Social care and support for elderly men and women in an urban and a rural area of Nepal

Abstract

This study has aimed to describe the care and support for urban and rural elderly people of Bhaktapur district, Nepal. Efforts were made to identify the feeling of some features of general well-beings associated to mental health, person responsible for care and support, capability to perform daily routine activities, sources of finance and ownership to the property. More than half of the respondents were found having single or multiple features of loneliness, anxiety, depression and insomnia. The rate of point prevalence loneliness was found higher in the above 80 years of age, urban respondents. Almost 9 in 10 respondents were capable themselves to dress, walk and maintain personal hygiene and majority of them were assisted by spouse, son/daughter-in-laws. Family support was common sources of income and ownership to the property was absolutely high.

Keywords::

• Financial support
• informal carer
• living arrangement
• preferred place of residence
• social care and support

Introduction

In Nepal, elderly people are well-respected people by families and societies. Traditionally, they live together with their spouse and grown-up children/grand children or spouse alone. Cohabitation is the only guarantee that elderly parents will receive support from their adult children [1]. The increasing trends in ageing are creating a crisis of care in Asian countries [2]. Older people are mostly healthy and independent, both physically and emotionally; however, some require care and support from others. To meet the need for care, families, communities, civil society and governments may provide various levels of assistance depending on their means.

Agriculture was the major source of economic productions, but being less productive young adults have been migrating to urban locations in search of better employment opportunities leaving their parents alone in rural area. The emergence of this trend has declined the quality of care and support to elderly people. As the young adults have to stay away from home at work place, it makes them unable to provide care and support. Eckerman’s study in Nepal also showed only a small percentage of elderly persons (7%) reported receiving care or assistance because of a long-term physical or mental illness or a disability [3] though they have to depend on their children, particularly sons, for support and security in their old age (1). The present trend of breakdown of joint families to nuclear families, changing lifestyles and migration from rural to urban areas has compelled them to live alone. The family network is often the only form of welfare and support for the elderly [4].

Now, the ageing is being considered a problem in our society. Since, older people are even considered as a burden for the family [5]. The processes of social change such as industrialization, urbanization and migration can have a negative impact on care for elderly people, particularly in rural areas [6]. Likewise, 70% of older people have been residing in low or middle-income countries. In those countries, the problem of ageing has been increasing very fast demanding additional supports and care along with additional resources to meet their requirements. They need to build the infrastructures necessary to address their needs and demands. So, the trend of fast ageing around the world has given new challenges to developing countries [7].

This study was designed to identify existing situation of social care and support for elderly people in Nepal, and it was conducted in an urban and rural part of Bhaktapur district of Nepal in 2009. The aim of this study was to describe the available social care and support for elderly men and women residing in an urban and a rural part of Bhaktapur district of Nepal and the objectives were as follows.

Objectives

• to describe available care and support to elderly people,

• to describe the general well-being of elderly people and

• to describe the residency and financial support for older people.

Methods

The study sites were selected in coordination with staff of district heath office, local bodies and local people of Bhaktapur by convenience sampling method as 9 wards from ward number 6 to 14 of Bhaktapur municipality (urban) and all 9 wards of Sirutar Village Development Committee (rural) studies areas. The estimated populations of the elderly people were 5431 people of the total 83,556 people in urban and 345 people (5319 people) in rural study areas.

The target population of this study was elderly people who completed 60 years of age. The sampling frame was the households of the respondents identified on the basis of the name list of elderly people obtained from respective local bodies. The sample size of this study was 204 respondents with equal number of men and women from urban and rural study areas. The selection of study areas were determined taking cooperation and support from local people and constraints of available resources, time, and cost factors were fully considered to make a small size study.

The demographic characteristics, age, sex, occupation, economic status, place of residence, were designed based on the demographic survey questionnaire module of Age-friendly Primary Health Care (PHC) Centers Toolkit [8]. The choice of accommodation, help or care, psychological well-being (symptoms of depression, anxiety and sleep habit) was developed from Measuring health, a review of Quality of Life Measurement Scale of Bowling [9]. In addition to this, the information on telephone communication, physical support, staying together, visits made by different persons/relatives and required assistance to perform routine daily activities and source of financial support were also designed based the same source.

