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A STUDY OF OLD AGE HOMES IN THE CARE OF THE ELDERLY IN GUJARAT

Project Report prepared by N.P. Das Urvi Shah

Population Research Centre Department of Statistics Faculty of Science M.S. University of Baroda

Baroda-390 002 December 2004

PROJECT TEAM

Dr. N.P. Das, Ph.D., D.P.S. Director

Research Investigator/Field Investigator

Saroj Bhavsar, M.Sc. Nitin H. Bhatt, M.A. Arvind J. Mistry, M.Sc.

Urvi Shah, M.Sc. Varsha Chitania, M.Sc., DCA Rajnikant M. Patel, M.Sc., MPS Nilam V. Panchal, M.A.

Computer Assistants

Varsha Chitania, M.Sc., DCA Mayank Ray, M.Sc., DCA Rupesh Shah, M.Sc. DCA

Secretarial Assistants

Y. N. Vaidya K.M. Upadhyay Bela Dalal

Alpana N. Parikh R.R. Mali (Driver) P.S. Vasava (Peon)

A STUDY OF OLD AGE HOMES IN THE CARE OF THE ELDERLY IN GUJARAT


INTRODUCTION The ageing of population is an obvious consequence of the process of demographic transition. While the countries of the west have already experienced and have planned for their elderly population, it is only in the last one and half decades that countries in Asia too are facing a steady growth of the elderly, as a result of the decline in fertility and mortality, better medical and health care and improvements in the overall quality of life of people. Within Asia, as India and China are the two largest countries in the region, it is expected that they would have a significant proportion of the worlds elderly because of their large population base. In fact, the situation in India presents two different scenarios with certain states grappling with curbing their high fertility rates while others, which have controlled high fertility rates, are already experiencing or are poised to experience an increase in their elderly population. There has been a progressive increase in both the number and proportion of the aged in India over time, particularly after 1951. Between 1901 and 1951, the proportion of population over age 60 increased marginally from 5 percent to 5.4 percent, while by 2001 this had increased to 7.0 percent. When changes in the decadal growth rate in the general population are compared with those for the elderly population, it is noted that the latter grew at a relatively much faster rate than the general population, since 1951. Furthermore, the decadal percent increase in the elderly population for the period 2001-2011 is likely to be more than double the rate of increase of the general population. The size of the elderly rose in absolute terms during the last century from 12 million in 1901 to approximately 71 million in 2001 and is likely to reach 113 million in 2016. Yet another feature of ageing in India is the fact that the proportion of elderly is much higher in the rural areas than in the urban areas. The sex-wise pattern of growth of elderly population reveals that the increase is greater among women in the recent past, which indicates that elderly women will outnumber elderly men in the future. There is therefore an urgent need to examine the various aspects of this new and fast growing population to ensure the design of appropriate policy and programmes directed to meet the varied needs of this vulnerable and dependent group. India, like many traditional societies, today faces a unique situation in providing care for its elderly as the existing old-age support structures in the form of family, kith and kin, are fast eroding and the elderly are ill-equipped to cope alone with their lives in the face of infirmity and disability. The onus of caring for the elderly is therefore now much more on the state than the family and will necessitate the creation of adequate institutional support. While the western

countries have a fairly well organised network of institutions for the care of the elderly, the growth and development of these facilities in India, which began as early as 1901, still remains inadequate. As per recent statistic, there are 1018 old age homes in India today. Out of these, 427 homes are free of cost while 153 old age homes are on pay and stay basis, 146 homes have both free as well as pay and stay facilities and detailed information is not available for 292 homes. A total of 371 old age homes all over the country are available for the sick and 118 homes are exclusive for women. A majority of the old age homes are concentrated in the developed states including Gujarat (Directory of Old Age Homes in India, Help Age India, 2002). The concern for the elderly in the country is reflected in the adoption of a recent National Policy on Older Persons in 1999, which has identified principal areas of intervention and action strategies. These include financial security for the elderly in the formal and informal sector, health care and nutrition, shelter and housing and development of trained manpower to meet the special health needs of the elderly. The construction of old age homes and multi-service centres for the elderly through special financial assistance to non-governmental organizations has also been articulated in the policy. However, few studies have been undertaken to document the condition of the elderly in the country and those living in old age homes (Dandekar, 1993, Das and Shah; 2001; GOI, 1991; 1998; 2000; Ranjan et al., 1999; Rao et al., 1982; Sharma, 1999; Sharma and Xenos, 1992; United Nations, 1987). In this context, the present study is an attempt to fill some of the gaps in the study of the elderly population and the existing institutional support available to them. The study was undertaken with the overall goal of understanding the existing institutional facilities available for the care of the elderly in the state of Gujarat and to obtain a perspective of the elderly on various aspects associated with institutional living. The specific objectives of the study are: 1. 2. 3. 4. To understand the functioning of the old age homes with regard to service provision To identify the various problems in ensuring the smooth functioning of the old age homes. To know the various health problems experienced by the elderly inmates and their management of the same. To know the opinion of the elderly inmates regarding the adequacy of facilities and services, their satisfaction and their views on such institutional living. DATA AND METHODS

