Aging in Place in Hong Kong and Its Implications for Sustainable Development: A Qualitative Study Exploring the Needs, Beliefs, Behaviors, and Well-Being of Older Adults through Self-Determination Theory and Social Cognitive Theory

Abstract

With the rapidly aging population, Aging in Place (AIP) assumes an increasingly pivotal role, as it aligns with SDG 3 (Good Health and Well-being) and Environmental, Social, and Governance (ESG) principles. Despite the contributions of AIP, there is a dearth of studies investigating the corresponding needs and well-being of older adults from psychological and sociocultural perspectives. This study aimed to investigate older adults’ needs, beliefs, behaviors, well-being, as well as perceived challenges and opportunities pertaining to AIP. Adopting a qualitative design, in-depth semi-structured interviews were conducted with 41 older adults on an individual basis. Through thematic analysis, a theoretical framework with reference to Self-Determination Theory (SDT) and Social Cognitive Theory (SCT) was established. Findings reveal that the psychological needs of autonomy, competence, relatedness, and dignity are conducive to well-being and decision making. Fear of being a burden to others emerges as a dominant sociocultural construct. This research extends SDT by incorporating the need for dignity as an overarching factor intersecting with SDT needs. Fulfilling psychological needs, honoring cultural beliefs, and aligning with SDG3 and ESG principles are crucial to the successful implementation of AIP. AIP policies should not only consider older adults’ practical needs but also their psychological needs, thereby fostering an age-friendly environment through sustainable development.

1. Introduction

Aging in Place (AIP)—aging in one’s own familiar living environment and community while preserving freedom, independence, and autonomy, without resorting to institutional care [1]—is widely recognized as a preferred living arrangement for older adults. It provides a sense of familiarity, continuity, and independence and is a significant focus of research in gerontology and sustainability [2]. It is a topic of paramount importance in rapidly aging societies such as Hong Kong, where the number of elderly individuals has reached a record high of 1.64 million, i.e., constituting 21% of the population, and is projected to increase to over 30% by 2039 [3]. AIP assumes a pivotal role in contributing to sustainable development, particularly in densely populated cities such as Hong Kong, aligning with Sustainable Development Goal 3 (SDG 3; Good Health and Well-being), which highlights the importance of healthy living and well-being for all ages [4]. A plethora of research findings converge on the notion that AIP not only alleviates public financial burden but also improves the physical as well as mental health of senior citizens [5,6]. Through maximizing the utilization of existing housing structures and minimizing the need to construct new residential buildings, AIP saves resources and decreases carbon emissions brought about by urban development. Since Hong Kong is a city renowned for its limited living space, adapting existing housing structures to suit the elderly’s needs not only utilizes space wisely but also reduces the consumption of raw materials and protects urban greenery, all of which contribute to biodiversity. Socially, AIP enables older adults to more actively interact with their familiar environments and communities, hence giving rise to the strengthening of social structures. Such interactions promote intergenerational solidarity and cultural continuity [7,8], contributing to social cohesiveness in Hong Kong. Through AIP, older adults can play a more active role economically and socially. AIP also facilitates the cultivation of social networks and collective identity. Social sustainability brought about by AIP protects the elderly against social isolation and facilitates their active engagement in the society, contributing to social resilience and inclusiveness. In terms of governance, AIP is the strategically sustainable response to Hong Kong’s aging population issue. By promoting elderly care at home, the implementation of AIP-friendly policies can alleviate the pressures imposed on medical, healthcare, and social services, resulting in financial savings from lowered long-term institutional care costs. In fact, AIP is considered a solution to the shortage of residential care homes [9,10]. Nonetheless, it is crucial to improve the quality of social services and the availability of barrier-free transportation to foster the development of AIP. Although the AIP policy is highly favored by policymakers and elderly individuals in Hong Kong, progress has been more gradual than expected. Various studies in the literature have indicated that AIP is not without its obstacles, as successful implementation of AIP policies requires orchestrated efforts involving careful planning and provision in terms of age-friendly living environments, community-based services, healthcare, and transport [11]. Nevertheless, ensuring that older individuals can age comfortably in their homes involves more than just the physical surroundings. It also involves considering sociocultural aspects, particularly in places such as Hong Kong where traditions, for instance, filial piety, greatly influence how people experience aging [12,13]. Yet, the impact of cultural norms and the rapid changes in society may have caused a shift in these values [14], which is further exacerbated by challenges faced in Hong Kong such as high property prices and limited community care services for older individuals, making Aging in Place an economically burdensome option [15,16]. As a result, older adults who cannot afford such costs may have no alternative but to resort to residential care homes.

2. Literature Review

Notwithstanding that Hong Kong is a society that emphasizes Confucian values of filial piety, which has a significant influence on family dynamics, particularly in relation to caring for elderly parents [17,18,19], older adults may feel obligated to opt for residential care homes to alleviate the pressure on their family members. Due to the fear of burdening their family members, older adults may hesitate to opt for AIP [20]. This internal conflict is heightened by their fondness for their adult children, who may also be accountable for providing financial, social, and emotional support to their own families and children. This situation presents a dilemma: maintaining family harmony versus fulfilling one’s true needs and desires. Thus, understanding older adults’ needs, beliefs, behaviors, and well-being is conducive to the successful implementation of AIP.

