Elderly citizen’s perception of their health and care provided in a rural South African community
Abstract: A descriptive survey of 201 senior citizens, 55 years or older was conducted June 2001, using face-to-face interviews to establish a database. Structured tools were used to measure self appraisal of family stress, perceived social support, caregiver satisfaction and psychological health of family members and of themselves. Even though the senior citizens had survived past the estimated life expectancy, the quality of life has not improved significantly in the post-apartheid period.
Keywords: Database, senior citizens, South Africa, post-apartheid, health status.
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” Article 25, Universal Declaration of Human Rights.
In 1998, the 50th Anniversary of the Universal Declaration of Human Rights adoption by the UN General Assembly was celebrated. The population of South Africa at that time was 41,660,406 (Health Review 1999). Equity is an underlying principle for meeting the health care needs for all people; a theme recognized in the 1978 Alma Ata. The Alma Ata was based on a primary health care model, which addressed the total health care needs of all of the citizens including socio-cultural and economical conditions. A goal of the Alma Ata was an acceptable level of health care for all people by the year 2000. Primary health care focuses on all individuals from birth to death weather they are residing in rural or urban communities. (Health Review 1998). In South Africa an editorial called for research into the medical and social problems of aging as a priority problem. (JARD Sept/Oct. 1991).
Although South Africa was still being governed under the apartheid system, when the Alma Ata was adopted, it was noted that the health status of all people was a worthy goal. However, in 1991, the estimated life expectancy for South Africa was 63 years (Health Review 1998). The end of apartheid and a democratically elected government was first implemented in 1994, with the election and inauguration of President Nelson Mandela at 76 years of age, a senior citizen (Handbook 2000). Moller (1998) noted that South African elderly voted in record numbers during the nation’s first open general election and many of them had lived over half of their lives under the South African apartheid system. She indicated that: “Expectations were also raised that fulfillment of basic needs would follow. The new government had promised to introduce equality and a better life for all the country’s people”.
Wicht (1991) projected that South African elderly population will reach 4,858,200 by 2030 with many over 80 years of age. Whereas, according to AnneMarie Muth (1997) the life expectancy in South Africa for males and females since the end of apartheid is as follow:
1995 1996 2000 2010
Males 57.8 57.2 55.0 50.5
Females 62.4 61.8 59.0 53.4
Senior citizens of South Africa have lived through many political systems including apartheid (apartness), a form of segregation. The implementation of apartheid policies in 1948 was a mechanism for the promotion of economic and political separation of races. Black South African was a cheap laborer. Black Africans apparently adapted to the harsh treatments and adjusted to the conditions imposed upon them. Abdi (1999) research noted that this form of adaptation demonstrated the African concept of Ubuntu, which describes the African people as trusting and unsuspicious of strangers. They recognized that all people should be treated with full humanity and dignity that no one has a right to violate another person’s right.
Moller (1998) research sought to determine whether improvements in living conditions and equality had occurred for the elderly during the years of the post-apartheid era. She describes the living conditions, as harsh, especially for the majority of African elderly, who continues to reside in rural areas, seven years after liberation. Frequently, elderly females, residing in rural areas, are poor, pensioners, also heads of households, generally consisting of multigenerational living.
South African’s pension program is vastly different from the social security of the U.S. Duflo (2000) indicated that whites received pensions since the 1920’s. However, she described the pension system as racially discriminatory related to eligibility, amounts of benefits, and methods used for disbursements.
In a white paper (1997) discussing transformation of South Africa health system for over 40 million citizen, it was determined that disparities and inequalities were a result of the previous apartheid system. Inequalities were noted by racial groups, residential location, as well as by gender and age. Care of older persons was one of the goals cited. Identified was a need to improve knowledge of the health status of the elderly and their access to health services. A goal was to improve the quality of life of older persons. An objective was to increase accessibility to and availability of health services. Peter Barton, equity overview noted, “South Africa … remains a land of stark contrasts, between those that have and those that have not. A land where some people have amongst the best standards of living and good health and access to health services and care, and where some have a very poor living standards, a great deal of ill health and poor access to health care.” (Health Review 1998).
