which an individual's needs are satisfied and enables them to compare results between different individuals. Maslow suggested that the need for shelter, food and clothing and to be free from undue harm were basic human requirements. However, Maslow also suggested that humans are not simply concerned with maintaining physical survival but also pursue more complex needs such as self-actualisation, happiness, and self-esteem (1).
Building on this, Doyal and Gough (1991) argued that human beings have universal and objective needs regarding health and autonomy and as such have the right to fulfil these requirements to achieve high levels of satisfaction. They further highlighted the importance of subjectivity and cultural relativism with regards to human needs. According to their theory, although people are usually aware of their needs, these differ in different cultural contexts and over time. They also argued that needs are based on a person's assessment of their capacity to achieve them (2). All humans have different goals with some degree of cultural specificity. It is clearly apparent that to achieve these goals, people must act. However, there are certain requirements for such action to be undertaken; that is, people must have the cognitive capability to choose and have the physical capacity to act (3). Peter Laslett’s theory of the Third Age argues that older age should not be seen as a residual life stage, in which people are on a declining path towards frailty and death. Instead, he argues that people are living longer, healthier lives with retirement income, and that older age should be viewed as the 'crown of life' in which self-development continues (4). Based on these theories, the CASP measure assessed the quality of life of 50+ older adults. Although CASP was developed in the United Kingdom, it has been employed in various cultural contexts, including Pakistan. In what follows I will critically analyse the limitations of the CASP measures in Pakistan, highlighting the need for alternative frameworks to assess peoples’ quality of life in different cultural contexts. This will provide a better understanding of the challenges arising from cross-cultural research and the pressing need for innovative approaches to understand this important topic-area.
Discussion of CASP 19
Control, autonomy, self-realisation, and pleasure were among the ‘higher requirements’ that served as the foundation for CASP domains. Autonomy means being without an unwanted exterior influence on one's life, whereas control refers to the capacity to manage one's surroundings and circumstances. Doyal and Gough identified autonomy and physical health as fundamental human needs. Based on their theory, autonomy was one of the domains selected for CASP (5). However, in Pakistan, autonomy is sensitive to cultural differences. Over the past thirty years, scholars have observed differences in the way autonomy operates in different cultures. According to cross-cultural theorists, autonomy is not simply a 'Western cultural ideal, but a universal need' (6). However, it is essential to recognise that people who regard family, values, customs, and conventions to be more important than their autonomy can still be satisfied (3). This understanding of cultural particularity can help us to recognise that autonomy can mean different things to different groups of people.
It is widely recognised that South Asia has 'inequalities’ regarding levels of ‘autonomy and power’ between ‘men and women' (7). Researchers have also found a substantial correlation between women's autonomy, rising gender inequality and social behaviour in South Asia (8). Diverse perspectives exist within Pakistani society regarding autonomy. For example, a study I conducted assessing quality of life using CASP in low-middle and high-income areas of Karachi identified restrictions on women's autonomy. One participant remarked, 'I cannot make any decision as a woman; my responsibility is to look after my children and take care of the home.' It is credible to suggest that those living in cultural contexts such as Pakistan, employ autonomy within structural contexts that end up restricting their overall ability to act. For example, a female participant in one of my studies residing in Karachi vividly illustrated culture's pervasive impact on women's choices: 'I am very good at stitching clothes and have always wanted to have a boutique to design clothes, but because of so many family responsibilities, I took care of my kids, my mother-in-law, my father-in-law, and my husband. Now I am 57 and feel too old to do anything. As I am now a grandparent, I also must look after my grandchildren'. This narrative powerfully highlights culture's role in shaping women's choices, something that men predominantly control. Similar findings were identified when I assessed women’s needs in a rural village in Sindh, Pakistan. Here most women said that they were dependent on their husbands, brothers and sons: 'We must listen to our husbands, as I am a widow, I do not have any right to say anything about house matters. It is my son who makes those decisions' (9).
After examining these results, one could argue that assessing quality of life based on autonomy and control may not be the most suitable approach to understand older adults' experience. However, the overwhelming sentiment among my female research participants was clear: the prospect of achieving financial independence is of more significance than it ever was. Achieving this would enable them to lead more satisfactory lives in their later years, and highlighting this issue demonstrates the necessity of economic empowerment for facilitating people’s sense of dignity.