Self-Determination Theory (SDT) underscores the psychological needs of autonomy, competence, and relatedness [21]. Such concepts are particularly relevant and applicable to AIP. Fulfillment of these needs is conducive to the motivation and well-being of older adults in the context of AIP. Autonomy plays a pivotal role in AIP, where older adults exert control by making decisions, no matter whether big or small, in accordance with their needs and desires, within their familiar environment. As older adults’ physical and cognitive functioning declines with age, their autonomy may become threatened. AIP provides a sense of control over daily tasks and routines, thus empowering seniors and contributing to their sense of contentment [22]. Given that older adults may feel a diminished sense of purpose following functional declines and retirement, the need for competence becomes more pronounced. Making relevant adjustments in roles, duties, and lifestyles can enhance self-efficacy and well-being. Such adjustments are more easily facilitated in AIP environments as opposed to institutional care settings. Relatedness refers to the need to feel connected with others, particularly with family and friends. AIP provides older adults with opportunities to maintain connections with their family and existing social network within their familiar environment. Hence, implementing targeted policies and strengthening community support are essential for fostering relatedness [8].

In conjunction, the application of Social Cognitive Theory (SCT) [23] is instrumental in understanding the thoughts, feelings, and behaviors pertaining to AIP. According to SCT, an individual’s beliefs affect their decisions, behaviors, and well-being. This is particularly relevant to the Hong Kong context, where sociocultural influences affect the perceptions of AIP and family dynamics. The decision to age in place is shaped by mastery experiences, social learning, observation, social norms, and beliefs, within a sociocultural context, all of which have implications for AIP policies. One of the most widely adopted applications of SCT is Cognitive Behavioral Therapy (CBT), which has been demonstrated to be effective in changing thoughts, feelings, and behaviors, thus enhancing well-being [24]. CBT strategies including cognitive restructuring and reframing can be applied to overcome the psychological issues pertaining to AIP, e.g., tackling the fear of being a burden to their family and coping with the adjustments and challenges brought about by aging and AIP. In synchrony, SDT and SCT form an empirical framework that is conducive to understanding and interpreting the needs, beliefs, behaviors, and well-being of older adults, in relation to AIP. Despite the overwhelming preference for AIP, progress has been slow. Research on AIP has mainly focused on Western nations including the U.S., Australia, and Canada. Comparatively few studies have been conducted in Asian regions, especially Hong Kong. However, findings and policy measures from the West may not be generalizable to Hong Kong due to specific differences in culture, housing and healthcare challenges, and demographic composition. Furthermore, previous research on AIP in Hong Kong has mainly centered on government policies, housing structures, and health outcomes [25], with less emphasis concerning psychological aspects, which are vital to the well-being of the elderly and achievement of SDGs. This gap is amplified by the scarcity of in-depth, qualitative studies employing empirical psychological theories or frameworks to guide AIP research. Such frameworks are crucial for developing evidence-based interpretations and recommendations. This study aimed to fill the gaps by investigating the needs, beliefs, behaviors, well-being, challenges, and opportunities linked to AIP among older adults in Hong Kong, against the backdrop of psychological frameworks of SDT and SCT for analysis. Valuable insights gained will inform the future of AIP, eldercare services, and relevant policies that have been operative for more than two decades. In this regard, this study aimed to address the following research questions: (1) What are the needs, beliefs, behaviors, and well-being of Hong Kong’s older adults regarding AIP? (2) What are the AIP challenges and opportunities they encounter?

3. Methods

The study recruited 41 older adults via purposive sampling, selecting participants from elderly community centers in Hong Kong. Purposive sampling is a widely adopted sampling method that involves selecting participants who are knowledgeable and experienced, willing to participate, and capable of expressing and reflecting on their ideas and experiences [26]. Participants were chosen to help achieve the study’s aims and address the research questions effectively. In alignment with quota sampling, a method of purposive sampling [27], the researchers selected interviewees as the interviews progressed, striving for balanced representation across key demographic categories. Participants were required to fulfil the following criteria: 1. aged 65 or above, in line with the minimum age for the Normal Old Age Living Allowance [28]; 2. living in a non-institutional setting; 3. fluent in Chinese (Cantonese or Mandarin); and 4. exhibiting a reasonable level of cognitive functioning, sufficient to participate in in-depth interviews. The demographics of the participants, including gender, age, education level, marital status, employment status, and housing types, are detailed in

Table 1. Demographic characteristics of participants.