Administratively, South Africa is divided into nine regions or Provinces. There is a wide variation of socioeconomic levels and ethnic distributions in the regions. This project was conducted in a rural South Africa area, which is located in the North West Province, 53 km (approximately 35 miles) from the Medical University of South Africa (MEDUNSA), and 70 km. (approximately 44 miles) from Pretoria. The research team traveled 160 miles round trip per day, from our lodging site, in Pretoria, to the data collection site. The population of North West Province in 1997 was 3.61 millions while 4.6% of those residents were 65 years and older. The percentage of households with tap water in the homes in North West Province, in 1995 was only 37.3%, which was further reduced to 30.6% in 1996. In addition, it was noted that just 42.9% of household reported that they never go hungry. In 1991, in the North West Province, where the projected was conducted, the life expectancy was 59.7 years, the lowest of all nine South African Provinces. The highest for the entire country was 67.7 years in Western Cape Province. Further, as previously noted, since 1991 the life expectancy of the South African is going down and is projected to decrease even lower. (Health Review 1998).
Specific questions posed for this study were:
* What are the major identifying characteristics of the elderly study group?
* What were the major concerns in terms of family strain, social support, personal resources and stressful events ?
* Are any significant health risks exhibited among the elderly population?
STUDY DESIGN AND SAMPLE
A survey was conducted with elderly citizens in South Africa in June 2001. A convenient sample of 201 elderly members of a South African community provided information about various aspects of their health status, needs and other psychosocial aspects of their lives.
Prairie View A&M University and the Medical University of South Africa (MEDUNSA) Internal Review Board (IRB) Committees approved the study. After an explanation about the purpose of the study, a review of the consent form was initiated with each participant. The interviewer assured confidentiality of the information. Participants signed the consent form or made an “X” at the printed name. If the participant could not read or write the name was copied from official documents presented to the interviewer. If a participant could not speak English, an interpreter was used to complete the interview
Recruitment occurred through dissemination of information provided by the teachers to the elementary school students and by word of mouth. The structures self reported data was collected for the quantitative study using a written instrument. The interview schedule was administered in face-to-face oral interviews with respondents taking approximately 30-45 minutes to complete. An incentive payment of 50 Rands ($6.25) was given to each participant who completed the survey.
Demographic, social and health data was obtained from a structured questionnaire. Additionally several other, The Family Inventory of Life Events (FILE), Impact of Family Scale, The Social Support Inventory (SSI), the Personal Resource Questionnaire (PRQ), and the Center for Epidemiological Studies Depression Scale (CESD) were used and have been described previously in the overview. Finally, parts of The Primary Care Evaluation of Mental Disorders (PRIME-MD), the Patient Health Questionnaire (PHQ) was tested to determine if it is an effective tool, with this population and to test its correlation with the CESD. It asked questions concerning symptoms experienced over the past two or four weeks.
Descriptive statistics were used for demographic data summary. The Wilcoxon Rank statistics was used to test the difference of age between the males and females. Correlation analysis using Pearson and Spearman Coefficients were used to test the existence of a relationship between the seniors’ levels of satisfaction on the satisfaction and social support scales and their correlations with depression. T-test were used to test age variables between the males and females and the relationship between the senior’s levels of satisfaction and whether or not they were pensioners or not receiving a pension.
Demographics of the study group indicated the following results. There were 201 subjects consisting of 154 (76.6%) females and 47 (23.4%) males. The mean age was 67.7; while the oldest participant was 87 years, a female. The oldest male was 84 years old. Demographic characteristics from question one are summarized in table 1.
All of the research participants were black South African. They reported their ethnicity as predominately Tswana 162 (80.6%), although there are eleven official ethnic groups designated. Most of the participants were Protestants. The majority, 89 (44%) were married. There were 79 (40%) widowed; 29 (14%) were single and only 4 (.2%) said they were divorced. The predominate 94 (47%) educational level ranged from 3-6 grade; while 57 (28.5%) reported completion of grades 7-12. Only one participant had obtained a diploma.
Eighty-six percent (68) of the participants were pensioners; while only four (5.1%) reported their occupation as laborer. There was one person who identified herself as a nurse. Subsequently, 133 of the participants reported that they were not receiving governmental pensions. The pensioners had a greater level of satisfaction; at least they had a small amount of income.