Pakistan is an Islamic country, and Islam undoubtably provides people with the freedom to take charge of their lives through making choices. However, people's interpretations of religion and cultural norms can limit their ability to live autonomous lives (7). Due to these complexities, CASP domains such as autonomy and control when applied to Pakistani culture cannot provide a valid understanding of older adult’s quality of life. Furthermore, my research also suggests that socioeconomic status has an impact on people’s ability to exercise autonomy and control: people in low-income groups and living in rural communities have limited capacities to care for their health, eat healthily, and obtain medical treatment (3).
Self-realisation and pleasure were two other CASP domains that were interpreted differently in Pakistani society. In the original CASP framework, pleasure and self-realisation referred to how people would engage in pleasurable activities and fulfil their life's ambitions as they aged. Lastlet (1991) made the case in A New Map of Life that retirement should be viewed as the pinnacle of life simply because one is free to pursue any interest that may appeal to them. On the other hand, Maslow’s concept of self-realisation indicates the necessity of continuing personal development throughout one's lifetime. The latter represents the pinnacle of Maslow's hierarchy of needs and demonstrates that individuals have attained their full potential and have self-actualised. Lastlet (1991) provided a similar idea in his third age theory: the third age is when a person has the ability to fulfil their ambitions and lead a happy life (10). This is only feasible, though, in nations with established policies for older adults and with low levels of economic deprivation. My research demonstrated that the only employees in Pakistan receiving a modest pension upon retirement were those employed by the government (11). Therefore, CASP can be used in nations with appropriate pension policies for all citizens, not simply for employers working in government organisations.
When participants in my research were asked about self-realisation, for example, with questions concerning their 'satisfaction with life, opportunities in life, and if the future looked good to them' (3), most responded by placing their religious beliefs in the forefront of their values. People wanted to attain things that God deemed advantageous because they were confident that whatever God bestowed upon them would be genuinely in their best interests. Furthermore, they firmly believe that God would assist them in their quest for happiness and life satisfaction. Some research participants were content that they would be able to accomplish their aspirations. In my research in Sindh, responding to a question about their ability to reach their life goals, villagers commented that 'growing older means we need to be more regular in our prayers and close to almighty Allah' (9). According to Islam, 'happiness is not merely a temporary state of joy and delight; rather, it is a lifelong process aiming primarily at bringing eternal happiness, peace of mind, the tranquillity of heart, and contentment in this world' (12). However, in my research in Karachi, when asking about the CASP domain of pleasure, most participants replied that whatever Allah has sent to this world, then there must be a purpose and meaning, and therefore, they do not have any life regrets (3). In the Islamic context, satisfaction is the result of meeting one's moral, spiritual, and material requirements, leading to a state of contentment. This contentment, in turn, is a key component of happiness for adherents of Islam (11).
Conclusion
The material in this blog highlights the crucial and urgent need for any quality of life assessment measure to be culturally sensitive and to take account of the participating country's unique socioeconomic and demographic characteristics.
My previous study, which assessed the quality of life in the 50+ population in Karachi, demonstrated the versatility of the CASP assessment (3). However, when the same assessment was applied to assess the needs and quality of life of women in the 50+ population in the rural villages it was concluded that CASP could effectively assess the quality of life of people living in high socioeconomic areas, but could not do this for more deprived regions (9).
It is recommended that assessments of peoples’ quality of life in countries like Pakistan should consider Amartya Sen's capability approach, which proposes that the ability to achieve well-being is based on what is attainable within certain constraints (13). For example participants from low-income areas of Karachi and participants from Pakistani rural villages mentioned the capabilities and the opportunities they would like to have in the later years of their lives. These capabilities include access to healthcare, education, and social support, among others. They also discussed their ability to achieve lives of value (9).
Assessing people’s quality of life is a complex task requiring a person-centred, culturally aware research approach. This approach should incorporate a range of theoretical frameworks and consider socioeconomic and cultural factors and how these affect people’s capabilities in their old age.
1. Huitt, W., 2007. Maslow's hierarchy of needs. Educational psychology interactive, 23.
8. Bhopal K. Gender, 2019 'race' and patriarchy: a study of South Asian women. Routledge;
About the Author
Dr Laila Surani was an Academic Visitor at the Oxford Institute of Population Ageing in Michaelmas 2023.
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