Interviewee	Gender	Age	Education	Marital Status	Employment	Housing Type
1	Male	67	Postgraduate	Widowed	Retired	Private
2	Male	65	Postgraduate	Married	Retired	Private
3	Male	67	Secondary	Never Married	Part-time	Private
4	Female	65	Secondary	Married	Part-time	Private
5	Female	76	Postgraduate	Never Married	Retired	Private
6	Female	66	Secondary	Married	Retired	Private
7	Female	67	Secondary	Married	Retired	Private
8	Female	66	Undergraduate	Divorced	Retired	Private
9	Female	73	Secondary	Married	Retired	Private
10	Female	70	Secondary	Married	Retired	Public
11	Female	67	Postgraduate	Never Married	Retired	Private
12	Female	73	Undergraduate	Married	Retired	Private
13	Female	71	Secondary	Widowed	Retired	Private
14	Female	67	Postgraduate	Widowed	Retired	Private
15	Female	65	Secondary	Married	Retired	Public
16	Female	71	Secondary	Widowed	Retired	Public
17	Female	85	Undergraduate	Widowed	Retired	Private
18	Female	70	Primary	Married	Retired	Private
19	Male	68	Postgraduate	Married	Part-time	Private
20	Female	67	Primary	Married	Retired	Public
21	Female	71	Primary	Married	Retired	Private
22	Female	65	Undergraduate	Married	Full-time	Private
23	Male	66	Postgraduate	Married	Full-time	Private
24	Female	68	Postgraduate	Married	Retired	Private
25	Female	65	Secondary	Divorced	Retired	Private
26	Female	75	Secondary	Widowed	Retired	Private
27	Male	74	Undergraduate	Married	Retired	Private
28	Male	67	Undergraduate	Married	Retired	Public
29	Female	73	Secondary	Widowed	Retired	Private
30	Female	96	Secondary	Widowed	Retired	Private
31	Male	66	Secondary	Married	Retired	Private
32	Male	70	Secondary	Married	Part-time	Private
33	Male	71	Secondary	Married	Retired	Public
34	Male	80	Primary	Married	Retired	Public
35	Male	70	Secondary	Married	Retired	Private
36	Male	68	Secondary	Married	Part-time	Public
37	Male	73	Secondary	Married	Retired	Public
38	Male	65	Secondary	Never Married	Part-time	Public
39	Male	72	Secondary	Married	Retired	Public
40	Male	75	Secondary	Married	Retired	Public
41	Male	80	Secondary	Married	Retired	Private

, which shows that 58.5% of participants were female, aged 65 to 96 years with a mean age of 71 and a median age of 70. Men constituted 41.5% of the participants, aged 65 to 80 years with a mean age of 70.2 and a median age of 69. Most participants (70.7%) lived in private housing while the remaining 29.3% resided in public housing. In Hong Kong, as of 2024, a two-person family is eligible to apply for public housing if the monthly family income and net asset amount are less than HKD 19,550 (approx. USD 2499) and HKD 376,000 (approx. USD 48,069), respectively. In terms of education levels, around 9.8% had primary education, over half (56.1%) completed secondary education, 14.6% held undergraduate degrees, and 19.5% possessed postgraduate qualifications. Most participants were married (65.9%), while the remaining 34.1% were widowed (19.5%), divorced (4.9%), or never married (9.8%). The majority of participants (80.5%) were retired, with only a fraction employed either full time (4.9%) or part-time (14.6%).

Approval following Ethical Review for Research Involving Human Subjects (RC/ETH/H/0113) was granted by the CPCE Research Committee, College of Professional and Continuing Education, the Hong Kong Polytechnic University. Informed consent was subsequently obtained from all participants. Data were collected through in-depth, semi-structured, individual face-to-face interviews, each lasting approximately 60 min. Participants received a supermarket coupon valued at HKD 300 (approximately USD 38) as an incentive for their involvement. The following questions were used to guide the in-depth interviews:

• What are your thoughts regarding AIP?
• What are your needs and why?
• What are the challenges and opportunities?
• How do you tackle these difficulties?
• What are your suggestions and recommendations on AIP?

This study acknowledges the roles that SDT and SCT play in data interpretation, enabling an understanding of participant responses within established frameworks. One of the strengths of this qualitative research approach lies in its ability to capture detailed data through in-depth discussions and to facilitate clarifications of responses via follow-up questions.

The interviews were conducted in Cantonese by the Principal Investigator, who possesses extensive experience in both conducting and teaching qualitative research. She has also contributed to various large-scale public engagement consultancy projects. The philosophy underlying qualitative research emphasizes the interaction between the interviewer and interviewee to obtain rich, meaningful data. It is acknowledged that qualitative study designs cannot be completely free of human biases. In light of this, the interviewer endeavored to maintain objectivity and consistency by adhering to the guiding questions, reading them out word-for-word. The interviewer refrained from sharing personal comments and viewpoints, focusing instead on posing open-ended questions. Follow-up questions were asked only when clarifications were necessary [29].

Subsequently, the interviews were transcribed verbatim and translated from Chinese to English by professional translators. The data collection and analysis were conducted concurrently, with interviews continuing until reaching data saturation where no new themes emerged [30,31]. Based on the guidelines and discussions pertaining to sample size benchmarks in the literature, there is a consensus that the number of interviews should not only depend on the principle of saturation but also be informed by previous studies with similar designs and research questions [32]. For qualitative studies employing Grounded Theory, a sample size of 20 to 30 is typically recommended [33]. Reviews of studies focusing on Aging in Place indicate that qualitative studies using interviews generally involve sample sizes fewer than 30 [11,34].

Following Yin’s model [35], the analysis involved stages including compiling (i.e., gathering information), disassembling (i.e., breaking it down), reassembling (i.e., reconstruction), interpreting results, and drawing conclusions. After compiling interview transcripts, the data were disassembled using a coding technique that assigned labels to identify recurring themes. Seasoned researchers individually reviewed the coding to enhance credibility and reduce redundancy [36]. The analytical robustness of this study was further enhanced by engaging two coders in the thematic analysis process, hence improving the reliability of theme identification. Since words can have multiple meanings and are open to interpretation, variations in coding between coders may arise due to differences in experience and knowledge. In addition, semi-structured interviews often generate open-ended responses, which may be extensive and require several codes at the same time [37]. When such discrepancies between the coders occurred, disagreements were discussed and negotiated to arrive at a reconciled final version of the coding [31]. If these discussions did not lead to a consensus, a third researcher was called upon to ensure alignment on the key topics. The key themes were then sorted, categorized, and understood with a focus on impartiality, trustworthiness, significance, inclusiveness, and precision. The interpretation process focused on recognizing patterns linked to the research inquiries.

