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An opinion survey of caregivers concerning caring for the elderly in Ilorin metropolis, Nigeria
Public Health (2005) 119, 1138–1144
ORIGINAL RESEARCH
An opinion survey of caregivers concerning caring for the elderly in Ilorin metropolis, Nigeria I.S. Abdulraheem Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, General Post Office, P.O. Box 5240, Ilorin, Kwara State, Nigeria Received 28 June 2004; received in revised form 26 January 2005; accepted 1 April 2005 Available online 24 August 2005
KEYWORDS Caregivers; Elderly
Summary The aim of this study was to determine the opinions of caregivers towards caring for the elderly in Ilorin. The caring patterns and relationships that exist between the elderly and caregivers, caregivers’ attitudes, and ways to improve care of the elderly were also examined. This cross-sectional study using structured questionnaires was conducted in seven of 11 wards within Ilorin metropolis over a 6month period. Of the respondents, 44.4% were daughters, 18.3% were sons and only 1.4% were employees to the elderly. The majority (90.7%) of respondents chose home as the place of care, and only 9.3% opted for institutional care. The majority (98.1%) of caregivers had a positive attitude towards caring for the elderly. Religious teaching was an important influence on this positive attitude. The difference between respondents with and without formal education concerning where to care for the elderly was not statistically significant (PO0.05). Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Care of the elderly by members of the informal system occurs worldwide.1 This includes caregivers, who could either be a relative, friend or neighbour, or members of a collective group such as a village, community or ethnic/clan group. Such care is usually provided voluntarily without remuneration. Care by family relatives (whether blood relatives or those by marriage) is predominant within the informal support system.2 Care of the elderly is one of the most important aspects of primary health care.3,4 Caregivers need to have certain
skills and knowledge to deal with problems that are common in the elderly. Religious teachings are often used to reinforce and support the cultural imperatives of caring for the elderly. Islamic cultural values strongly support and emphasize kindness towards elderly people, as expressed in the Holy book of Allah, the Holy Quran; ‘Serve Allah, and join not any partners with Him and do good to parents’.5 Such values have given a comprehensive view of being kind to parents, which should not be ignored even if the father and son have different religious beliefs.6 Other religions like Christianity
0033-3506/$ - see front matter Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2005.04.005
Ceregivers’ opinions of caring for the elderly in Nigeria and Judaism also support caring for the elderly. There are few studies concerning care of the elderly in Nigeria. Thus, the present study was conducted to survey the opinions of caregivers concerning care of the elderly and to determine an acceptable way of caring for them. For the purpose of this study, caregivers are defined as people who live with an elderly person and who are directly responsible for looking after his/her needs on a daily basis, whatever those needs might be. There is little or no information available on caregivers of elderly people in Nigeria. The paucity of institutions, facilities and specialist manpower for taking care of elderly people leads to greater reliance on caregivers whose opinions have not been explored. Current trends at all levels suggest an increasing demand and emphasis on care of the elderly. This is because of the increasing number of elderly people in our population and the high level of migration of young people from rural to urban areas to seek employment due to economic recession.7 Old peoples homes in Lagos and Kano represent the only institutional care for elderly people at the present time. Some of the crucial issues in care of the elderly include the attitude of caregivers towards care of the elderly, where caregivers would prefer to care for the elderly, the types of care being provided by caregivers, and the effects of caring for the elderly on caregivers. These are issues that informed this study. These issues are particularly important in our culture because care of the elderly has been undertaken by the nuclear and extended family system for many years.
Materials and methods The study was carried out in Ilorin metropolis, which covers a land mass of about 32,500 km2. It comprises three local government areas (Ilorin West, Ilorin East and Ilorin South), and is dominated almost exclusively by the Yorubas.8 Ilorin metropolis consists of 11 wards, namely Alanamu, Ajikobi, Gambari, Fulani, Baboko, Badari, Mogaji-Ngeri, Adewole, Ubandawaki, Ojuekun-Sarumi and OsinEgbejila. Of these 11 wards, the study was carried out in seven: Alanamu, Ajikobi, Gambari, Fulani, Ubandawaki, Baboko and Adewole. The seven wards were chosen by a simple random sampling technique using balloting. Ilorin metropolis is politically grouped as part of Northern Nigeria and is dominated by the Yorubas. Other ethnic groups in the metropolis are Nupes,
1139
Barubas and Gambaris but they are minorities. Most inhabitants of Ilorin metropolis behave traditionally and culturally like the Yorubas. The most predominant religions in the metropolis are Islam and Christianity. However, traditional religion worshippers and non-believers represent the minority. The residents are mostly traditional cloth weavers, civil servants, traders, pot makers and commercial drivers. This study is a descriptive cross-sectional survey that used a structured questionnaire to collect information from caregivers. The questionnaire was prepared in English, and was translated into Yoruba language, the most widely spoken language in the study area, and used to determine the opinions of caregivers concerning care of the elderly. The questionnaire consists of items on socio-demographic variables, types of caregiving, preferred place of care, traditional socio-economic support, and attitude to care of the elderly. The questionnaire was pretested in Oko-erin ward that did not participate in the study. In the pretesting phase of the study, a draft questionnaire was examined for validity and application by the interviewers. From the responses, modifications were made and wordings were fine turned to make them suitable for application. After final modification of the questionnaire, the study was conducted for 6 months (January–July 2003). To ensure uniformity of administration, the questionnaire items were read to both literate and illiterate caregivers. The chosen caregivers in the seven selected wards agreed to be interviewed after the aim of the study had been explained. Subjects who did not know their dates of birth had their ages determined by reference to a calendar of important events for each locality. Four hundred and fifty subjects were interviewed. A proportionate sampling method was adopted to determine the number of caregivers that was interviewed from each ward. This is because the number of caregivers varied from ward to ward. There are no available data for the number of caregivers in Ilorin metropolis. It is assumed that there is at least one caregiver per elderly person. The 1991 population census projected figure currently puts the total population of elderly people in Ilorin metropolis at 36,000.9 Two or three streets in each ward, depending on the relative size of the ward, were selected by a simple random technique (using balloting). One caregiver, selected at random by balloting, was interviewed from each house visited in the selected streets until the required number of caregivers from each ward was obtained.
