Assessment of facilities and reasons for settlement in old age homes of Himachal Pradesh, India

INTRODUCTION

Ageing is a natural, normal and inevitable biological phenomenon.¹ Chronological age of 65 years has been accepted as a definition of ‘elderly’ or older person by the most of the developed world countries. ‘Senior citizen’ or ‘elderly’ is a person who is of age 60 years or above as defined by ‘National Policy on Older Persons’ by Government of India.² The world’s population is ageing and key demographic changes such as declining fertility, reduction in mortality and increasing survival at older ages contribute to population ageing. The demographic transition gives rise to increasing bulge in older cohorts, compared to younger cohorts and this proportion is projected to increase to about 22% by 2050.³ The elderly population in India is also projected to climb dramatically up to 19% by 2050. Undoubtedly, therefore, relatively young India today will turn into a rapidly ageing society.⁴ The number of people aged 80 years or over, the “oldest-old” persons is growing even faster. Women are outliving men leading to feminising of elderly population.^2,3

The state of Himachal Pradesh has also been affected by this transition and has 7 lac elderly people, constituting 10.2% of its total population, which is higher than the national average.⁵ With a good family tradition in Himachal Pradesh, elderly play an important role in decision-making, participate in social affairs but industrialization, urbanization, education and exposure to life styles is bringing changes in the family values. About 12% of the elderly have reported experiencing some form of abuse and 8% of the elderly live alone.⁵

The older persons without family support are more vulnerable and need institutional care as the last resort when personal circumstances are such that their stay in old age homes becomes absolutely necessary.⁶ "Old age homes" or the homes for the aged a western concept are totally alien to the Indian people. With the increasing elder’s population, the number of persons in OAHs is also increasing. In Himachal Pradesh first OAH was started in 1963 and now there are seven old age homes.^7,8 NGOs run the old-age home industry which is mostly unregulated. Often institutionalization itself becomes the underlying cause of ill health. Adjustment in new environment has been conceived as a problem for elderly living in old age home. Vulnerability to morbidities increases which in turn reduce the quality of life (QOL). Good facilities and age friendly environment give a sense of satisfaction which improves QOL also.⁹

With strong family tradition and where old age home settlement is a stigma in the state it is very important to know the reasons for living in OAHs which also gives reflection of degrading family values. Keeping all these considerations in mind, the present study was designed and conducted with objectives to assess reasons for settlement, evaluation of facilities available in such institutions and determination of satisfaction level among inmates living in the old age homes of Himachal Pradesh.

METHODS

It was a descriptive cross sectional study conducted in all the seven old age homes in Himachal Pradesh, a hilly state located in the northern part of India. According to 2011 census, the elderly population in the state was 703,009 in 2011, which was about 10% of state’s total population.⁵ There were six government aided old age homes giving free facilities and one private old age home giving pay and stay type of facility.⁸ The study population comprised of all the elderly people living in all the old age homes who are ≥60 of age and who gave consent for the study participation. Universal sampling was done while conducting the study. Sampling unit was elderly residing in old age home. The study was conducted for a period of one year from October, 2016 to September, 2017.

Selection criteria

Elderly people ≥60 years who were residing in old age home for ≥6 months and those having a score of ≥20 on mini mental state examination (MMSE) along with willingness to participate in study were included while the severely ill, bedridden, audio-visually impaired, mentally retarded elderly were excluded.

Methodology

List of old age homes was obtained from Department of Social Justice and Empowerment, Himachal Pradesh. Written permission was taken from trusty/warden of these old age homes to carry out the study. Written informed consent was taken from the inmates after explaining them about the study in Hindi or their local language and also assuring them of confidentiality of their identity. Adequate opportunities were given for discussion on any of their questions about the study. Anonymous questionnaires were used for data collection. Individuals were interviewed and examined in separate room. For assessment of facilities in OAHs inmates were asked to rate the following services: food, medical service, recreational facilities, safety, space and staff availability on Likert five point (1-5) scale separately ranging from very poor to very good. After that individuals were divided in two groups (below average and average and above).

Study tool

Translated Hindi version of mini mental state examination (MMSE) developed by Folstien et al was used to assess the cognitive function.^10,11 The domains assessed were orientation to time and place (10 points), registration of three words (3 points), attention and calculation (5 points), recall of three words (3 points), language (8 points) and visual construction (1 point). The elderly who scored more than 20 points were included in the study. In addition, structured questionnaires were used for collecting information on socio-demographic characteristics, reasons for living in OAHs and facilities provided in OAHs.