4. Results

Theoretical Framework

1. 

Psychological Needs

1.1. 

SDT

1.1.1. 

Autonomy

A common theme emerged from the analysis of participants’ comments—the strong desire to maintain control and self-determination in their daily lives, which is a key factor in their preference for AIP. They consistently linked AIP with freedom preservation, the ability to make choices, and avoidance of strict schedules and social pressures, as are often found in institutional settings. The focus on autonomy reflects the psychological needs for independence and personal empowerment, viewed as essential for their well-being and quality of life.

• “Aging in place is definitely my preferred choice because of autonomy. Freedom is priceless. I have been an independent person all my life. Self-determination is also important—I get to decide what I want to do and whenever I please. I like the feeling of control, e.g., when I go hiking, I can choose the path I like, and I can take a rest and take photos whenever I feel like. It is all up to me. At residential care homes, there are so many rules to follow, e.g., what time to get up, sleep, eat, and so on. I can’t stand that.” (Interviewee 1, 67-year-old male)
• “Since I don’t like living with a group of people, AIP would be my first choice as it offers autonomy. I can enjoy the freedom to go in and out whenever I please. You can’t do that at residential care homes. I don’t want to be bound by the rules and restrictions. Sometimes I don’t feel like talking to people, but at residential care homes you might feel obliged to entertain other people and make small talk.” (Interviewee 2, 65-year-old male)

1.1.2. 

Competence

1.1.2.1. 

Generativity Versus Stagnation

Evaluating the feedback from individuals regarding their competence in the AIP context highlighted the importance of making a positive impact on society and guiding the next generation, aligning with the generativity versus stagnation concept from Erikson’s Psychosocial Development Theory [38,39]. Participants expressed a desire for continuous learning, passing on their wisdom to the younger generation, and feeling useful, suggesting the noteworthiness of generativity, a sense of purpose, and engagement in affecting overall wellness. The significance of independence and financial self-sufficiency for maintaining self-worth was also evident, suggesting that AIP settings should support competence to encourage experiences that are satisfying for older individuals.

• “Even though I have stage-four cancer, I am still taking a professional credit-bearing course. I am not sure if I will live long enough to graduate, but I want to set a good example for my young classmates and fellow cancer patients. I am still teaching gardening to the elderly. It is important to me to keep learning, be useful, and pass on the torch. This gives me a fulfilling feeling and I don’t feel empty.” (Interviewee 28, 67-year-old male)
• “Now that my children have grown up, I can finally enjoy my life. Even though I have to help look after my grandkids, I enjoy it because it makes me feel useful and needed. When I was young, I had to financially support my family and hence had no chance to study. Now, I can learn as much as I want at the elderly center downstairs from home, which offers numerous interesting courses at low fees. It makes me feel good to be so productive and to make continuous improvements, and that is why I go to every one of them.” (Interviewee 16, 71-year-old female)
• “I have been a renovation worker since 1972, and I am still working part-time. It makes me happy and productive because I can help my elderly friends renovate their apartments. I am like a volunteer because I only charge a minimal fee. I feel happy because I can help people in need. I also feel useful as I am good at what I do. My work keeps me going. My son offered me USD 1000 as pocket money but I refused, as I am independent and can make my own living doing odd jobs.” (Interviewee 39, 72-year-old male)

1.1.3. 

Relatedness

Participants stressed the importance of community and social relationships for their well-being. Social activities such as group workouts and shared meals were valued for bonding and enjoyment. The thought of being separated from their communities caused distress among participants, highlighting their need for social connections. Engaging in pursuits such as group games with peers was not just enjoyable but also crucial for providing emotional comfort and facilitating the sharing of resources. These results indicate that AIP strategies should focus on maintaining community bonds to support the sense of belonging and well-being of individuals.

• “My friends and I have an aerobics chat group. We belong to a community of elderly ladies who will gather in Victoria Park at 8:00 a.m. every morning. Strangers are welcome to join. After doing our morning exercise, we go for dim sum. It is so much fun because we can talk and laugh. It is the highlight of my day and it makes me happy.” (Interviewee 13, 71-year-old female)
• “It is sad for the elderly to be removed from their familiar community where they have a network of family, relatives, friends, neighbors, shopkeepers, etc. It is disheartening for them to be uprooted. They must feel abandoned and dumped, as if they have been discarded in a landfill.” (Interviewee 4, 65-year-old female)
• “The community is very important for the elderly. My mother is turning 100 this year. She still lives at home. Even though she has been living in the Taikoo district for the last 30 years, she still goes back to the North Point district to buy groceries because she grew up there and she is connected to the community. She likes buying food from the shopkeepers she knows well.” (Interviewee 27, 74-year-old male)
• “Friends are an important source of support and resources for healthy lifestyle tips and doctor referrals. I vent my frustrations to them. I love playing mahjong and it keeps me happy and active. We spend hours at the mahjong table, chatting and bonding.” (Interviewee 17, 85-year-old female)

1.2. 

Need for Dignity

The significance of dignity can be viewed as a need that is ingrained in all three psychological needs as posited by SDT: autonomy, competence, and relatedness [21]. Dignity is closely associated with autonomy since it entails being treated as capable of making one’s own decisions. Moreover, the need for dignity is intertwined with feelings of competence. Competence refers to feeling competent and proficient in one’s pursuits. In other words, it involves having one’s skills and contributions acknowledged, thereby upholding dignity. Additionally, dignity is connected to relatedness, as feeling connected and valued by others plays a role in one’s sense of dignity. Elderly individuals try to form and maintain connections and experience a sense of belonging. When they receive genuine care and support, their dignity remains intact [40]. In a culture influenced by Confucianism, dignity is enmeshed with respect and preserving one’s ‘face’ [41]. The emphasis on filial piety enhances the importance of dignity for elders, as familial respect and care are associated with societal standing [42].

