The paper examines how the healthcare and social care pillars of social policy for aging societies shape inequalities in health and well-being at old age, utilizing qualitative and quantitative datasets. The results intimate the lack of geriatric infrastructure, hence the inadequacy of geriatric care provision for older adults. Systemic problems or gaps existent in Ghana led to private individuals taking advantage of the situation, turning it into an opportunity for service providers. Thus, the evolution of recreational/residential homes in Ghana is situated along three distinct patterns or forms namely the occasional, the adult day care center and residential archetypes. Collectively, these constitute formal and informal care facilities. These are often privately owned and at a cost. The nature of quality of care may be affected by the types of homes available, especially in the globalized cultural setting. A growing number of older adults resort to care homes as an alternative measure. These are discussed from two viewpoints. First, geriatric data generation, the absence of which impedes healthcare provision. Second, cash-for-care policies may exacerbate existing inequalities in care with negative consequences for health and well-being. In short, policies for aging populations are being implemented across Ghana with too little known about their consequences for inequalities in health and well-being in later life. The paper sought to address this knowledge gap by exploring a significant infrastructure by undertaking a systematic examination of how recent policy developments for aging exacerbate or reduce inequalities in health and well-being among older adults. The paper concludes that social policy for aging societies’ specific key pillars (healthcare and social care research) offers opportunities for analyzing and understanding internal dynamics including the effects of policy implementation for inequalities in health and well-being at older ages, therefore enabling the identification of strategies to improve older adults’ circumstances, without which older adult population will far outpace elder care provision.
Introduction
Role of Social Change
Social change has been the factor of transformation in contemporary life worldwide including Africa and Ghana. The latter is fostered by a myriad of drivers. Social change is induced by modernization, urbanization, globalization (Apt, 2012; Kpessa-Whyte, 2018). This, in turn, has necessitated societal and familial changes, which could be explained by social and economic conditions. The social conditions encompass weakened extended family support system (Aboderin, 2006; Doh et al., 2014; van der Geest, 2016; Dovie, 2018a); inadequate formal support infrastructure (Aboderin, 2006; Dovie, 2018a) and increasing nucleation of the family. Similarly, the neglect of older people (Dovie et al., 2018) may be responsible for the lack of care for them. The economic conditions consist of the occurrence of “brain drain” among doctors and care staff who migrate to developed countries, labor and economic conditions that force women, who are often made responsible for the care of the family to work outside the home (Schatz and Seeley, 2015; van der Geest, 2016; Coe, 2017) among others. All these have implications for geriatric and institutional care particularly for older adults.
Concerns With Care Provision for Older People
Care for older people is a widespread phenomenon. In some high-income countries, there is variable funding for social care; for example, Germany has a special tax to help fund this. In the United Kingdom (UK), social care for patients in institutions is means tested, for example, above a certain level of assets this is self-funded. The same is in the United States. Consequently, this is an issue facing all countries (Robertson et al., 2014). The evolution of the aging population is faster to live in low-and-middle-income countries (LMICs). Eighty percent of older adults will live in LMICs (Agbogidi and Azodo, 2009; WHO, 2017a), including Ghana.
A study conducted in Malaysia observed that older people with education, income and the need for healthcare was associated with healthcare services utilization (Yunus et al., 2017). Hamiduzzaman et al. (2016) also ascertained factors that influenced older female’s utilization of healthcare services in rural Bangladesh. They identified deprivation of adequate education, social and economic dependency on males and family, inadequate and ineffectual institutional healthcare arrangements and misappropriation of funds. In a similar study, Hren et al. (2015) revealed that older persons in Slovenia often sought out-patient-department services and hospitalization. The study found that age and education were the factors that influenced the use of healthcare and other related services. Also, worth reiterating is the fact that increase in the population of older adults is occurring along the same timelines as the breakdown in the traditional system of social protection and care (Kpessa-Whyte, 2018) due to urbanization, socio-economic development, and globalization. This has implications for the well-being of older adults and policy.
In sub-Saharan Africa (SSA), a rapidly aging population is presenting challenges to healthcare systems. Doctors need specialized knowledge to be prepared for the increase in age-related medical conditions. Further, older adults are likely to be challenged with physical, mental, and social changes that require adjustment as they attain later life (Martin et al., 2008). These are indicative of an impending burden of elder care. Geriatric care is associated with hospitalization irrespective of the form it takes. A study conducted by Frost et al. (2015) shows that 4% of medical schools in SSA taught geriatrics while 40% had no geriatrics teaching. Additionally, the most significant perceived barriers to geriatric education and the attendant care were a lack of staff expertise (72%), lack of funding (52%), and absence of geriatrics in the national curricula (48%). There are still a large number of medical schools in SSA who do not teach geriatrics. Healthcare needs such as orthostatic hypertension measurement/management, vision assessment, toileting schedule (Colon-Emeric et al., 2018; Sharma et al., 2018) may require comorbidity management. This has implications for the quality of care delivered (Colon-Emeric et al., 2018) to them.