The most prevalent physical disorder was high blood pressure 68 (32.4%), arthritis 23 (11%), diabetes 12 (5.7% and back pains 11 (5.2%). Of the population, 44 (20.8%) stated that they were healthy and most were involved in family or church related activities. The majority 131 used the public clinic for health care. Only 22 reported having been hospitalized within the last three months. Whereas, 85 reported having consulted a doctor within the last three months because of illness. A follow-up question asked, “where do you receive health care” 96.3% reported at the clinic.
Even though, the community based clinic is a nurse-managed clinic and most of the respondents receive their care from the clinic, when asked: “from whom do you receive care”? Most of the participants said the doctor (65.5%); four reported care was received from the traditional healer. When asked, “do you go for regular routine care” 119 (59.2%) reported no. In response to the question: “how do you travel to the clinic or doctor’s office for routine care?” A total of 124 (95.4% reported that they walk to the health care site. In response to the question: “are you pleased with the health care received?” Ninety-six (96) responded yes.
For the question, “what is the one most important thing that you need that is not available to you” the responses were money 79 (31.1%); food 43 (16.9%); house 34 (13.4%) and refrigerator 15 (5.9%). When asked: “are there any things that you anticipate needing in the future?” The responses were: money 33 (28%), food 15 (12.7%), house 11 (9.3%,) clothes 9 (7.6%) and blankets 6 (5.1%). Most participants did not have city water supply-piped into their home, although many had, a faucet located in the yard or shared an outdoor faucet. Participants used wood or coal-burning stoves and some reported that they used paraffin (wax) burning stove.
Findings for question two are assessed in the Family Life Changes, and Intra-Family Strains questions. Many of the senior citizens were providing care and financial support for grandchildren and often for the parents of the children. There was a significant correlation between support and satisfaction (r = .0001, p =.05). In some households, the parents of the children were in the urban areas either seeking employment or working, predominately in domestic or other low paying jobs. Therefore, the grandparents were caring for school aged children, which included food, clothing and paying school tees from their minimal pension. There was a significant correlation between satisfaction and depression (r = .0173, p =.05). Very few seniors admitted to family members with alcohol or drug abuse problems. No one admitted to problems with jail or juvenile detention; physical or sexual abuse; violence in the home or among family members.
Although the seniors were satisfied in their roles of caregivers for their grandchildren and/or their adult children, they frequently stated that not having enough finances to provide an adequate level of care did not provide satisfaction for them:-There was a significant correlation between depression and support (r = .0152, p =.05). Participants expressed satisfaction with the social support of residents of the community. Most senior had reared their own families within the community and therefore felt it to be a good place to raise their grandchildren.
Answers to the third question can be summarized from disclosures of physical problems and symptoms of depressions from the two depression scales. The CESD, a 20-item scale measured how the respondent felt within the past week. The level of significant was at 0.392. The PHQ asked if participants had been bothered with somatic complaints over the last four weeks and asked for symptoms experienced over the last two weeks. The third scale asked how much participants had been bothered during the last four weeks and questions for a history of physical abuse within the last year; the most stressful events currently; and medication taken for anxiety, depression or stress. Although there were some somatic complaints, most participants denied feeling depressed. The PHQ depression scale was significantly correlated (r = .057901, p =.05). In addition, there were significant correlations between the two scales, the CESD and the PHQ at (r = .0001, p = .05).
The population of senior citizens exceeded the life expectancy identified by Muth (1997) for South African. Mean age for the cohort was 67.70. A majority, 162 (80.6%) identified themselves as members of the Tswana ethnic group. The predominate religious affiliations were Lutheran.
The participants were all residing in a rural community and they were poor. Today, most (75%) of the poor reside in rural and/or former homelands. These people are more disadvantaged than those living in urban areas. In the rural area, most (80%) of the poor did not have piped water to their homes, lacked adequate sanitation or had no modern toilets (90%) and did not have electricity (85%). Kirigia (2000) noted that the investigation of toilet ownership was one of the objectives of the post-apartheid government. Their goal was to increase to 80% the numbers of people with access to basic needs such as sanitation, water, shelter and safe food through public policy initiatives. The infrastructure such a adequate roads, electric, schools, and other amenities are missing in the rural areas, often because of the low socioeconomic population residing in the area and because of a lack of governmental resource allocations, and public policies resulting from apartheid.