Prior to the collection of information the questionnaires were pretested in adjoining ward of Bhaktapur municipality and in a ward of adjoining village development committee as an urban and rural study sites. Serial meetings were held with the local town/village leaders prior to the study, and the purpose of the visit was explained and permission requested to conduct the survey. During the survey the first household was selected for interview from ward number one of Sirutar Village Development Committee and ward number five of Bhaktapur municipality. Once the interview within a household was completed the nearest household was selected until 102 respondents were interviewed in both study areas. In case of unavailability of an eligible elderly person at home, or the household had no one at home during the visit, the household was later revisited in the day or the following day to conduct the interview.

At each household, the purpose of the research was explained and their willingness to participate elicited prior to the conduct of the interview. After taking formal consent, the elderly people were asked the series of questions from the questionnaires. Responses were taken from a carer after taking prior consent from elderly people/ head of households for those who were unable to respond to questions. Likewise, those who were unable to respond in Nepali were interviewed with the help of head of house hold or closest carer. The responses of elderly people of both study areas were entered into computer, tabulated, and analyzed. The proposal was approved by Nepal Health Research Council. The informed consent was obtained from each respondent prior to interview.

Results

In this study, 286 households with residents of above 60 years of age were visited and face-to-face interviews were administered to 204 respondents acquiring 71.3% of response rate. The classification of respondents by age showed that 109 (53.4%) respondents were in the age group of 60–69 years, 72 (35.4%) respondents were in the age group of 70–79 years and 23 (11.2%) respondents were in the age group of 80 years and above. Two thirds of the respondents were living together either with their spouses or with son/daughter-in-laws. Ethnically, 120 (58.8%) Newar, 46 (22.5%) Brahmin, 35 (17.2%) Chhetri and remaining 7 (3.5%) respondents from other castes were found. All of them were Hindus and only one third were found literate. The demographic statuses along with age, sex, place of residence are presented in Table I showing mean age 71.3 years with marriage rate of (99.1%).

Table  I.  Marital status of respondents by age group and the place of residence (%).

Marital status	Age groups (%)								Total
	60–69 years		70–79 years		80+ years		Total
	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural	%	No.
Couples	88.9	89.1	68.3	80.6	42.9	62.5	62.5	82.3	79.9	163
Widowed	11.1	10.9	29.3	16.1	57.1	37.5	37.5	16.7	19.1	39
Unmarried	0	0	2.4	3.2	0	0	0	1	0.9	2
Total number	54	55	41	31	7	16	102	102		204

Persons involved in the care of elderly people

Table II shows the persons involved in the care of elderly people as an informal care giver/informal carer: 74.1% (79.4% in rural people compared to 68.7% in urban elderly people) were living with their spouse with son or grandson together, and others (1.5% each) with daughter/son-in-law and alone.

Table  II.  Informal care givers by age group and place of residence (%).

Care givers (informal care giver)	Age groups (%)						Total (%)
	Urban			Rural
	60–69 years	70–79 years	80+ years	60–69 years	70–79 years	80+ years	Urban	Rural	Both
Spouse with son or grandson	64.8	68.3	71.4	70.9	87.1	87.5	68.7	79.4	74.1
Spouse	35.2	31.7	28.6	21.9	9.7	6.2	31.4	14.7	23.1
Daughter/son-in-law	0	0	0	5.5	0	0	0	2.9	1.5
Alone	0	0	0	1.8	3.2	6.3	0	2.9	1.5
Total number	54	41	7	55	31	16	102	102	204

Visits to elderly people by different groups of people

The number of visit to elderly people by their family members, relatives, friends and others were recorded and analyzed revealed 2.5 visits per respondents per year (Table III) with higher visit rate among rural respondents compared to urban. It also revealed that visits to 80 and over years of respondents were declining order resulting inclined number of respondents in loneliness. The χ² tests also showed a significantly greater number of individuals above 80 years with loneliness, anxiety and depression as compared as compared with insomnia (p = <0.05).

Table  III.  Visits to elderly people by different groups of people.

Age groups	Family Members			Relatives			Friends			Others
	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
60–69 years	36	50	80*	29	49	78*	24	39	63*	32	19	51*
70–79 years	19	31	50*	23	29	52*	13	20	33*	18	21	39**
80+ years	5	11	16**	5	8	13**	4	9	13**	5	9	14**
Total	60	92	146*	57	86	143*	41	68	109*	55	51	103

Statistically significant *p < 0.05.