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Completed questionnaires were reviewed at the end of each day and subjects whose questionnaires could not be completed at the first visit were revisited. The data were coded and analysed on a computer using EpiInfo version 6. Chi-square test was used for statistical analysis, and a significant level was taken to be 5%.
Table 1
Sociodemographic characteristics.
Variable
Frequency (%)
Age (years) !20 21–30 31–40 41–50 51–60 O60 Total
31 (7.3) 122 (28.6) 129 (30.3) 46 (10.8) 22 (5.1) 28 (6.6) 426 (100)
Sex Male Female Total
136 (31.9) 290 (68.1) 426 (100)
Ethnic group Yoruba Hausa/Fulani Igbo Others Total
327 (76.7) 72 (16.9) 16 (3.8) 11 (2.6) 426 (100)
Monthly income !N2000 N2000–5000 N5100–10,000 ON10,000 Total
200 (46.9) 68 (16) 105 (24.6) 53 (12.5) 426 (100)
Marital status Single Married Separated Widowed Divorced Total
80 (18.8) 284 (67) 14 (3.2) 32 (7.4) 16 (3.6) 426 (100)
Education No formal education Primary education Secondary education Tertiary education Total
130 (30.6) 95 (22.1) 122 (28.6) 79 (18.7) 426 (100)
Occupation Civil service Trading Artisan Farming Unemployment Total
80 (20.6) 153 (35.9) 79 (18.7) 47 (11) 59 (13.8) 426 (100)
Results Of the 450 questionnaires administered, 426 [136 (31.9%) males and 290 (68.1%) females] were duly completed, giving a response rate of 94.7%. The mean age of the males (49G19 years) was not significantly different from that of the females (45G17 years) (PO0.05). Table 1 shows the sociodemographic characteristics of the study population. Monthly income was generally low and caregivers depended on their earnings from sales of their farm products and other materials, as well as support from other family members. This support varied from cash to materials. Of the respondents, 80 (20.6%) were civil servants, 153 (35.9%) were traders, 79 (18.7%) were artisans, 47 (11%) were farmers and 59 (13.8%) were unemployed. More than half (62.7%) of the caregivers were daughters (44.4%) or sons (18.3%), and only 1.1% were employees to the elderly. The attitudes and reasons of caregivers concerning caring for the elderly are shown in Table 2. The majority [418 (98.1%)] of respondents said that the elderly should be cared for, while only eight (1.9%) of them felt indifference. More than half of the respondents who wanted the elderly to be cared for gave religious teaching (35.9%) and tradition/ customary obligation (28.7%) as reasons. Only 10 (2.4%) respondents gave reciprocity of elder’s help as a reason for caring for them. Caregivers’ opinions regarding where elderly people should be cared for and reasons for caring for them at home are shown in Table 3. The majority [385 (90.3%)] of caregivers Table 2 Attitudes and reasons of caregivers concerning caring for the elderly. Items
Frequency (%)
Attitude Elderly should be cared for No difference Total
418 (98.1) 8 (1.9) 426 (100)
Reasons for caring for elderly people Traditional/customary 120 (28.7) obligation Religious teaching 150 (35.9) Personal feeling 88 (21.1) Elderly person needs help 20 (4.7) Reciprocity of elder’s help 10 (2.4) Want to be cared for in old age 30 (7.2) Total 18 (100)a a
Total number of caregivers that wanted elderly people to be cared for.
Ceregivers’ opinions of caring for the elderly in Nigeria
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Table 3 Opinion of caregivers on where elderly people should be cared for and reasons for caring for elderly people at home.
Table 4 Types of care provided by caregivers and traditional socio-economic support available for elderly people.
Items
Items
Where to care Home Institutions Total
Frequency (%) 385 (90.3) 41 (9.7) 426 (100)
Reasons for caring for elderly people at home Prompt adequate family support 260 (61) Cultural fulfilment 330 (77.5) Elderly people feel more at ease in 345 (81) their home It is cheap 200 (46.9) Helps to spread the load of care 224 (52.6) Note: all the respondents chose more than one response concerning reasons for caring for the elderly.