In the sociocultural context, dignity holds significant importance, particularly among the older generation [43]. When examining discussions on dignity within this context, a strong focus on respect and dignity emerged rather than material possessions among older adults. Participants expressed a desire for policymakers to prioritize the maintenance and enhancement of dignity. Concerns were raised about how the elderly are treated in residential care homes with mentions of practices that do not uphold older individuals’ dignity. These findings emphasize the need to effectively incorporate dignified care practices into policies for the aging population to ensure their fundamental need for dignity and respect is recognized and met.

• “Policymakers don’t understand the needs of older people. We don’t need a fancy house or car. We don’t care about material possessions anymore. What we need is dignity. We just want to feel respected.” (Interviewee 37, 73-year-old male)
• “I used to visit my mother-in-law at the residential care home. The staff may have been overworked and they treated the elderly with limited respect. For example, they would be rough with them when changing diapers and while dressing or undressing. Imagine how that would feel—no dignity at all. That is so sad and depressing. We have worked hard all our lives to contribute to society, and this is what we get?” (Interviewee 4, 65-year-old female)

2. 

Beliefs

2.1. 

SCT

2.1.1. 

Beliefs Shaped by Sociocultural Factors

2.1.1.1. 

Fear of Being a Burden to Others and Filial Piety

The interviews revealed a fear among older individuals of being a burden to their families, reflecting the principles of collectivism and harmony. This may also be attributed to the fear of losing ‘face’ and dignity, as elders are expected to be highly respected and admired in Chinese culture [44]. Participants expressed a preference for living with their family if circumstances allowed, while also recognizing the challenges it could pose for their loved ones. The priority of maintaining family harmony and avoiding causing trouble was evident, even if it meant opting for institutional care rather than imposing on their children. This selfless mindset, coupled with the belief that younger generations may not uphold familial duties, demonstrates a conflict between sociocultural expectations and modern-day realities. These findings point to AIP solutions that consider the significance of autonomy and connectedness without placing undue strain on family members.

• “I would most prefer to live with my son if he is single and willing; otherwise, I don’t want to invade his privacy. My husband is a filial son and all these years I had no choice but to live with my parents-in-law and I understand it is too much to handle. Do unto others as you would have them do unto you.” (Interviewee 4, 65-year-old female)
• “I will only live in a residential care home if I absolutely can no longer care for myself, even though I deeply dread this. It is very important to me to not be a burden to my family. I would feel hurt if they showed annoyance or disgust. I know it is too much to ask for and I want them to stay free. Nevertheless, my first preference is to live with my loved ones, as there is love among family members. Family will never be enemies, even if we have arguments from time to time. I trust that they will always attend to my needs.” (Interviewee 33, 71-year-old male)
• “There is a Chinese saying that goes, ‘Even a filial child will be fed up with taking care of a chronically ill parent’. I understand that and I don’t expect my adult children to look after me if I am very sick. Anyone would get fed up under that kind of stress. It is too much to ask for.” (Interviewee 8, 66-year-old female).
• “I have heard horror stories about adult children abandoning their parents in Hong Kong. Times are different. Young people nowadays do not have strong filial values anymore. You cannot expect adult children to look after you or financially support you.” (Interviewee 10, 70-year-old female)

3. 

Practical Needs

The financial situation plays a role in determining whether elderly individuals can continue living in their own homes, which resonates with SCT’s emphasis on how external factors impact behaviors and well-being. In Hong Kong, older adults encounter obstacles such as limited living space and expenses associated with making their homes more accessible. Although there is government assistance, it is often insufficient. Additionally, decisions about AIP are influenced by health status and self-care capabilities, as many seniors prioritize maintaining independence over depending on their children. They may choose to seek help from their spouse to maintain autonomy and manage their living arrangements.

• “Aging in Place is an easy choice. There is no doubt about that. However, my health status and self-care ability would be critical deciding factors. I don’t want to burden my adult children. They have their own families and financial burden. I don’t want to bother them. It depends on whether there is someone to look after me. I would hire a domestic helper. My spouse and I would look out for each other.” (Interviewee 9, 73-year-old female)
• “My first choice is Aging in Place. However, it also depends on the living conditions. In Hong Kong, the living space is limited for most households. You need a home big enough to fit wheelchairs and relevant equipment. There are also additional costs to renovate your place to make it age-friendly and barrier-free. However, it is extremely costly to install such gadgets.” (Interviewee 31, 66-year-old male)
• “It all comes down to money. If money was not a problem, then Aging in Place would be the first choice. Months before my mother passed away, my brothers and I took my mother back home from the hospital. We spent a hefty sum of money to transform her place into an elder-friendly home, with relevant fittings and equipment. We also hired a physiotherapist to make house calls, and oh boy, were they expensive.” (Interviewee 23, 66-year-old male)
• “The renovation costs to fit railings and barrier-free fittings are high. The government has subsidies for that but not they are means-tested. That is why when my father aged at home, we had to buy the equipment out of our own pocket. Such expenses are rather costly.” (Interviewee 36, 68-year-old male)

4. 