Most (133) of the participants stated that they were not receiving a pension. Although according to Duflo (May 2000) this inequality should be changing. The survey did not substantiate this change. Many of the children were living with the grandparents. Of the pensioners, most were sharing their limited income with their own children and/or their grandchildren and frequently, they were the only source of household income according to findings (Moller, 1996). This study supported these findings.
Many senior citizens reported that they were not receiving pensions because of the inability to travel to the required site for the application process. Additionally, there were widespread reports of robbery at the distribution sites, and it was further noted that senior citizens were distrustful of the banks or had no accounts for direct deposits. Finally, it was determined that in many rural areas there were limited or no infrastructures for safe distributions of the social security checks.
In South Africa, nearly 95% of poor people were African. South Africa still had one of the worst records in terms of social indicators and income inequality. About half (44% of South Africans were poor. Unemployment was rife. Fewer than 30% of the poor working-age adults are working. Employment was not surprisingly, the major priority (57%) for the poor, followed by water (44%), food (34%), and housing (32%). These same indicators were also noted among the elderly participants, a primarily poor population.
The most frequent disclosures of somatic complaint and diseases were backaches, hypertension, arthritis and diabetes. Visual observations indicated that most of the participants appeared healthy and only a few were using devices to aide walking, such as a cane; no one was in a wheelchair or ambulating with a walker. The most frequent anomaly noted was severe dental caries; very few seniors wore glasses and no one reported using a hearing aide. Depression was denied by most of the seniors. Most indicated that they had an adequate sense of belonging and were especially supportive of the rural community and their families’ members and friends. Hagerty (1999) seems to suggest that often depression is directly linked to lack of social support and a lack of a sense of belonging in addition to loneliness.
The elderly predominately reported that they walked to the clinic for treatment. There is the sparse availability of health care providers and an inadequate health care infrastructure, in this rural community. There was one nurse-managed clinic for the provision of services, no local hospital and only a few physicians. Additionally, public transportation was absent.
Equity has not yet been achieved in this one rural South African community. This study was limited in that it included predominately black South African from one rural geographic area.
Findings supported previous studies, especially in relationship to needed resources such as food, shelter and water. The primary health care model is being implemented through the services of a community-based nurse managed clinic. However, the resources allocated are inadequate. Policy changes are slow in the seven years post apartheid, many of the inequities and deficits remain. The ramifications of apartheid are evidence with the senior citizens interviewed. Although they have survived past the life expectancy for black South Africans, their quality of life needs improvement.
A majority of the residents interviewed did not have an adequate standard of living. Although eligible for the pension, many were not receiving these meager benefits. Inadequate financial resources was identified as the primary stressor for these seniors, while a majority of them were the primary provider for their grandchildren. All were very poor. Disparities as found by Moller (1996,1998) were noted not only in standards of living, but also in availability of community resources. The seniors identified a need for basics such as food, water and shelter.
Recommendations for future research include replication of the database study to include comparisons with other rural South African communities. Recommendations for practice include providing exposure of nursing students to rural communities and including gerontology in the nursing curriculum. Additional research among the black elderly population is needed. There is a need for effective policy development to help alleviate disparities among the black South African elderly. The development of employment opportunities for parents and family members are critical.
Table 1. Frequency Distribution: Age/Sex/Number/Percentage
Age Gender/Frequency Percent
Numbers Perentage Female (Male) Female (Male)
55-59 31 (15.4) 24 (7) 15.6 (14.9)
60-69 91 (45.3) 73 (18) 47.4 (38.3)
70-79 62 (30.8) 45 (17) 29.2 (36.2)
80+ 17 (8.5) 12 (5) 7.8 (10.6)
The authors thank Dr. Beverly McElmurry at the University of Illinois at Chicago for funding this project. Special appreciation to Dr. Juanita Fleming from the University of Kentucky for her special leadership and expertise as a researcher.
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Dollie Brathwaite, RN, PhD, is a professor at Prairie View A&M University, College of Nursing, Houston Texas. Sophie Mogotlane, RN, PhD, is dean/professor of Nursing at the Medical University of South Africa.
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