said that they would prefer to care for an elderly person at home and only 41 (9.7%) opted for institutional care. Three hundred and forty-five (81%) respondents said that they would prefer to care for an elderly person at home as elderly people feel more at ease in their own homes. As caregivers, the respondents were asked to indicate the types of care they provided and enumerate the traditional socio-economic support available for caring for the elderly. As shown in Table 4, there were fairly high percentages for the various types of care purported to be provided by the caregivers. Payment of house rent (20.7%) and sending for other relatives (23.2%) were the least services (care) provided. According to the respondents, the majority [334 (78.4%)] of children of the elderly sent money home regularly for the upkeep of their elderly parents. In terms of paying hospital bills when elderly people are ill, family relatives played an important role (96.4%), particularly if the elderly person had no surviving children. In this study, 74.8% of caregivers reported that caring for an elderly person is a large burden if there is no support at all. Lack of adequate time for one’s leisure (66.2%), inadequate financial resources (81.3%) and bedwetting (21.3%) are areas of burden to caregivers of elderly people. Despite these burdens, over two-thirds (69.8%) still expressed a positive attitude towards caring for the elderly. The responses (opinions) of caregivers concerning who should be responsible for the welfare of elderly people in our society are shown in Table 5. Government (80%), son (77%) and daughter (62%) were the principal agents mentioned in terms of
Frequency (%)
Types of care Feeding Taking to hospital when sick Washing clothes and dishes Cleaning of houses Buying of medicines from chemists Bathing Cooking Shopping and marketing Paying of house rent Provision of money Assisting in dressing and undressing Assisting in taking or driving to places out of walking distance Cleaning of teeth Cutting, shaving and combing of hair Taking out for social interaction Sending for other relatives Paying of house help Traditional social and economic support Monetary remittances from children Regular visits by the relative(s) Pension and gratuity Fees from houses and properties rented out Land lease Provision of clothes and other materials by relative Spouse in gainful employment Participation in religious activities Dividends from daily contribution and co-operative Union of retired or senior citizens Children and spouses alive and living together
340 440 311 260 370 250 310 290 75 410 280 193
(79.8) (96.4) (73) (61) (86.9) (58.7) (72.8) (68) (20.7) (96.2) (65.7) (45.3)
217 288 296 99 308
(51) (67.6) (69.5) (23.2) (72.3)
334 208 59 297
(78.4) (48.8) (13.8) (69.7)
118 (27.7) 215 (50.5) 244 (57.3) 200 (46.9) 176 (41.3) 50 (11.7) 291 (68.3)
Note: most respondents chose more than one response.
Table 5 Caregivers’ responses (opinions) on who should be responsible for care of the elderly. Responses
Frequency (%)
Son Daughter Relatives Government Friends Daughter-in-law Son-in-law Old peoples home
328 264 73 341 54 217 169 27
(77) (62) (40.6) (80) (12.6) (50.9) (39.7) (6.3)
Note: more than the number of study respondents because of multiple responses.
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I.S. Abdulraheem
who should be responsible for the welfare of elderly people in our society. It is important to note that old peoples home constituted 6.3% of all the agents mentioned. The association between the level of education of respondents and where to care for elderly people was tested and was not found to be significant (X2Z6.39, PO0.05), and those with formal education [230 (68.7%)] preferred home care for the elderly. This study found that religion is a predictor of positive attitude towards caring for the elderly. This is because the difference between those with and those without religion was statistically significant (X2Z7.38, P! 0.05). Caregivers made the following suggestions regarding how care of the elderly could be improved: training of professionals on geriatrics and gerontology (40.5%); training of caregivers on basic geriatric skills (70.1%); provision of incentives like loans and allowances for caregivers (66.9%); adequate and prompt payment of pension and gratuity by the government to elderly people (80.9%); free accommodation to homeless elderly (59.1%); and free transportation for the elderly (38.4%). It is important to note that each respondent gave more than one suggestion. As caregivers, the respondents were asked to indicate the types of help they would need in caring for the elderly. As can be seen in Fig. 1, the help needed ranged from prayers (20%), financial and material resources (46%), subsidised or free
Figure 1
medical care (19%), and assistance in house chores and farming (15%). The reasons given for the help required included inadequate financial and material resources (40.3%), lack of time (30.7%), proper and adequate caring of elderly people (14.2%), paying attention to nuclear family responsibilities and obligations (8.8%), and sharing the load of care (6%).
Discussion Nigerian people are getting more interested and aware of the geriatric discipline as evidenced by publications in journals, newspapers, and talks on the radio and television all focusing attention on custodial care of elderly people. The provision of care for the elderly is an important issue for the society; the lack of good information on caregivers concerning care of the elderly is an important deficiency that should be addressed. Caregivers’ opinions are important in caring for the elderly since most elderly people live in their own homes where these caregivers are, in most cases, easily available and accessible. Caregivers will continue to be the single most important source of care for most of these elderly people. It is important to note that a number of cultural factors are responsible for some of the findings in this study. The age range of respondents was between 19 and 73 years. Of the respondents,
Help needed in caring for the elderly.
