Friday, Jan. 12, 2018
Young adults raised in Pampas Grande — a small farming village perched more than 12,000 feet above sea level in the Andes Mountains of Peru — often leave in pursuit of a more prosperous future in Lima and other bustling cities. They lead a life away from the clear air and terraced agricultural fields that are cut into the slopes surrounding their hometown.
As the village’s youth flock to urban areas, older generations choose to stay and continue a traditional lifestyle on lands often held by families for generations. This trend can negatively impact older adults, who are left with minimal living assistance and are isolated due to Pampas Grande’s remoteness, said Denise Burnette, Ph.D., professor and Samuel S. Wurtzel Endowed Chair in the Virginia Commonwealth University School of Social Work.
Burnette, who studies aging populations in a global context, said despite the hardships, these residents often prefer to stay in Pampas Grande instead of joining their children in Peru’s cities.
We can’t leave our land. This is all we have ever known.
“We asked them, why don’t you want to go to Lima to live with your kids?” Burnette said. “They would say, ‘We can’t leave our chickens. We can’t leave our donkeys. We can’t leave our land. This is all we have ever known.’”
Burnette is developing an action plan, based on surveys and observations she has collected, for community stakeholders and remaining residents to age in place and remain independent.
She is currently interpreting the results of a study conducted last summer and plans to implement the strategy when she visits Pampas Grande this summer with Richmond Global Health Alliance — a nonprofit organization that provides primary care and other health services to impoverished areas in Peru and Nicaragua. The organization is chaired by Sean McKenna, M.D., an assistant professor of pediatrics at Children’s Hospital of Richmond at VCU. It unites specialists in physical therapy, dentistry, pharmacy and other health care professions from VCU, the University of Richmond and other organizations.
Every June for the past 10 years, RGHA has traveled to Pampas Grande to deliver care. Burnette joined the organization last summer to bring mental health services to the population. She is spending the academic year building a culturally sensitive strategy to enable the village’s older adults to live independently.
“Culture deeply influences how we perceive, experience and express sources of stress and strain in our lives and how we conceive and make use of possible solutions that are acceptable,” Burnette said. “To be effective, any intervention must therefore be rooted in the structure of one’s beliefs and values.”
More than 1,000 people live in Pampas Grande and nine surrounding hamlets, known as caserios. The area is home to hard-working, resourceful farmers who have spent generations making a living from rocky soils worked mostly by hand. The manual labor ensures low incidences of heart disease among the area’s older residents but arthritis and other musculoskeletal pains are common. Gastrointestinal disease and other ailments related to malnutrition are also prevalent.
Older adults in the Pampas Grande community traditionally have been dependent on subsequent generations to take over the physical demands of an agrarian lifestyle. Cohabitation of extended families also has been common, which enabled interdependence. But as the migration of youth continues, these familial structures are deteriorating. Pampas Grande’s remoteness and inaccessibility also disconnects its older adults from government services and the Catholic Church, a central part of life in Latin America, Burnette said. The village church is empty for most of the year except for funerals and other special occasions. This loss of the familiar has taken a toll on the mental health of older adults.
“In conversations with these people, the dominant theme is a sense that they feel isolated and abandoned by their government. They feel abandoned by their children and they feel abandoned by God,” Burnette said.
Pampas Grande’s unique cultural geography — the role geography plays in shaping culture — has been radically altered by environmental change and migration, she added. The mountains that cut off Pampas Grande from the outside world helped forge a subsistence economy supported by familial interdependence. When remote locations experience a shakeup in the family unit, it’s more disruptive than in populated areas where resources and ties to a larger community are more readily available, Burnette said.
In conversations with these people, the dominant theme is a sense that they feel isolated and abandoned by their government. They feel abandoned by their children and they feel abandoned by God.
Examples of familial rifts can be seen across the world. In rural China, more than 60 million children remain with grandparents and other caretakers while their parents head to urban areas for work. These children, commonly referred to as left behind, are shown to be more susceptible to mental health disorders and delinquency.
Burnette said that across the world, migration has resulted in healthier lives on the whole, but it disrupts families and causes profound hardships for older people and children who are left behind.
“The scope and pace of migration, which is in response to forces such as advances in technology and communication, changing labor markets, conflict and environmental degradation is paralleled by longer and, on balance, healthier lives worldwide,” Burnette said. “However, it challenges intergenerational relationships and supports, and demands new ways of organizing life to ensure well-being.”
Building effective solutions
Burnette said older adults in Pampas Grande could benefit from establishing an infrastructure of interdependence to obtain food and other necessities. Instead of relying on the family unit, they could turn to each other for assistance. A resident with proven leadership could, with proper training and supervision, perform wellness checks and interact with community health workers and primary care providers to recognize and address signs of mental illness and other health issues.
Burnette said residents could be trained to help others cope with the emotional strain of isolation and abandonment. She said an evidence-based intervention model of peer counseling called the Friendship Bench might be readily adapted in Pampas Grande. Developed by psychiatrist Dixon Chibanda and his colleagues in Zimbabwe, the model was established in the early 2000s to address the country’s lack of mental health professionals. Older women, affectionately called grandmothers, are trained to provide problem-solving therapy to patients who experience the so-called common mental disorders of depression, anxiety and traumatic stress. Park benches take the place of stuffy offices as a safe space for patients to share their problems. The program is being implemented in primary care clinics across Zimbabwe and has been replicated in other countries.
“Indigenous community health workers who are invested in the village, who have leadership capacity and motivation can deliver these evidence-based interventions effectively and efficiently,” Burnette said.
To develop a strategy for community health workers, and to assess the mental health status of the community, Burnette partnered with J.C. Hodges, who graduated with his masters in social work from VCU last year, to survey groups of residents in Spanish. They used psychiatrist Arthur Kleinman’s Explanatory Models of Illness — a series of eight questions designed to elicit a person’s beliefs about their illness, the personal and social meaning they attach to the disorder, and their expectations about what will happen to them. The model also is used to determine a clinician’s treatment plan and the patient’s own therapeutic goals.
Burnette and Hodges also conducted interviews with key stakeholder groups in the Pampas Grande community including: residents, primary care providers, staff members from PAN Peru (a nonprofit organization that focuses on educational opportunities for children), the community health workers for the caserios and local government officials. They were asked what they thought were the community’s main challenges and how they think these challenges can be solved.
Burnette said recognizing that older adults in Pampas Grande and across the world are vital to their families and communities is important to ensuring well-being and self-sufficiency during the aging process.
"The key is to both practically and philosophically shape roles for older people that are meaningful and can fill different needs in society rather than casting people aside,” she said. “They can do things like peer counseling, caring for younger people, and advocating for policies and services in their communities. They can still be highly productive and influential members of society.”
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