Statistically insignificant **p > 0.05.

Reported assistance to perform daily activities

Table IV shows capability to perform or assistance provider to run daily activities living in urban and rural respondents. In managing house hold matters, cooking and serving food and washing clothes, spouse was more commonly reported by urban respondents whereas son/daughter-in-law was more common in the rural area. Likewise, almost equal proportions of the respondents in both study areas were able to maintain their personal hygiene, to walk inside home without assistance and capable to dress themselves. The assistance from daughter/son-in-law was very little.

Table  IV.  Abilities to perform activities (%) (n = 204).

Activities	Able themselves		Assisted by spouse		Assisted by son/daughter-in-law		Assisted by daughter/son-in-law
	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural
Managing house hold matters	16.6	8.8	45.1	30.2	37.3	55.8	1.1	5.3
Cooking & serving foods	42.2	46.1	24.7	6.8	32.4	44.1	1.0	4.9
Washing cloths	10.7	6.8	35.2	20.6	53.2	70.6	1.4	1.2
Maintaining personal hygiene	94.2	93.2	1.1	1.1	5.3	5.9	0	0
Walking inside	90.2	93.3	3.2	0	5.8	7.9	1.1	0
Dressing clothes	92.7	93.7	2.3	0	4.7	7.9	1.2	1.2

Help or care during illness

During illness, 127 (62.3%) were looked after by son/daughter-in-law, 72.6 % in the rural area compared to 52.0% in the urban area. Fifty-two (25.5%) were looked after by their spouse, and only 11 (5.4%) by daughter/daughter-in-law.

Assessment of general well-being

Some forms of “normal” emotional experiences related with mental health viz. depression, anxiety, loneliness and sleep disorder (Table V) were assessed to explore point prevalence of feature of general well-being by asking some relevant questions. Of the 204 respondents, 59 (28.9%) were found with features of loneliness, 30 (14.7%) anxiety, 15 (7.4%) depression and 28 (13.7%) insomnia. The number of respondents with loneliness and depression were found higher number in urban residences where as anxiety and insomnia in rural respondents. The distribution of those respondents in relation to age and place of residence showed that of the total 59 reported cases of loneliness, 33 (55.9%) respondents were found in urban study areas and others 26 (44.1%) from rural study areas. The χ² tests showed that there was no significance association between urban and rural respondents in all of the above mentioned features (p = >0.05) in spite of those features were proportionally increased with aging.

Table  V.  Reported psychological features by age group and residency.

Age group	Loneliness (n = 59)		Anxiety (n = 30)		Depression (n = 15)		Insomnia (n = 28)		Total respondents no.
	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Urban	Rural	Total
60–69 years	14.8%	10.9%	3.7%	7.2%	5.5%	3.7%	0.0%	1.8%	54	55	109
70–79 years	44.7%	32.5%	18.4%	17.6%	18.4%	8.8%	13.1%	5.8%	38	34	72
80+ years	80.0%	69.2%	40.0%	53.8%	50.0%	30.7%	80.0%	92.3%**	10	13	23
Total	33	26**	13	17	15	9	13	15**	102	102	204

Statistically significant *p < 0.05.

Statistically insignificant **p > 0.05.

Income sources

The Table VI shows the different sources of income among all respondents. Family support was the most common and the number receiving a pension was higher (14.7%) in the rural area compared to 9 (8.8%) in urban respondents.

Table  VI.  Income sources (earning).

Source of incomes	Urban		Rural		Total (n = 477)
	No.	%	No.	%	No.	%
Agriculture	58	56.9	90	88.2	148	31.1
Pension	9	8.8	15	14.7	24	5.1
Old age allowance	48	47.1	47	46.8	95	19.9
Business	12	11.8	2	1.9	14	2.9
Share/debenture	12	11.8	0	0	12	2.5
Family support	89	87.3	84	82.4	173	36.3

The ownership of the residence and preferred place of accommodation

Among the respondents, 183 (89.7%) owned their own home and 179 (87.7%) preferred to live at home compared to a residential home or a holy place.

Discussion

This study aimed to describe the social care and support for elderly men and women residing in an urban and a rural part of Bhaktapur district of Nepal. The findings are discussed in the availability of care and support, psychological well-beings and ownership over residency and financial support for the urban and rural elderly people.