Ceregivers’ opinions of caring for the elderly in Nigeria 7.3% were aged less than 20 years and 6.6% were more than 60 years old. The largest group (30.3%) of respondents were between 31 and 40 years of age. This pattern of age distribution is in keeping with the population pyramid of most developing countries, with preponderance of the young compared with few elderly individuals. This pattern of population distribution may also be suggestive of a high birth rate and a high child death rate, which is peculiar to developing countries. The majority (69.4%) of respondents had received a formal education. The high proportion of educated respondents was not surprising since Ilorin metropolis is largely populated by the Yoruba, and as an ethnic group, the Yoruba place a high value on formal education. A fairly high percentage (68.1%) of caregivers were females. This finding is in agreement with the findings of earlier researchers who reported that female members of the family have been the major caregivers of elderly people in most countries of the world.10,11 Indeed, while caring for the elderly can make demands on all family members, the brunt of the burden is undoubtedly usually borne by wives, daughters, daughters-inlaw, sisters, mothers and grandmothers. Part of the explanation for this is due to the traditional role of females as caregivers. In the past, in most developing countries, women remained at home, thus making them available to provide care for elderly relatives, while men usually worked in jobs outside the home. The reliance on women to perform the caring role is due to the deliberate socialization for gender-specific roles. Women have generally been known to perform the nurturing role of raising children and caring for sick members of the family. Furthermore, since women are usually younger than their husbands, the probability is high that a wife, in later years, would be responsible for the care of her older, impaired husband.2 Attitude reflects our likes and dislikes and may often come from personal experience or that of close associates. Attitude either attracts one to things or makes one wary of them. Other things like education, knowledge, belief, intelligence and memory influence attitudes to caregiving.12 This study found that children and close relatives who have close contacts with elderly people are more disposed to care of the elderly. This supports the notion that a negative attitude to care of the elderly is least in those who are closest to the elderly.12,13 From the information gathered during this study, children and close family relatives were mainly responsible for care of the elderly. They
1143
take the elderly to hospital when sick. These findings are similar to those of Ogunsakin, who reported that the majority of care provided to elderly people came from children and close family relatives.14 Thus, it appears to be the norm in African society, especially Nigeria, for elderly people to be cared for by their children and close relatives. In this study, 98.1% of respondents had a positive attitude towards caring for the elderly. In Nigeria, a positive attitude towards caring for elderly people has been documented by other researchers.15 Religious teachings, traditional/ customary obligation and personal feelings are important motivating factors for caregivers towards caring for the elderly. The great majority (90.3%) of caregivers in this study preferred to care for the elderly at home. This is similar to the finding of researchers from the Western world.16 In contrast to this study, the work of Terri et al. showed that fewer respondents preferred home as a place of care.17 In comparison with a study undertaken in the UK, the majority of caregivers (general practitioners, community nurses and health visitors) in the UK felt that care of the elderly should be done at home.18 This study found several reasons for caring for the elderly at home. Among these is ‘prompt and adequate family support’. This finding agrees with the report of Ogunsakin that care of the elderly is better at home where family relatives will be easily available and immediate and adequate family support would be given.14 Although the move towards increased home care is driven in part by efforts to curtail costs, it is also predicated on the assumption that the home environment is more comfortable. Virtually any individual requested to assume the status of an elderly person would prefer home to institutional care of any type, not just for personal comfort but also because, even at their best, institutions are foreign environments. Considering the various types of care given to the elderly, this study found that a high percentage of caregivers took elderly people to the hospital when they were sick. This finding is similar to the report of a study performed in Ghana.19 In this study, the caregivers complained that caring for the elderly was a burden. Jacobson’s study supports this finding.20 Jacobson’s study showed that many caregivers had a negative attitude towards caring for the elderly as the majority of cases involved one person providing most of the ongoing care for each elderly person in need.
1144
Conclusions and recommendations In this study, the majority (69.8%) of caregivers were willing to continue caring for the elderly despite the burdens highlighted above. Caregivers’ opinions should be sought and, most importantly, they should always be involved in the planning and implementation of geriatric programmes. Since most caregivers preferred home to institutional care, it is recommended that basic geriatric skills should be given to them as demanded for in this study, and only professional geriatrics and gerontologists can achieve this.
Acknowledgements I am most grateful to Dr Bade Ajayi, Associate Professor of Linguistics, Department of Linguistics and Nigerian Languages for serving as an English Native speaker and checking the manuscript.
References 1. Chappel NL. Ageing and social care. In: Binstock RH, George LK, editors. Ageing and social sciences. 3rd ed.. New York: Academic Press; 1990. p. 438–54. 2. Koserg JI. Social changes affecting family care of the elderly. J Int Inst Ageing 1991;1:2–5. 3. Murray JL. Health maintenance: care of the ageing patient. Primary Care 1989;16:289–303. 4. Morley JE. Geriatric update. Saudi Med J 1989;10:15–20. 5. The Holy Quran. Surat al-Naissa, Verse 36. 6. The home care for elderly does not drop rights of parents due on son. Contemp Jurisprud Res J 1993;18:80–5.
I.S. Abdulraheem 7. World Health Organization. Our planet, our health. Report of the WHO commission on health and environment. Geneva: World Health Organization; 1992 p. 38–54. 8. Jimoh LAK. Ilorin: the journey so far. Ilorin: Attoto; 1994. 9. Nigerian population. 1991 provision census results. 10. Brody EM. Women in the middle and family help to older people. Gerontologist 1981;21:471–80. 11. Gibson MJ. Family support patterns, policies and programmes. In: Nursberg C, editor. Innovation ageing programmes abroad. Implications for the United States. Westport, CT: Greenwood; 1984. p. 159–95. 12. Dooley S, Frankel BG. Improving attitude towards elderly people: evaluation of an intervention program for Adolescents. Can J Ageing 1990;9:400–9. 13. Aday RH, Mcduffie IN, Sims CR. Impact of intergenerational program of Black adolescents. Adolescents’ attitude towards the elderly. Educ Gerontol 1993;19:663–73. 14. Ogunsakin EA. Home care of the elderly among the selected ethnic groups in Kwara state of Nigeria. Centre Point 1994;4: 52–3. 15. Baiyewu O, Andrew F, Bella J, Adeyemi B, Benson A, Bamigboye EA, et al. Attitude to ageing among different groups in Nigeria. J Psychosoc Gerontol 1997;44:284. 16. Burton LC, Left B, Harper M. Acceptability to patients of home-hospital care. J Am Geriatr Soc 1998;605–9. 17. Terri R, Friol ED, John CD, Leary RO, Mary E, Tinetti M, et al. Old persons’ perception of home and hospital as sites of treatment for acute illness. Am J Med 1997;107: 317. 18. Tremellen J, Jones D. Attitudes and practices of the primary health care team towards assessing the very elderly. J R Coll Gen Pract 1989;3:142–4. 19. Brown CK. Caring for the elderly—the view of the carers in Ghana. In: Textbook of caring for the elderly. Perspectives from Ghana and Japan. Cape Coast: Catholic Mission Press; 1999 p. 99. 20. Jacobson S. The role of caregivers in the black community— Executive Summary. Institute for the Study of Human Systems, Inc., Prepared for Administration on Ageing, Washington DC; 1980.