Also, substantial social class differences exist in preferences for activities including perceptions about institutional care. It also has economic effects on these range of possible activities. Some social class differences in activities culminate from differences in what people are taught to prefer whereas others reflect differences in financial capacity (Atchley and Barusch, 2004) notwithstanding the notion of need. The divisions between social classes are becoming wider, not narrower. In the UK, for example, figures from the Equality Trust (2017 cited in Manstead, 2018) show that the top one-fifth of households have 40% of national income, whereas the bottom one-fifth have just 8% (Manstead, 2018). Research by Savage et al. revealed that the differences between the social classes they identified extended beyond differences in financial circumstances. There were also marked differences in social and cultural capital, as indexed by the size of social networks and the extent of engagement with different (cultural) activities, respectively.
The Institutional Care Challenge
Populations around the world are aging rapidly, and this demographic transition is placing new demands on societies to provide comprehensive systems for long-term care at home, in communities or institutions. An institutional home denotes a place of residence for older adults who require continual nursing care and have significant difficulty in relation to coping with the essential activities of daily living (ADLs). In sub-Saharan Africa, 46 million older people live in the region and this number is expected to more than triple (to 165 million1) by 2050. A significant proportion of these people will require long-term care at some point in their lives (De-Graft Aikins and Apt, 2016).
Long-term care can be provided in a range of settings including people’s homes and by a range of people. Currently, families provide the most long-term care in sub-Saharan Africa and do so without any organized training or support. Reliance on families alone to provide this care culminates in inconsistent care quality and places a particularly heavy burden on women and girls. Moreover, it may be unsustainable given the rapidly increasing number of older people (WHO, 2017a, p. 1). WHO’s (2017b) “Global Strategy and Action Plan on Aging and Health” (1) calls on all countries to develop a system of long-term care. The Strategy stresses that no single system of long-term care can be applied in every setting, even in countries with similar resource constraints. Governments need to take into account the number of older people as well as their need for long-term care, existing models of service delivery, the availability, and skills of unpaid caregivers.
Demographic trends including slowed fertility, the killing of the middle generation by HIV/AIDS and an aging population have led to a “care deficit” for the young and old. Those who fill this care deficit are often women, and in many cases, older women (Schatz and Seeley, 2015). As reported elsewhere, 60% of AIDS orphans in Zimbabwe, South Africa, and Namibia live with grandparents (Apt, 2012). The majority of South African HIV caregivers in one study were female (68%); of these, 23% were 60+ (Steinberg et al., 2002). Therefore, age and gender come together to shape the experience of care.
Gender assists in the definition of how care is framed, who provides it and how it is experienced. In other words, gender determines who gives care and who receives the same (Schatz and Seeley, 2015). In East and Southern Africa, both men and women live with impacts of the care deficit. However, sexual division of labor has meant women predominantly fill the void in care (Oppong, 2006). Cultural beliefs about “maternal instinct” and men’s “natural” roles as breadwinners have led to assumptions that women are better suited to the daily care of the young, old, and sick, while men are supposed to provide financial assistance.
For example, women (and men) may see care for an aging or sick husband as a continuation of “wifely duties.” Likewise, caring for the young or sick may not be reported as care work, as it fulfills routine family expectations and obligations (Schatz and Seeley, 2015). On the other hand, men’s physical and emotional care work is often more visible. Because men’s care work is further outside men’s normative familial roles, it is more likely to be perceived as care work and reported as such.
The Westernization and/or modernization of our society has resulted in the challenge of caring for older people. With the increasing rate of population aging and increased life expectancy, the need for institutional homes may be required as a supportive measure. The upsurge in need for an institutional support system for older adults in Ghana is becoming imperative due to their inability to care for themselves, loneliness due to the loss of family relations including social change, the lack of spouses and children, modernization, urbanization, migration, multiple careers including busy work schedules. These factors have all made care for older people an impending challenge. Older people take up residence in institutions. This implies that social care even in a number of Western countries is means tested, which is a key issue going forward (e.g., responsible for a considerable amount of bed blocking in UK hospitals) (Robertson et al., 2014), whereas in developing countries such as Ghana, it is not means tested as yet, perhaps because state institutional homes are non-existent. Besides, older adults requiring care are still looked after within the informal structure of the family (Apt, 2012) in some LMICs.
There is also an increase in the number of neglected, abused, and abandoned older adults. Further, the modern economic system has projected old age as a social problem. In developed countries, when older people become handicapped by virtue of illness and disability, they take up residence in institutional homes. However, such facilities are not extensively provided in developing countries. As a result, older people are cared for at home. The situation may be different in the near future, necessitating taking refuge in institutional homes. These homes may be classified as formal and informal, which may draw on paid and unpaid labor (Daly et al., 2015).