The findings in availability of care and support showed more than four fifth of the elderly people were living in cohabitation with spouse together with son in both study areas which was similar to the Chalise’s [10] and UN [11] studies where 80% and 73% elderly people respectively living with their children. Furthermore, the UN study also showed 13% were lived with their spouse and 6% lived alone similar to this study where one fifth were living with their spouse alone which is higher and may be due to migration of adult population far away from home.

Likewise, the care of elderly people during sickness was performed primarily by son together with spouse; however, the proportion was higher among rural respondents compared to urban respondents. Nominal numbers of carers, 1 in 20, were provided by daughter or son-in-law showing primary responsibility of care goes to the son.

Older people were visited by different people showing that more than three fourth elderly people were visited by close family members, relatives and friends averaging 2.6 visits per year with higher rates of visit in rural areas compared to urban study area. The frequency of visits also was higher rate in above 80 years of age group, similar to Regmi’s study in Socio economic and cultural aspect of aging in Nepal where he has reported that as the age grows above 60, dependency on others in day-to-day living increases and usually help from children/spouses particularly during sickness [12]. Their wellness was communicated through telephone and half of the respondents communicated with their relatives several calls in a week although some were not using the telephone service.

It was found that more than 9 in 10 respondents were found capable to maintain personal hygiene, walking independently and changing dresses, likewise almost equal numbers of respondents were able to cooking and serving food themselves whereas only one in ten were able to wash cloths and managing house hold matters. These finding are similar to neighboring South Asian countries as longer life expectancy means an increasing proportion of old among the elderly resulting in a smaller proportion of the elderly in the workforce and have traditionally relied on their children for personal care and financial support in Southeast Asia [13].

Assessment of psychological well-being found that almost half reported the problem of loneliness, and 1 in 4 were found with features of insomnia and anxiety, and 1 in 10 were depressed. This is less than Gautam’s study which revealed 63.1% were suffered from anxiety and 70.2% depression among 22 respondents and expressed their desire of living together with all family members rather than to move towards new places [14].

The source of income to maintain daily subsidence came from different income sources such as family support, agricultural products and old age allowance to above 70 year aged persons which was similar to the Dahal’s report (1) where the majority of elders depend upon agriculture in Asia Pacific region. The major portion of the income was obtained from agriculture however multiple sources were needed to meet their daily economical needs. The family remained the most important source of support for the elderly in both study areas. Regarding preferred place of residence, almost all 9 out of 10 elders were home owners and preferred to live there instead of residential home or public homes (at holy places).

The property inheritance maintains ownership in almost all households however, as Sidney advocated in Asia’s next challenge, caring for the elderly as land and buildings are becoming a scarce resources, cultural traditions are breaking down through modernization and the living conditions of the elderly are likely to deteriorate as this process continues.

Almost 8 elders in 10 were living with spouse and 1 in 5 was found widow or widower which was similar to the findings of Singh’s study [15] which revealed 17.1% were widows/widower. Likewise, Geriatric Center Nepal’s report also revealed that 9.11% of males and 24.94% of females were widowers/widows [16].

Limitation of study

Some of the respondents were not able to concentrate on the interview, being busy with their routine activities. During that time there were political movements leading to market closure, imposing of curfew with time limitation made it difficult to gather information particularly in the urban study area. There is the possibility of under reporting in amount and income sources. Some respondents were not able to reply to those questions due to mental disorder or language barriers and had to rely over the information from third person. The received information was considered accurate and complete, and it is expected that the results are reliable and valid. However, the study size and geographical location may limit the generalizability of the findings.

Conclusion

The increasing trend of living with spouse alone at home in urban area reflects the need of additional support/care. The higher frequency of visits to the respondents of 80 years and above suggested that the elderly people are still well respected in the community. The principal carers in the rural community were either son or daughter-in-law but spouse remained in urban community. The distribution of felt mental illness as feelings of anxiety, depression and insomnia were almost equal in both study areas; however, the feelings of loneliness were more common in urban respondents. Agricultural and family supports were the common sources of income in both study areas.

Declaration of Interest: This article has met the requirements of The Nepal Health Research Council and permission was granted to conduct study. The author declares no conflict of interest.