ORIGINAL RESEARCH
An opinion survey of caregivers concerning caring for the elderly in Ilorin metropolis, Nigeria I.S. Abdulraheem Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, General Post Office, P.O. Box 5240, Ilorin, Kwara State, Nigeria Received 28 June 2004; received in revised form 26 January 2005; accepted 1 April 2005 Available online 24 August 2005
KEYWORDS Caregivers; Elderly
Summary The aim of this study was to determine the opinions of caregivers towards caring for the elderly in Ilorin. The caring patterns and relationships that exist between the elderly and caregivers, caregivers’ attitudes, and ways to improve care of the elderly were also examined. This cross-sectional study using structured questionnaires was conducted in seven of 11 wards within Ilorin metropolis over a 6month period. Of the respondents, 44.4% were daughters, 18.3% were sons and only 1.4% were employees to the elderly. The majority (90.7%) of respondents chose home as the place of care, and only 9.3% opted for institutional care. The majority (98.1%) of caregivers had a positive attitude towards caring for the elderly. Religious teaching was an important influence on this positive attitude. The difference between respondents with and without formal education concerning where to care for the elderly was not statistically significant (PO0.05). Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Care of the elderly by members of the informal system occurs worldwide.1 This includes caregivers, who could either be a relative, friend or neighbour, or members of a collective group such as a village, community or ethnic/clan group. Such care is usually provided voluntarily without remuneration. Care by family relatives (whether blood relatives or those by marriage) is predominant within the informal support system.2 Care of the elderly is one of the most important aspects of primary health care.3,4 Caregivers need to have certain
skills and knowledge to deal with problems that are common in the elderly. Religious teachings are often used to reinforce and support the cultural imperatives of caring for the elderly. Islamic cultural values strongly support and emphasize kindness towards elderly people, as expressed in the Holy book of Allah, the Holy Quran; ‘Serve Allah, and join not any partners with Him and do good to parents’.5 Such values have given a comprehensive view of being kind to parents, which should not be ignored even if the father and son have different religious beliefs.6 Other religions like Christianity
0033-3506/$ - see front matter Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2005.04.005
Ceregivers’ opinions of caring for the elderly in Nigeria and Judaism also support caring for the elderly. There are few studies concerning care of the elderly in Nigeria. Thus, the present study was conducted to survey the opinions of caregivers concerning care of the elderly and to determine an acceptable way of caring for them. For the purpose of this study, caregivers are defined as people who live with an elderly person and who are directly responsible for looking after his/her needs on a daily basis, whatever those needs might be. There is little or no information available on caregivers of elderly people in Nigeria. The paucity of institutions, facilities and specialist manpower for taking care of elderly people leads to greater reliance on caregivers whose opinions have not been explored. Current trends at all levels suggest an increasing demand and emphasis on care of the elderly. This is because of the increasing number of elderly people in our population and the high level of migration of young people from rural to urban areas to seek employment due to economic recession.7 Old peoples homes in Lagos and Kano represent the only institutional care for elderly people at the present time. Some of the crucial issues in care of the elderly include the attitude of caregivers towards care of the elderly, where caregivers would prefer to care for the elderly, the types of care being provided by caregivers, and the effects of caring for the elderly on caregivers. These are issues that informed this study. These issues are particularly important in our culture because care of the elderly has been undertaken by the nuclear and extended family system for many years.
Materials and methods The study was carried out in Ilorin metropolis, which covers a land mass of about 32,500 km2. It comprises three local government areas (Ilorin West, Ilorin East and Ilorin South), and is dominated almost exclusively by the Yorubas.8 Ilorin metropolis consists of 11 wards, namely Alanamu, Ajikobi, Gambari, Fulani, Baboko, Badari, Mogaji-Ngeri, Adewole, Ubandawaki, Ojuekun-Sarumi and OsinEgbejila. Of these 11 wards, the study was carried out in seven: Alanamu, Ajikobi, Gambari, Fulani, Ubandawaki, Baboko and Adewole. The seven wards were chosen by a simple random sampling technique using balloting. Ilorin metropolis is politically grouped as part of Northern Nigeria and is dominated by the Yorubas. Other ethnic groups in the metropolis are Nupes,
1139
Barubas and Gambaris but they are minorities. Most inhabitants of Ilorin metropolis behave traditionally and culturally like the Yorubas. The most predominant religions in the metropolis are Islam and Christianity. However, traditional religion worshippers and non-believers represent the minority. The residents are mostly traditional cloth weavers, civil servants, traders, pot makers and commercial drivers. This study is a descriptive cross-sectional survey that used a structured questionnaire to collect information from caregivers. The questionnaire was prepared in English, and was translated into Yoruba language, the most widely spoken language in the study area, and used to determine the opinions of caregivers concerning care of the elderly. The questionnaire consists of items on socio-demographic variables, types of caregiving, preferred place of care, traditional socio-economic support, and attitude to care of the elderly. The questionnaire was pretested in Oko-erin ward that did not participate in the study. In the pretesting phase of the study, a draft questionnaire was examined for validity and application by the interviewers. From the responses, modifications were made and wordings were fine turned to make them suitable for application. After final modification of the questionnaire, the study was conducted for 6 months (January–July 2003). To ensure uniformity of administration, the questionnaire items were read to both literate and illiterate caregivers. The chosen caregivers in the seven selected wards agreed to be interviewed after the aim of the study had been explained. Subjects who did not know their dates of birth had their ages determined by reference to a calendar of important events for each locality. Four hundred and fifty subjects were interviewed. A proportionate sampling method was adopted to determine the number of caregivers that was interviewed from each ward. This is because the number of caregivers varied from ward to ward. There are no available data for the number of caregivers in Ilorin metropolis. It is assumed that there is at least one caregiver per elderly person. The 1991 population census projected figure currently puts the total population of elderly people in Ilorin metropolis at 36,000.9 Two or three streets in each ward, depending on the relative size of the ward, were selected by a simple random technique (using balloting). One caregiver, selected at random by balloting, was interviewed from each house visited in the selected streets until the required number of caregivers from each ward was obtained.