Relocation adjustment in nursing homes Lee (2010) purports predictors such as self-efficacy, self-reported health, preconception about nursing homes, emotional support from staff and other residents, family satisfaction and general satisfaction with the facility in question. Nursing homes are a relatively new phenomenon in the Ghanaian context. People do not cope or adjust to aging or old age in isolation. Instead, they do so in the company of others who provide social and emotional support. This may depend on the financial independence and sacrificial investments in their children, who may become adults with the moral duty to support their aged parents (Doh et al., 2014; Dovie, 2018a). This implies that prior lifestyle determines to a great extent the quality of care and support older adults are accorded, and when it becomes inevitable for them to depend on others.
There exists universal healthcare (such as in South Africa and countries such as Namibia), where elements are free such as in government/faith hospitals and facilities, and the extent of co-pay afterward (Ataguba and Akabili, 2010). Ghana operates the National Health Insurance Scheme (NHIS) to provide citizens with health insurance. The level of premiums citizens must pay varies according to their level of income. Elements are free particularly for people aged 70+ (Dovie, 2018b, in press), which is a reflection of discrimination even among older adult members. Also, Ghana still has a high burden of infectious diseases and a very growing burden of non-communicable diseases (NCDs) including hypertension, diabetes, and stroke (De-Graft Aikins and Apt, 2016) that must also be tackled within available resources. In other words, “the NHIS prescribes the same basic healthcare without taking into consideration the tertiary healthcare needs of older people especially in the area of non-communicable diseases, such as retention of urine, incontinence, prostrate and colon cancers” (van der Geest, 2016, p. 11).
De-Graft Aikins et al. (2016) posit that research on aging in Ghana has focused on six empirical areas: demographic profiles and patterns of aging; the health status (physical, mental, and sexual) of older adults; care and support for older adults; roles and responsibilities of older adults; social representations of aging and social responses to older adults; and socio-economic status, social and financial protection and other forms of support for older adults. This study falls within the care and support for older adults’ framework. Yet, few investigations or little work has been done on geriatric care and institutional homes and adjustment to it in Ghana. Hence, the paper seeks to address the following research questions: How can geriatric care be improved on to ensure adequate related care in Ghana? What has been the evolutionary pattern of institutional homes in Ghana? To what extent do older adults adjust to old age by living in institutional homes? The first and second questions were addressed using qualitative interview data while the third was answered with a combination of quantitative and qualitative data. It is noteworthy that for this paper, institutional home, and nursing homes are used interchangeably.
Materials and Methods
The research project began with some concerns and questions about older adults and care system in Ghana. The study used quantitative and qualitative datasets and a cross-sectional design to investigate the healthcare and social care pillars of aging social policy and how these shape inequalities in health and well-being. Use was made of in-depth interviews to explore geriatric care dynamics, while the questionnaire survey provided the necessary data for the development of an understanding of Ghana’s repertoire of institutional care homes including qualitative interview data obtained from medical doctors, nurses, near old workers, and retirees.
Site Selection
Accra and Tema were chosen as the study sites because they are typical of major African cities that are privy to extended family support system and associated issues, hence their selection. They were also chosen because they depict the epitome of an urban setting which articulates the deepened prongs of individualization and the reality of the weakened nature of the extended family support mechanism. Also, they present a web of social relations, occupational diversity, a variety of activities as well as various events over time that provides richer and more interesting data (Ghanaweb, 2015), and suitability.
Sample Selection and Recruitment
The study adopted the simple random sampling technique in selecting the respondents. This technique of sampling was used in this research project for two reasons. First, almost old and older adults are a distinct group of study participants. Second, the study purports to identify particular types of cases for in-depth investigation (Neuman, 2004). For the quantitative data, 230 workers in the near old age category and retirees took part in the study. In the case of the qualitative data, 16 in-depth interviews were conducted with a section of individuals with the requisite information. The sampling process entailed the random sampling of working individuals aged 50–59 years (50) in the Tema Metropolis based on a list obtained from Tema Development Corporation. People aged 60+ years (180) were selected using a list obtained from the National Pensioners’ Association in Accra and Tema. The samples were selected from a total population of 364 and 700+ respectively. The sample size was calculated using the following formula: n = 2(Za+Z1–β)2σ2/Δ2, with a power of 80% and constant of 1.65 and a p < 0.05 (Kadam and Bhalerao, 2010).
Therefore, 270 questionnaires were given out, and 230 were returned. Although the sample size was constrained by resources, 230 observations were selected as adequate for the study. The sample is large enough to help address the research questions accurately. The study also sought to explore the association between living in institutional homes and adjustment to old age based on sex. The usage of the simple random sampling technique means the results are statistically representative and to the general population. Thus, generalizability to the general population is permissible.