Factors Affecting Well-being (SDG 3) and Decisions: Suggested Solutions and Coping Strategies

It is not surprising that AIP was the preferred choice among participants. Given this, the crucial questions to ask were the following: How can one make AIP more achievable? If health conditions or financial limitations make it difficult, how can residential care homes be made a more attractive choice? Understanding the factors influencing well-being and how personal beliefs affect decision making is key. Finding solutions and coping mechanisms is crucial for addressing these challenges.

4.1. 

Fear of Being a Burden to Others in Relation to SDT Needs and Generativity

Participants recognized the importance of balancing their desire not to inconvenience others with staying connected. Asking for small favors helps the elderly involve their family members, promoting relatedness. Additionally, by contributing to their families, seniors can achieve autonomy and competence, which helps maintain familial bonds and meaningful interactions across generations. These observations indicate that encouraging these interactions can enhance the well-being of individuals, thus strengthening their sense of generativity and connectedness.

• “It is good for your adult children to feel needed. That is why I always make small requests, such as asking them to book air tickets for me or asking them to arrange an outing with my grandkids, and so on. Chinese people always fear inconveniencing other people. This is not a good practice. Small requests are fine. Your kids will not only be happy but also feel useful. When I asked them to buy an iPad for me, I would pay them back. They would ask me to keep the money and I would gratefully keep it. It is important to reciprocate to maintain a good relationship. I would reciprocate, like buying toys for my grandkids or babysitting them so that my adult children can enjoy some time away from their kids.” (Interviewee 40, 75-year-old male)

4.2. 

Fulfillment of Psychological Need for Dignity

Maintaining the dignity of residents is a crucial aspect in residential care home management. Participants emphasized that hiring staff who cater to both the emotional and physical needs of the elderly is essential. Participants underscored the significance of caregivers’ behaviors, such as their facial expressions and body language, to prevent residents from feeling rejected. The proposal to introduce a rating system for residential care homes reflects a need for transparency in ensuring quality care and fostering caring environments that uphold dignity.

• “With regard to maltreatment at residential care homes, it is important to recruit staff who are good-natured and caring, to look after the elderly’s psychological as well as practical needs. They need to have empathy and be mindful of their facial expressions and body language so that the elderly don’t feel rejected. Even a glance showing disgust or rejection could hurt an older person’s feelings.” (Interviewee 37, 73-year-old male)
• “Residential care homes vary in terms of quality, so it is important to have staff who are loving and caring. Such attributes should be assessed by an evaluation system like “TripAdvisor”. The government should set up such a system.” (Interviewee 31, 66-year-old male)

4.3. 

Coping Strategies in Relation to SCT to Enhance Well-being (SDG 3)

Elderly individuals often turn to their beliefs and personal philosophies as ways to overcome obstacles and promote overall well-being as they age. Embracing challenges including illness and mortality becomes easier when individuals have guiding beliefs or religions. Moreover, valuing autonomy and prosocial behaviors reflects a mindset that aligns with the beliefs pertaining to various religions.

4.3.1. 

Religious Beliefs

• “Everything is fated and we can’t force fate. Death and sickness are a natural part of life. I entrust everything to Buddha. Everything will be fine.” (Interviewee 5, 76-year-old female)
• “Spring will always follow winter. My religion has taught me self-reliance, and that by lighting a lamp for somebody, I also brighten my path.” (Interviewee 27, 74-year-old male)
• “God tells me not to worry about tomorrow. I can leave my worries and sadness to him. He will never abandon me. That is how I cope and maintain my well-being. Whenever I need guidance, I just pray.” (Interviewee 20, 67-year-old female)

4.3.2. 

Life Philosophy

• “Troops for the enemy, earth for floods. Roll with the punches. All for one, one for all. Have empathy and think from the perspective of others and then you will be happier.” (Interviewee 26, 75-year-old female)
• “Enough is as good as a feast. I always try to count my blessings and be grateful for what I have. Always think positively and never complain. Don’t be calculating, e.g., if someone asks you for a favor, you should always help them because it means you are capable. That is how I stay happy.” (Interviewee 21, 71-year-old female).

A summary of the main findings can be found in

Table 2. Summary of Main Findings.

Psychological Needs: Autonomy, competence, relatedness, and dignity are key factors that influence decisions and well-being, aligning with SDG 3. Extension of SDT: SDT was expanded to include dignity as an overarching construct that intersects with existing SDT needs. Primacy of Dignity: Dignity is of primal importance to older adults and is significantly impacted by the fear of being a burden to others—a dominant cultural construct. Importance of Psychological Needs: Psychological needs are as important, if not more so, than practical needs. Coping Strategies in Relation to SCT Enhance Well-being (SDG 3): Embracing age-related challenges becomes easier when individuals have guiding beliefs or religions. Implementation of AIP: For AIP to be successful, it is crucial to fulfill psychological needs, practical needs, and respect cultural beliefs.

below:

5. Discussion

The present study set out to identify the needs, beliefs, behaviors, and factors affecting well-being of Hong Kong’s older adults regarding AIP, and to explore the challenges and opportunities they encounter. This research highlights the significance of developing a theory-based approach to understanding the AIP needs of older adults in Hong Kong, one that caters to not only to practical issues but also to psychological needs (as shown in Table 2). SDT plays a key role in examining AIP needs. This theory highlights autonomy, competence, and relatedness as crucial factors in promoting well-being and motivation. Such findings are consistent with the existing literature. Previous research studies seldom employed SDT to understand and explain all three SDT needs of older adults [45] except for a few studies (e.g., [46,47], etc.), which simultaneously examined all SDT needs. Their findings not only support SDT as an effective framework to guide the understanding of age-related challenges but also suggest that the fulfillment of such needs is conducive to the attainment of well-being [46,47]. However, applying these findings to the context of Hong Kong requires consideration of local sociocultural values, which can add complexities to these constructs.