Ethical considerations

Prior permission was taken from Institute Ethical Committee to go ahead with the study. A written informed consent was taken from each participant after explaining the full purpose of the study in local language. Participants were fully assured regarding the confidentiality and anonymity of the information provided by them.

Statistical analysis

The data collected was entered on Microsoft Excel spreadsheet. Data was analyzed by using Epi Info version 7.2 utilizing relevant statistical tests. Proportion, mean, standard deviation and standard error were calculated.

RESULTS

After assessing for eligibility criteria, a total of 145 inmates were included in the study; about 44.1% were males and 55.9% were females. The mean age of males and females was 70.9±6.5 and 74.4±7.7 respectively. About 48.3% of elderly were in the age group old-old (70-79). Most of respondents (86.2%) belonged to rural area before coming to old age homes. Most of the inmates (75.9%) were Hindu by religion. Three fourth of the elderly were illiterate and most of them were females. About half (44.1%) were homemakers before coming to old age homes followed by (22.8%) inmates worked as labourers. Only 9% elderly were retired from government jobs. About half of the inmates (53.8%) had no children. Most of the inmates were living alone before old age home settlement. About one third of children visited their parents frequently (Table 1).

About half of the elderly (45.5%) were widowed/widowers followed by (26.9%) divorced and (23.4%) were unmarried. Only (4.1%) of elderly were currently married. (64.1%) of the inmates were getting old age pension, (19.3%) had no source of income and (15.9%) were government pensioners (Figure 1).

Regarding reasons for settlement in the OAH, about 60.7% responded with only one reason for settlement in OAH while about 39.3% stated two or more reasons. The present study revealed that most common reason (66.9%) for the elderly for old age settlement was no care giver followed by self-satisfaction (31%). Other reasons for old age home settlement were no money to support self, for independence, misbehave by son or daughter in law etc.

Among young-old and old-old group, no care giver was the main reason for settlement in old age homes. Among males the main reason for old age home settlement was no care giver (78.1%), no money to support among (35.9%) male subjects. No care giver was the main reason for OAH settlement in illiterate and education below graduation. Among participants with education level graduation and above, the main reasons were self-satisfaction and for independence.

No care giver (58.0%) was also the main cause for going into OAH among females followed by self-satisfaction (39.5%). No care giver in was the main cause given by widower, divorcees and unmarried inmates. Only (5%) reported that they were misbehaved by son or daughter in law. The inmates who had no children also gave no care giver as main reason followed by no money to support self. Inmates, who had only daughters, gave self-satisfaction as the main reason. No care giver in the family is the main reason for OAH settlement in both partially dependent (67.3%) and totally dependent categories (75.0%). In economically independent elderly self-satisfaction was the main reason (33.3%).

It was observed that all the old age homes were being provided funds for maintaining certain minimum standards with regards to accommodation, food, clothing and bedding. In medical care regular health checkup, medicines and referral services have to be provided. They also have to provide indoor and outdoor recreational facilities.¹² All the old age homes were connected to roads. Only (42.9%) had own buildings. All had separate room for kitchen and separate toilets for males and females. Half of the OAH were having dining room and area for worshiping. Most of them had dormitories for sleeping with adequate lighting and ventilation. Overcrowding was present in (57.1%) OAHs. Facilities for couples were present in only in (28.6%) old age homes (Table 2).

Staff availability was as per guidelines in almost all the OAHs. Facilities for food, clothing, and bedding were present in most of the OAH. Most of the OAHs had television, newspaper and library facility. About half of OAHs were carrying out religious activities. Only one old age home was carrying out income generating activities (Table 3).

No OAH had full time doctor; most of them had part time doctor with regular visits in half of the OAHs. Yoga and meditation was being done only in one OAH. Ambulance facility was present only in one old age home (Table 4).

When enquired about satisfaction with facilities like food, medical service, recreational facilities, safety, space and staff availability, (85.5%) inmates were of the opinion that facilities were average and above in the old age homes (Figure 2).

DISCUSSION

Out of 145 respondents, most of the respondents (55.9%) were females. The mean age of females (74.4±7.7) was more than that of males (70.9±6.5). This is in keeping with the observations made by Asadullah et al in a study done in 2011 in Karnataka.¹³ Almost half of elderly were in the age group old-old (70-79), which is in accordance with the results of a study done by Modiwala et al in Indore.¹⁴ In the old-old and oldest-old group females were outnumbering the males in this study which is similar to study done by UNFPA in Himachal Pradesh, suggesting feminization of ageing.¹⁵ Most of respondents belonged to rural area before coming to old age homes.