1140
I.S. Abdulraheem
Completed questionnaires were reviewed at the end of each day and subjects whose questionnaires could not be completed at the first visit were revisited. The data were coded and analysed on a computer using EpiInfo version 6. Chi-square test was used for statistical analysis, and a significant level was taken to be 5%.
Table 1
Sociodemographic characteristics.
Variable
Frequency (%)
Age (years) !20 21–30 31–40 41–50 51–60 O60 Total
31 (7.3) 122 (28.6) 129 (30.3) 46 (10.8) 22 (5.1) 28 (6.6) 426 (100)
Sex Male Female Total
136 (31.9) 290 (68.1) 426 (100)
Ethnic group Yoruba Hausa/Fulani Igbo Others Total
327 (76.7) 72 (16.9) 16 (3.8) 11 (2.6) 426 (100)
Monthly income !N2000 N2000–5000 N5100–10,000 ON10,000 Total
200 (46.9) 68 (16) 105 (24.6) 53 (12.5) 426 (100)
Marital status Single Married Separated Widowed Divorced Total
80 (18.8) 284 (67) 14 (3.2) 32 (7.4) 16 (3.6) 426 (100)
Education No formal education Primary education Secondary education Tertiary education Total
130 (30.6) 95 (22.1) 122 (28.6) 79 (18.7) 426 (100)
Occupation Civil service Trading Artisan Farming Unemployment Total
80 (20.6) 153 (35.9) 79 (18.7) 47 (11) 59 (13.8) 426 (100)
Results Of the 450 questionnaires administered, 426 [136 (31.9%) males and 290 (68.1%) females] were duly completed, giving a response rate of 94.7%. The mean age of the males (49G19 years) was not significantly different from that of the females (45G17 years) (PO0.05). Table 1 shows the sociodemographic characteristics of the study population. Monthly income was generally low and caregivers depended on their earnings from sales of their farm products and other materials, as well as support from other family members. This support varied from cash to materials. Of the respondents, 80 (20.6%) were civil servants, 153 (35.9%) were traders, 79 (18.7%) were artisans, 47 (11%) were farmers and 59 (13.8%) were unemployed. More than half (62.7%) of the caregivers were daughters (44.4%) or sons (18.3%), and only 1.1% were employees to the elderly. The attitudes and reasons of caregivers concerning caring for the elderly are shown in Table 2. The majority [418 (98.1%)] of respondents said that the elderly should be cared for, while only eight (1.9%) of them felt indifference. More than half of the respondents who wanted the elderly to be cared for gave religious teaching (35.9%) and tradition/ customary obligation (28.7%) as reasons. Only 10 (2.4%) respondents gave reciprocity of elder’s help as a reason for caring for them. Caregivers’ opinions regarding where elderly people should be cared for and reasons for caring for them at home are shown in Table 3. The majority [385 (90.3%)] of caregivers Table 2 Attitudes and reasons of caregivers concerning caring for the elderly. Items
Frequency (%)
Attitude Elderly should be cared for No difference Total
418 (98.1) 8 (1.9) 426 (100)
Reasons for caring for elderly people Traditional/customary 120 (28.7) obligation Religious teaching 150 (35.9) Personal feeling 88 (21.1) Elderly person needs help 20 (4.7) Reciprocity of elder’s help 10 (2.4) Want to be cared for in old age 30 (7.2) Total 18 (100)a a
Total number of caregivers that wanted elderly people to be cared for.
Ceregivers’ opinions of caring for the elderly in Nigeria
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Table 3 Opinion of caregivers on where elderly people should be cared for and reasons for caring for elderly people at home.
Table 4 Types of care provided by caregivers and traditional socio-economic support available for elderly people.
Items
Items
Where to care Home Institutions Total
Frequency (%) 385 (90.3) 41 (9.7) 426 (100)
Reasons for caring for elderly people at home Prompt adequate family support 260 (61) Cultural fulfilment 330 (77.5) Elderly people feel more at ease in 345 (81) their home It is cheap 200 (46.9) Helps to spread the load of care 224 (52.6) Note: all the respondents chose more than one response concerning reasons for caring for the elderly.