The present research findings emphasize the significance of autonomy, alongside family cohesiveness and social harmony, in shaping elderly individuals’ preferences for AIP. The study highlights an inclination among senior citizens towards preserving independence, suggesting that autonomy plays a vital role in maintaining dignity and life satisfaction during old age. Such findings align with existing research on long-term care in Mainland China and Hong Kong, which indicates that older adults’ reluctance to age in residential care homes is associated with a perceived loss of autonomy and respect, leading to compromised dignity [48,49]. Since Chinese elders are strongly influenced by Confucian and collectivist cultures, dignity is considered of utmost importance [50]. Additionally, the present findings are supported by recent research that highlights the importance of empowerment and control over one’s environment, indicating that a perceived loss of autonomy and control is associated with negative mental and physical health outcomes [51].

In relation to competence, participants emphasized the significance of engaging in meaningful and/or enjoyable activities, aligning with Erikson’s concept of generativity vs. stagnation [38,39], which suggests that finding purpose, passing on knowledge and wisdom to the younger generation, and contributing to the society are instrumental to enhancing self-worth and satisfaction [52]. Such findings align with research suggesting that engaging in activities such as volunteering helps older adults find a sense of meaning, which is considered an important goal in successful aging [53]. Through engagement in meaningful community activities that enhance a sense of purpose and meaning, AIP can help prevent or curtail feelings of isolation associated with aging. In addition, these findings are supported by studies that highlight the importance of leisure, specifically the engagement in activities that elders enjoy, in achieving competence. Consequently, positive outcomes such as health and well-being can be achieved [47].

Participants’ need for relatedness was met through interactions with family and friends, who played a critical role in their well-being and motivation to age in place. Such findings are consistent with research highlighting the importance of relatedness in AIP, i.e., connections to social networks and the community, which fosters well-being [7]. Furthermore, the present findings align with research suggesting that regular users of senior community centers are at a lower risk of dementia and other mental illnesses, due to their active cultivation of social networks and relationships [47,54]. Indeed, compared to institutional settings, AIP evidently provides more opportunities for developing and maintaining social connections and family ties.

This study extends SDT by incorporating the need for dignity as an overarching construct, which intersects with the existing SDT needs of autonomy, competence, and relatedness. Consistent with existing research, the need for dignity in Chinese older adults is particularly important due to the influence of the Confucian family value and cultural belief of filial piety [55], where elders are expected to be treated with utmost respect and admiration.

This, in turn, partly explains the strong fear of being a burden to their family, which emerged as a dominant factor. This may be attributed to the fear of loss of ‘face’ and respect, as well as the cultural norm to maintain harmony. These findings are in line with previous research comparing help-seeking behaviors between collectivistic and individualistic cultures, which suggests that older adults from collectivistic cultures enjoy a relatively high status and expect to be deeply respected by family members [56]. Consequently, they tend not to proactively build relationships with the younger generation. Due to collectivistic cultural norms, help-seeking is often perceived as being a burden on others and as violating cultural expectations such as being self-sufficient, upholding harmony, maintaining reciprocity, and avoiding indebtedness [57]. Older adults’ perception of being a burden to others has been shown to increase the risk of developing depressive symptoms [58], which has implications for corresponding psychological interventions, to be discussed in the following sections.

At the same time, the overwhelming majority of participants expressed a strong aversion towards residential care homes, which is commonly observed in the existing literature [48,49]. By applying SCT, such feelings and behaviors can be explained by their beliefs, i.e., negative beliefs towards residential care homes, which are associated with the loss of dignity, respect, and autonomy, acquired through personal experience, observation, or vicarious learning via family, friends, or the media. This has implications for policies promoting dignified and respectful care in residential care homes [43]. Another finding related to SCT worth noting is that participants’ positive thoughts and beliefs, which could be religious or non-religious life philosophies, gave rise to resilience, well-being, and effective coping. Consistent with the present findings, previous research suggests that although religious beliefs provide elders with strength to cope with aging-related challenges, such resilience is not solely attributed to religious faith per se, but more so to the beliefs that lead participants to think more positively, thereby enhancing well-being [59]. Similarly, in another study among Hong Kong’s Chinese elders, religion was found to be instrumental in helping participants overcome adversities through religious beliefs and coping mechanisms, bolstering their self-reliance through spiritual support [60].

This study also recognizes the practical difficulties associated with AIP, which include, for instance, financial constraints, and compact living space. Solutions such as adapting public housing to facilitate AIP, increasing financial assistance and subsidies, and providing door-to-door escorted transportation and outreach services will enable more elders to age in place. These findings align with existing research that identifies similar practical challenges commonly observed in AIP studies, especially in densely populated Asian regions that lack social security systems with generous protections and benefits [61,62]. As a matter of fact, these challenges are directly relevant to several Sustainable Development Goals: SDG 11 (Sustainable Cities and Communities), which advocates for accessible transport and affordable housing; SDG 1 (No Poverty), which includes initiatives related to financial assistance, poverty prevention, and pension schemes; and SDG 10 (Reduced Inequalities), which emphasizes social protection and participation [63].

