Addressing Long Term Care for Nigeria’s Aging Population

Eniola Olubukola Cadmus is a lecturer at the University of Ibadan in Nigeria and CARTA PhD Fellow (Cohort 7) based at the University of Ibadan in Nigeria. CARTA+ (Consortium for Advanced Research Training in Africa+) is one of the eleven Developing Excellence, Leadership, and Training in Science in Africa (DELTAS Africa) programmes.  DELTAS Africa funds Africa-based scientists to amplify the development of world-class research and scientific leadership on the continent while strengthening African institutions. DELTAS Africa is implemented through the Alliance for Accelerating Excellence in Science in Africa (AESA), a funding, agenda-setting, programme management initiative of the African Academy of Sciences (AAS) in partnership with the African Union Development Agency (AUDA-NEPAD) and with the support of Wellcome and the United Kingdom’s Department for International Development (DFID).

Summary

Eniola’s study reveals that long term care provisions for older persons in both rural and urban communities must preferably facilitate their ability to  ‘Age in Place’ within their homes or communities. Interestingly, older persons in this study did not outrightly reject institutionalization as a long term care option. Such arrangements, however, must cater to their basic needs and not interfere with their freedom, dignity and access to their family. Importantly, the respondents’ preferences for an age-friendly community aligned with the World Health Organization’s (WHO) recommendations. These include age-friendly housing, transport and recreational facilities.

Background

Aging Populations are an ongoing demographic trend with public health implications in many low- and middle- income countries (LMICs). According to the United Nations 2015 World Population Ageing report, there were at that time 900 million people aged 60 years and over, 46 million of whom were in Africa. By 2050, the number globally is expected to increase to over 2 billion by 2050, including 220 million in Africa.

Eastern Africa has the highest number of older persons, at 18.9 million, followed by Northern Africa (17.9 million) and Western Africa (16 million). About 5% of the 200 million persons in Nigeria, the most populous country in Africa, are aged 60 years and above. This number is projected to increase to about 25.3 million by 2050.

Aging is associated with functional decline and health and social support needs. Traditionally, the responsibility of providing long term care and support for older persons has been accepted by African families. However, modernisation, urbanisation and increased participation of women in the workforce has led to a reduction in available family primary caregivers for older people. Consequently, many families are either unable or unavailable to provide long term care and support for older people.

According to the WHO, long term care includes: “the series of activities undertaken by others to ensure that individuals at risk of significant loss or with ongoing loss of intrinsic capacity can maintain a level of functionality that is consistent with their basic rights, fundamental freedom, and human dignity.” Types of long term care provided vary and depend on the individual’s level of functional decline and disability. Institution-based care places the older person in a formalized care setting or arrangement; non-institution-based care supports the individual within the home or community.

Non-institutionalized long term care has evolved. Initially, the concept of “Aging in Place” focused on the preference of older persons to remain in their homes with care provided at the person’s residence without relocation of the individual to a residential facility. However, the definition has grown to include a wider scope of arrangements, such as retirement communities and assisted living facilities. The concept of  Aging in Place is particularly relevant in the traditional African setting where older persons tend to prefer to remain in their homes and familiar environments.

Description of study

This study describes and compares models for long term care and their associated factors for persons aged 60 years and above in selected rural and urban communities in Oyo State, Southwestern Nigeria. The research recognizes the evident shift away from the tradition of huge reliance on family to provide care for older people. The community-based, cross-sectional study was conducted with multiple methods in Oyo State, one of the 36 states in Southwestern Nigeria. The novelty of this study was to document the views of the end-users themselves. Also, the two study sites were chosen because they are under the purview of the Department of Community Medicine in the College of Medicine at the University of Ibadan and have been previously mapped and listed. Utilizing these sites for the study offers a unique opportunity for subsequent development and testing of interventions to suit the particular needs of older persons in the community.

Outcome of the study

The approach of the study was to acknowledge aging as a natural process in which individuals function at different levels. Some older people remain active and healthier for longer; support for those who are unable to care for themselves must be prioritized. Care and support for older persons in a traditional setting are expected from family, but the unavailability of this option is an ongoing trend. Solutions must be developed which account for the spectrum of care needs of older persons, ranging from independence to those who require total care.

For the first time, the preferences of older persons in Nigeria for long term care have been documented. A huge proportion of the respondents in both urban and rural communities desired to Age in Place. Those interviewed also provided valuable information about their priorities for features for the provision an of Age-friendly environment in both types of communities. Findings will inform long term care planning that is appropriate to a typical low resource setting where government support is sub-optimal. The next step is to transform these findings into actionable plans to serve the long term care needs of older persons in Nigeria and other low-resource settings.

Lessons

There are few services and little support dedicated to older persons in the country. Respondents saw no need to develop such services outside the family, which they expected to provide care. However, a majority of respondents recognised the difficulty for many families to serve this role and were open to the concept of institution-based long term care.

These findings provide insights on the impact of societal changes on older persons readiness to accept institutional care within the traditional African setting. In order to support long term care provisions by the family, much planning and resources are required for community-based interventions. Future research must inform the development of acceptable, affordable, and accessible long term care in the community as well as institutional settings.

Impact

This study provides evidence that while Aging in Place is preferred amongst Nigerians over 60, particularly those who participated, institutional care is not unwelcome. The study suggests that policymakers must provide long term care support for older persons in their own communities. Preferences expressed by older respondents are consistent with WHO guidelines for the Age-Friendly Community. However, even basic amenities are not broadly available at present in Nigeria. Much must be done to build the infrastructure necessary and to provide basics such as water, electricity, satisfactory sanitation, and age-appropriate transportation. Communities must be designed to include these and other long term care provisions for older persons with the involvement of families, the broader community, and with sufficient support of the government.