said that they would prefer to care for an elderly person at home and only 41 (9.7%) opted for institutional care. Three hundred and forty-five (81%) respondents said that they would prefer to care for an elderly person at home as elderly people feel more at ease in their own homes. As caregivers, the respondents were asked to indicate the types of care they provided and enumerate the traditional socio-economic support available for caring for the elderly. As shown in Table 4, there were fairly high percentages for the various types of care purported to be provided by the caregivers. Payment of house rent (20.7%) and sending for other relatives (23.2%) were the least services (care) provided. According to the respondents, the majority [334 (78.4%)] of children of the elderly sent money home regularly for the upkeep of their elderly parents. In terms of paying hospital bills when elderly people are ill, family relatives played an important role (96.4%), particularly if the elderly person had no surviving children. In this study, 74.8% of caregivers reported that caring for an elderly person is a large burden if there is no support at all. Lack of adequate time for one’s leisure (66.2%), inadequate financial resources (81.3%) and bedwetting (21.3%) are areas of burden to caregivers of elderly people. Despite these burdens, over two-thirds (69.8%) still expressed a positive attitude towards caring for the elderly. The responses (opinions) of caregivers concerning who should be responsible for the welfare of elderly people in our society are shown in Table 5. Government (80%), son (77%) and daughter (62%) were the principal agents mentioned in terms of
Frequency (%)
Types of care Feeding Taking to hospital when sick Washing clothes and dishes Cleaning of houses Buying of medicines from chemists Bathing Cooking Shopping and marketing Paying of house rent Provision of money Assisting in dressing and undressing Assisting in taking or driving to places out of walking distance Cleaning of teeth Cutting, shaving and combing of hair Taking out for social interaction Sending for other relatives Paying of house help Traditional social and economic support Monetary remittances from children Regular visits by the relative(s) Pension and gratuity Fees from houses and properties rented out Land lease Provision of clothes and other materials by relative Spouse in gainful employment Participation in religious activities Dividends from daily contribution and co-operative Union of retired or senior citizens Children and spouses alive and living together
340 440 311 260 370 250 310 290 75 410 280 193
(79.8) (96.4) (73) (61) (86.9) (58.7) (72.8) (68) (20.7) (96.2) (65.7) (45.3)
217 288 296 99 308
(51) (67.6) (69.5) (23.2) (72.3)
334 208 59 297
(78.4) (48.8) (13.8) (69.7)
118 (27.7) 215 (50.5) 244 (57.3) 200 (46.9) 176 (41.3) 50 (11.7) 291 (68.3)
Note: most respondents chose more than one response.
Table 5 Caregivers’ responses (opinions) on who should be responsible for care of the elderly. Responses
Frequency (%)
Son Daughter Relatives Government Friends Daughter-in-law Son-in-law Old peoples home
328 264 73 341 54 217 169 27
(77) (62) (40.6) (80) (12.6) (50.9) (39.7) (6.3)
Note: more than the number of study respondents because of multiple responses.
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I.S. Abdulraheem
who should be responsible for the welfare of elderly people in our society. It is important to note that old peoples home constituted 6.3% of all the agents mentioned. The association between the level of education of respondents and where to care for elderly people was tested and was not found to be significant (X2Z6.39, PO0.05), and those with formal education [230 (68.7%)] preferred home care for the elderly. This study found that religion is a predictor of positive attitude towards caring for the elderly. This is because the difference between those with and those without religion was statistically significant (X2Z7.38, P! 0.05). Caregivers made the following suggestions regarding how care of the elderly could be improved: training of professionals on geriatrics and gerontology (40.5%); training of caregivers on basic geriatric skills (70.1%); provision of incentives like loans and allowances for caregivers (66.9%); adequate and prompt payment of pension and gratuity by the government to elderly people (80.9%); free accommodation to homeless elderly (59.1%); and free transportation for the elderly (38.4%). It is important to note that each respondent gave more than one suggestion. As caregivers, the respondents were asked to indicate the types of help they would need in caring for the elderly. As can be seen in Fig. 1, the help needed ranged from prayers (20%), financial and material resources (46%), subsidised or free
Figure 1
medical care (19%), and assistance in house chores and farming (15%). The reasons given for the help required included inadequate financial and material resources (40.3%), lack of time (30.7%), proper and adequate caring of elderly people (14.2%), paying attention to nuclear family responsibilities and obligations (8.8%), and sharing the load of care (6%).
Discussion Nigerian people are getting more interested and aware of the geriatric discipline as evidenced by publications in journals, newspapers, and talks on the radio and television all focusing attention on custodial care of elderly people. The provision of care for the elderly is an important issue for the society; the lack of good information on caregivers concerning care of the elderly is an important deficiency that should be addressed. Caregivers’ opinions are important in caring for the elderly since most elderly people live in their own homes where these caregivers are, in most cases, easily available and accessible. Caregivers will continue to be the single most important source of care for most of these elderly people. It is important to note that a number of cultural factors are responsible for some of the findings in this study. The age range of respondents was between 19 and 73 years. Of the respondents,
Help needed in caring for the elderly.