The study findings have various implications for sustainable development. Notably, they most closely align with SDG 3, which aims to ensure health and well-being for all ages [64]. Based on the findings discussed above, it can be summarized that the fulfillment of SDT needs (autonomy, competence, and relatedness), preservation of dignity, having positive beliefs and attitudes through adaptive thoughts or mindsets, and not being a burden on others are factors contributing to well-being and SDG 3. Such findings echo those of another study by Chong et al. [59], conducted with Hong Kong’s Chinese middle-aged and older adults, which indicates that positive aging may be attributed to psychological constructs including active participation (i.e., competence), social support (i.e., relatedness), residential stability (i.e., Aging in Place), and positive attitudes (i.e., adaptive beliefs and cognition).

Based on the present findings concerning the psychological needs and sociocultural beliefs of Hong Kong’s older adults in relation to AIP, recommendations aligning with SDG 3 and ESG will be provided. Against the backdrop of AIP in Hong Kong, this research underscores the vital roles of autonomy, competence, relatedness, and dignity in influencing well-being. Through positive reframing of thoughts and beliefs, CBT can be used as a tool to modify feelings and behaviors. Thus, by applying the principles of CBT, public education campaigns on well-being awareness and self-help techniques, support groups, workshops, and counseling sessions can be conducted to foster feelings of autonomy, competence, relatedness, and dignity, for better mental health and well-being in older adults. Similarly, fear of burdening others can also be alleviated using the same techniques. Such suggestions are consistent with previous research in which older adults demonstrated effective CBT coping strategies that contributed to their well-being and resilience. This was achieved by positively reframing realities and events they are unable to change (e.g., physical decline) and by deriving meaning from adversities, losses, and transitions [65,66].

Effective governance is pivotal to the attainment of SDGs. Policies and implementation supporting such psychological needs are pivotal to the enhancement of well-being and mental health in older adults. Policies should also place the dignity of the elderly as a priority, in alignment with SDG 3. Programs and campaigns should be culture-sensitive, with dignified care as a core objective. Initiatives should promote connectedness through the cultural lens of Confucian family culture. Leveraging concepts of filial piety that are still prevalent, public education and workshops can enhance relatedness and, consequently, bolster feelings of dignity by fostering communication and cultivating family relationships. Encouraging independent living, social interactions with others, and community engagement is conducive to the enhancement of generativity and a sense of belonging. For the widespread adoption of AIP, practical assistance is also vital, which can be provided through age-friendly home modifications, increased financial assistance, accessible outreach services, and user-friendly integrated medical services. AIP’s contribution extends to environmental sustainability. Adapting existing housing structures by utilizing eco-friendly and sustainable materials is not only beneficial for the environment but also instrumental in creating healthier living environments for the elderly. Consequently, this prevents illnesses that are exacerbated by poor living conditions and pollution. Such recommendations align with SDG 3 as well as the environmental component of ESG, contributing to wider environmental protection and sustainability.

Limitations and Future Perspectives

While this research has provided an exploratory analysis that has enriched our understanding of older adults’ needs, beliefs, behaviors, and well-being pertaining to AIP in Hong Kong, its generalizability to other populations can be further enhanced. The initial findings serve as a valuable foundation upon which future quantitative studies can be based. Future studies should adopt a mixed-methods approach to combine the strengths of both quantitative and qualitative research. Another limitation lies in its cross-sectional design, which does not take into consideration the changes over time, e.g., how changes in health status influence decisions and behaviors. Conducting longitudinal surveys that incorporate validated questionnaires and involve a large sample will improve the robustness of the results and further enrich researchers’ understanding of the sustainability of AIP in rapidly changing urban environments. Given the significance of sociocultural beliefs and values in influencing AIP, future studies should further delve into the intricate dynamics and formulation of corresponding policies and implementation measures to better cater to the psychological needs of older adults, thereby enhancing their well-being and contributing to sustainability. User-friendly smart home designs and technologies are likely to significantly enable more elderly individuals to age comfortably at home. Nevertheless, such designs should be research-informed, based on not only the objective needs but also the subjective needs of older adults, which may vary widely across different countries, regions, and cultures.

6. Conclusions

To conclude, this research provides insights into the needs, beliefs, behaviors, and well-being of Hong Kong’s older adults in relation to aging in place, which are influenced by sociocultural beliefs and values. Through the perspectives of SDT and SCT, this research underscored the significance of beliefs and psychological needs for dignity, autonomy, competence, and connectedness in influencing well-being, behaviors, and decisions. Furthermore, the findings suggest that AIP aligns with SDG 3, emphasizing the beneficial effects of AIP on the well-being of older adults through the fulfillment of needs for autonomy, competence, relatedness, and dignity. Through the integration of AIP with the key principles of ESG, communities can make adaptations to existing housing structures to facilitate AIP and thus decrease burdens on the environment by reducing construction waste and carbon emissions. Socially, AIP not only alleviates the existing burdens imposed on institutional care and medical services but also fosters social cohesion and connectedness through interactions with the familiar environment. The provision of sufficient services by the government, including outreach services, medical services, escorted transportation, etc., will foster inclusiveness, widespread adoption, and sustainability. Finally, yet importantly, effective governance is pivotal to the successful implementation of AIP, which includes quality assurance, sufficient resource allocation, and cross-collaborations among bureaus and stakeholders, to create an AIP-friendly environment that is equitable, inclusive, culture-sensitive, and sustainable.