Research Instruments
Questionnaire
A questionnaire containing three sections was used in data collection. Section one was on the socio-demographic characteristics namely age, educational level, and ethnicity. The second section explored issues of geriatric concern. Section three comprised social care dynamics were measured with 5-point verbalized scale from “‘extremely associated” to “not at all associated.” The questionnaire was created based on previous research, input from colleagues and also the study’s research interests. Examples of questions that have been previously used in published studies include questions about the perceived older adult care (i.e., relational needs, care homes, and geriatric training) (Frost et al., 2015; WHO, 2017a; Dovie et al., 2018). After the initial pool of questionnaire was written, qualified experts were made to review it, especially for grammatical corrections and accuracy. Before conducting a pilot of the questionnaire on the intended respondents, it was tested on a small sample of 30 individuals following the guidelines of Perneger et al. (2015). Afterward, a pilot test among the intended respondents for initials validation was undertaken. All participants completed the same questionnaire.
Together these were collectively contextualized to fit this study and the Ghanaian scenario. The survey questionnaire instrument’s reliability was ensured in diverse ways, namely, facilitation by clear instructions and wording of questions. The questionnaire contained standardized instructions namely “please tick where appropriate.” Also, trait sources of error were minimized through interviewing respondents at their convenience. To attain this, interview appointments were scheduled severally. The validity of the survey data was attained following Nardi’s (2006) guidelines. The validity of the data was obtained from face-to-face interviews. Also, the survey sought an alternative source for confirmation through further in-depth interviews.
The administration of the questionnaire took the form of face-to-face interviews including self-administration. The face-to-face interviews were conducted in both English language and Ghanaian languages namely Ga, Ewe, and Twi.
Interviews
The sample for the qualitative phase was selected from that used in the quantitative phase as well as other stakeholders—physicians, nurses, social workers, etc. utilizing the purposive sampling technique. Purposive sampling was used for diverse reasons including its importance in the selection of participants who had specific characteristics such as sources of information. The 16 participants were divided into the three planned interviews based on their convenience (i.e., participants’ preference of time and location). Participants were excluded if they were younger than 50 years. The interviews were conducted in February 2017, ~2 months after completion of the questionnaire. The interview themes that emerged were related to the perception of geriatric care training, the emergence of institutional care homes, and suggestions for future studies.
The interviews were designed to gain an understanding of older adults’ perceptions regarding geriatric care and social care dimensions of aging policy. The interviews focused on geriatric care and aspects of institutional care. The interviews lasted ~45 min. Initially, the researcher reminded participants about the aim of the study and that the discussion would be used to suggest future directions.
Each in-depth interview took the form of a semi-structured interview and was conducted individually in the participant’s office or chosen place. The interviews were audio-taped. Face-to-face interviews are endowed with the merit of providing pertinent information while allowing the researcher the opportunity to control the line of questioning (Neuman, 2004).
Data Analysis
Methodological triangulation was deployed to include the combination of methods to understand and explain (Greenstein et al., 2003) geriatric and institutional care. The answered questionnaire were cleaned and serialized for easy identification. The survey data were entered into Statistical Package for Social Science (SPSS) and were analyzed with selected descriptive statistics namely frequencies, percentages, Chi-square statistics, and Cramer’s V test.
Transcripts from the interviews were subjected to thematic analysis. Thematic analysis entails the process of encoding qualitative as well as textual information. Despite the strict procedural nature of coding and themes that emerged from constant immersion with qualitative data, Joffe and Yardley (2004) contend that thematic analysis is more exploratory. For the interviews, data analysis was first conducted by the researcher and subsequently by an independent researcher with experience in qualitative data analysis to increase confirmability and dependability. Both researchers ensured dependability by keeping a coding manual, which entailed original extracts from the interviews and definitions of the emergent themes (Johnstone, 2006). Inductive thematic analysis using NVivo10 software was undertaken (Bazeley and Jackson, 2014). Each of the researchers read the scripts in detail, and then individually coded and categorized data from the same interview. Data from the interviews were coded by the researchers and across the entire interview data capturing diverse views. Through comparison, constant refining resulted in a list of themes (e.g., geriatric care challenges, steps in comprehensive geriatric assessment, archetypes of institutional homes in Ghana, institutional residence for older adults, adjustment to old age homes, the aging policy) with their importance determined by frequency, multiplicity of participants’ views as well as uniqueness.
Results
Socio-Demographic Characteristics of Respondents
The study population consisted of males (47.3%) and females (52.8%) aged between 50+ years (Table 1). The respondents (58%) were married. Most of the respondents had some level of education. On the whole, the highest educational level attained by the majority of the respondents (80.3%) was tertiary education. The discussion above shows that the sample is composed of high proportions of university graduates. Some of them are engaged in paid work (51.3%).