Ceregivers’ opinions of caring for the elderly in Nigeria 7.3% were aged less than 20 years and 6.6% were more than 60 years old. The largest group (30.3%) of respondents were between 31 and 40 years of age. This pattern of age distribution is in keeping with the population pyramid of most developing countries, with preponderance of the young compared with few elderly individuals. This pattern of population distribution may also be suggestive of a high birth rate and a high child death rate, which is peculiar to developing countries. The majority (69.4%) of respondents had received a formal education. The high proportion of educated respondents was not surprising since Ilorin metropolis is largely populated by the Yoruba, and as an ethnic group, the Yoruba place a high value on formal education. A fairly high percentage (68.1%) of caregivers were females. This finding is in agreement with the findings of earlier researchers who reported that female members of the family have been the major caregivers of elderly people in most countries of the world.10,11 Indeed, while caring for the elderly can make demands on all family members, the brunt of the burden is undoubtedly usually borne by wives, daughters, daughters-inlaw, sisters, mothers and grandmothers. Part of the explanation for this is due to the traditional role of females as caregivers. In the past, in most developing countries, women remained at home, thus making them available to provide care for elderly relatives, while men usually worked in jobs outside the home. The reliance on women to perform the caring role is due to the deliberate socialization for gender-specific roles. Women have generally been known to perform the nurturing role of raising children and caring for sick members of the family. Furthermore, since women are usually younger than their husbands, the probability is high that a wife, in later years, would be responsible for the care of her older, impaired husband.2 Attitude reflects our likes and dislikes and may often come from personal experience or that of close associates. Attitude either attracts one to things or makes one wary of them. Other things like education, knowledge, belief, intelligence and memory influence attitudes to caregiving.12 This study found that children and close relatives who have close contacts with elderly people are more disposed to care of the elderly. This supports the notion that a negative attitude to care of the elderly is least in those who are closest to the elderly.12,13 From the information gathered during this study, children and close family relatives were mainly responsible for care of the elderly. They
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take the elderly to hospital when sick. These findings are similar to those of Ogunsakin, who reported that the majority of care provided to elderly people came from children and close family relatives.14 Thus, it appears to be the norm in African society, especially Nigeria, for elderly people to be cared for by their children and close relatives. In this study, 98.1% of respondents had a positive attitude towards caring for the elderly. In Nigeria, a positive attitude towards caring for elderly people has been documented by other researchers.15 Religious teachings, traditional/ customary obligation and personal feelings are important motivating factors for caregivers towards caring for the elderly. The great majority (90.3%) of caregivers in this study preferred to care for the elderly at home. This is similar to the finding of researchers from the Western world.16 In contrast to this study, the work of Terri et al. showed that fewer respondents preferred home as a place of care.17 In comparison with a study undertaken in the UK, the majority of caregivers (general practitioners, community nurses and health visitors) in the UK felt that care of the elderly should be done at home.18 This study found several reasons for caring for the elderly at home. Among these is ‘prompt and adequate family support’. This finding agrees with the report of Ogunsakin that care of the elderly is better at home where family relatives will be easily available and immediate and adequate family support would be given.14 Although the move towards increased home care is driven in part by efforts to curtail costs, it is also predicated on the assumption that the home environment is more comfortable. Virtually any individual requested to assume the status of an elderly person would prefer home to institutional care of any type, not just for personal comfort but also because, even at their best, institutions are foreign environments. Considering the various types of care given to the elderly, this study found that a high percentage of caregivers took elderly people to the hospital when they were sick. This finding is similar to the report of a study performed in Ghana.19 In this study, the caregivers complained that caring for the elderly was a burden. Jacobson’s study supports this finding.20 Jacobson’s study showed that many caregivers had a negative attitude towards caring for the elderly as the majority of cases involved one person providing most of the ongoing care for each elderly person in need.
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Conclusions and recommendations In this study, the majority (69.8%) of caregivers were willing to continue caring for the elderly despite the burdens highlighted above. Caregivers’ opinions should be sought and, most importantly, they should always be involved in the planning and implementation of geriatric programmes. Since most caregivers preferred home to institutional care, it is recommended that basic geriatric skills should be given to them as demanded for in this study, and only professional geriatrics and gerontologists can achieve this.
Acknowledgements I am most grateful to Dr Bade Ajayi, Associate Professor of Linguistics, Department of Linguistics and Nigerian Languages for serving as an English Native speaker and checking the manuscript.
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I.S. Abdulraheem 7. World Health Organization. Our planet, our health. Report of the WHO commission on health and environment. Geneva: World Health Organization; 1992 p. 38–54. 8. Jimoh LAK. Ilorin: the journey so far. Ilorin: Attoto; 1994. 9. Nigerian population. 1991 provision census results. 10. Brody EM. Women in the middle and family help to older people. Gerontologist 1981;21:471–80. 11. Gibson MJ. Family support patterns, policies and programmes. In: Nursberg C, editor. Innovation ageing programmes abroad. Implications for the United States. Westport, CT: Greenwood; 1984. p. 159–95. 12. Dooley S, Frankel BG. Improving attitude towards elderly people: evaluation of an intervention program for Adolescents. Can J Ageing 1990;9:400–9. 13. Aday RH, Mcduffie IN, Sims CR. Impact of intergenerational program of Black adolescents. Adolescents’ attitude towards the elderly. Educ Gerontol 1993;19:663–73. 14. Ogunsakin EA. Home care of the elderly among the selected ethnic groups in Kwara state of Nigeria. Centre Point 1994;4: 52–3. 15. Baiyewu O, Andrew F, Bella J, Adeyemi B, Benson A, Bamigboye EA, et al. Attitude to ageing among different groups in Nigeria. J Psychosoc Gerontol 1997;44:284. 16. Burton LC, Left B, Harper M. Acceptability to patients of home-hospital care. J Am Geriatr Soc 1998;605–9. 17. Terri R, Friol ED, John CD, Leary RO, Mary E, Tinetti M, et al. Old persons’ perception of home and hospital as sites of treatment for acute illness. Am J Med 1997;107: 317. 18. Tremellen J, Jones D. Attitudes and practices of the primary health care team towards assessing the very elderly. J R Coll Gen Pract 1989;3:142–4. 19. Brown CK. Caring for the elderly—the view of the carers in Ghana. In: Textbook of caring for the elderly. Perspectives from Ghana and Japan. Cape Coast: Catholic Mission Press; 1999 p. 99. 20. Jacobson S. The role of caregivers in the black community— Executive Summary. Institute for the Study of Human Systems, Inc., Prepared for Administration on Ageing, Washington DC; 1980.