Similar results were observed in the study done by Isha in Punjab where 65.6% inmates belonged to rural area.¹⁶ About half of the elderly (45.5%) were widowed/widowers followed by (26.9%) divorced and (23.4%) were unmarried. Only (4.1%) of elderly were currently married. Similar results were observed in study by Modiwala et al in Indore and in a study by Rani et al in Chennai in 2004.^14,17 Three fourth of the elderly were illiterate indicating poor level of literacy. Only (8.3%) were having education up to graduation and above. Majority (90.1%) of the females were illiterate. In a similar study done by Panigrahi et al in Odisha in 2012, it was observed that (58%) of inmates were having no education and (76.9%) of the females were illiterate.¹⁸ About half (44.1%) were homemakers before coming to old age homes followed by (22.8%) inmates working as labourers. Only (9%) elderly were involved in government jobs. Three fourth of the females were homemakers before joining old age homes as they were housewives. Results of the study done by Akbar et al in Lukhnow revealed that (70.7%) of the elderly were involved in household and unskilled work. (90%) of the elderly females were homemakers.¹⁹

The present study showed that source of income after coming to old age homes for most of the inmates (64.1%) was old age pension, (19.3%) had no source of income and (15.9%) were government pensioners. In contrary to present study, only (22%) were getting old age pension in old age homes of Odisha.¹⁸ This may be due to better awareness of inmates and good governess in Himachal Pradesh. Majority of the inmates (69.7%) were partially dependent on others for fulfilling their basic needs, (22.1%) were fully dependent and only 12 (8.2%) were independent. Almost similar distribution was observed in the study in Lukhnow by Abhishek et al.⁹ Half of the inmates (53.8%) had no children and (46.2%) had one or more children. Majority of males were not survived by any child (60.9%). Results were consistent with the study by Panigrahi et al where (60%) elderly had no children.¹⁸ Contrary to this, in the study by Asdullah et al, in Karnataka it was seen that (61%) inmates had children.¹³ This may be due to the fact that there is still strong family tradition in Himachal Pradesh.

Majority of the elderly inmates (60.7%) were living alone before coming to old age homes followed by (18.6%) were living with children only and (17.9%) were living with others. Distribution was similar in the study by Modiwala et al, where (83%) were alone and also in the study by Panigrahi et al, it was observed that (50%) elderly were living alone. In general population of Himachal Pradesh (7%) of the elderly live alone as per census 2011 and Study by UNFPA which is increasing and this may be a reason behind the larger proportion of elderly living in the old age homes were living alone. Out of 67 elderly who had children; (41%) were visited regularly and (23%) were not visited. Most of the inmates (87.6%) were never visited by their relatives and no one was visited by their friends. However the study by Asdullah et al showed that most of the inmates were visited by children. The present study revealed that most (66.9%) of elderly were in OAH because of no care giver, about one third (31.0%) for self-satisfaction and 39 (26.9%) had no money to support him/herself. Among young-old and old-old group, no care giver was the main reason for settlement in old age homes. In a study in Punjab by Jasmeet et al (68.20%) did not have anyone to look after them.²⁰

CONCLUSION

No care giver and no money to support self were the main reasons for old age home settlement given by most of the inmates. Family conflicts as a reason was stated only by a few inmates. Only half of the old age homes had infrastructure and living conditions as per guidelines by Department of Social Justice and Empowerment, Himachal Pradesh. Most of the OAHs had staff availability, food, clothing and bedding as per guidelines. Some facilities for recreational activities were also present in most of the OAHs. All OAHs had part time doctors. No OAH had physiotherapist. Health checkups were not at regular intervals in most of the old age homes. Yoga and meditation facilities were available only in a few OAH. But most of the inmates were satisfied with the facilities available. Most of the inmates rated the facilities as average and above.

Keeping the results in consideration, it is recommended that as the number of elderly females is also increasing in OAHs, so the living arrangements should be such which can maintain dignity and privacy of the female inmates. Increase in pension should be based on market inflation rates. The state should be prepared to meet the need for good institutional living arrangement for the elderly as the demand for such care is likely to rise in near future. Regular medical checkups should be made mandatory. Screening and counselling services should be started. Elderly should be educated about the concept of healthy ageing and life course approach. There is need to conduct further studies in similar settings involving some care interventions and their impact on quality of life of the elderly people.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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