For the present study, an effort was made to compile and update the list of existing old age homes in the state from various sources including from Department of Social Justice, Government of Gujarat and other NGOs. A list of 99 old age homes, located in various districts of Gujarat, formed the universe to draw a sample of institutions and the inmates residing in them, for the study. A sample of 25 old age homes were selected to represent government aided and NGO supported institutions, across the various regions of the state of Gujarat. Since the proportion of NGO supported homes was more than the government-aided homes, a larger number of the former type of institutions was selected. From each selected institute, approximately 9-10 inmates were selected from the list of inmates to represent the views of both men and women about institutional life and other issues. Thus, a total sample of 233 elderly inmates comprising elderly men (114) and elderly women (119) living in these 25 institutions was interviewed with a view to explore the physical and socio-emotional aspects associated with institutional living. In particular, interviews focussed on the reasons for choosing institutional living arrangements, the problems faced in such an arrangement, the type of accommodation, amount of money paid, if any, for accommodation and other services, and the various health problems/illnesses experienced by the elderly. Their satisfactions and dissatisfactions with the various services provided were also explored. An attempt was also made to understand the attitudes of the elderly towards institutional living versus familial living and whether they still consider, children (especially sons) as the main support for the aged in the context of changing familial values in India. Interviews were also held with the heads/managers of the institutes to obtain information on various aspects related to services provision (including health care) as well as to understand the type of problems faced by them in providing various services to the elderly, the available governmental support, the arrangements made by the institution so that the elderly can maintain contact with their children/family and the adequacy of infrastructural facilities to ensure appropriate service provision. Study Instruments Data were obtained using semi-structured interview schedules. Two types of schedules were used, namely, those for interviewing the elderly men and women and those for interviewing the managers of the selected old age homes, to obtain the requisite information on the above described aspects. RESULTS The results are presented in two sections. Section I deals with the analysis of data obtained from interviews with the managers of the 25 selected old age homes

while Section II presents the perspective of the selected elderly men and women living in these old age homes. I. Perspectives of Institutional Managers This section is based on interviews conducted with the managers/heads of the 25 old age homes selected for the study and deals with the facilities and services provided for the elderly, the adequacy of these facilities and the problems faced by them in service provision.

Characteristics of the Old Age Homes

An analysis of the characteristics of the old age homes such as year of establishment, type of institute, nature of management, source of funding and charges for service provision, presented in Table 1, reveals that 56 percent of the homes have been in existence for more than 15 years, one fifth had been established in the recent period i.e. less than five years and another 12 percent each have been in existence either for 6 to 10 years or 11 to 15 years. All the twenty-five homes are residential in nature and 7 of them (28 percent) are government aided, whereas the majority i.e. 18 do not have such assistance and
Table 1: Background Characteristics of the Old Age Homes in Gujarat, 2003 Background characteristics Years since establishment < 5 years 6-10 11-15 15+ Type of institute Day care Residential Others Whether Government aided Yes No Whether any government control/ supervision on the institution Yes No Source of funding Government Religious organization Individual donors Trust Number of institutions (in percent)

20.2 (5) 12.0 (3) 12.0 (3) 56.0 (14) 100.0 (25) 28.0 (7) 72.0 (18) 20.0 (5) 80.0 (20) 28.0 (7) 16.0 (4) 68.0 (17) 56.0 (14)

Person/Institution who established the Institute Trust Individual Religious organization Charges for service provision Free for all Free for those who cannot pay Subsidised payment Compulsory full payment for all Total

56.0 (14) 40.0 (10) 4.0 (1) 36.0 (9) 12.0 (3) 8.0 (2) 44.0 (11) 100.0 (25)

are entirely private in nature. Similarly 20 of the respondents reported that there is no government control or supervision on their functioning. Regarding the source of funding, multiple sources have been reported with the majority, (68 percent) reporting about individual donors followed by private trust (56 percent) as their source of funding while 28 percent have mentioned about government funding and 16 percent have reported about religious organization as a source of funding. Fourteen (56 percent) of the old age homes have been established by a trust, individuals had established 10 old age homes (40 percent) while only one had been established by a religious organization (Table 1). Finally an enquiry about charges which the elderly have to pay for their stay in these old age homes reveals that 36 percent (9 homes) do not charge anything, 12 percent (3 homes) reported that they do have a charge but provide free accommodation for those who are unable to make payment, 8 percent or two of the old age homes charge a nominal amount from the inmates as they are subsidized from their source of funding, but as high as 44 percent (11 homes) require compulsory, full payment from all those residing at the old age home.

Intake Capacity and Criteria for Admission


Information on the capacity of the selected old age homes for accommodating the elderly indicates that 6 old age homes may be considered small as their intake capacity does not exceed 25, two homes are large as they can provide accommodation to more than 100 elderly, 7 homes have a capacity ranging from 50 to 100 inmates and the remaining i.e. 10 institutions can accommodate between 26 and 50 elderly inmates (Table 2). With regard to the sex wise norms for accommodating the elderly, it can be noted from Table 2 that 60 percent (15 institutions) do not have any specific norms about the number of men and women to be admitted. Three of the homes have provision to accommodate equal numbers of men and women and three other institutes stated that they can accommodate more men than women, while one of them has provision for more women than men. Out of 25, three institutes are for single sex inmates, two are exclusively for women and

one for men only (Table 2). This indicates that almost all of the old age institutes studied have the provision to accommodate both men and women and only three institutes are exclusively for one sex only. Regarding the criterion for admitting an elderly person in the institute, 19 of the 25 homes studied admit persons who are at least 60 years old whereas 55 years is the minimum age criterion in the remaining 6 institutes (Table 2). Economic consideration is the other criterion considered before admitting an elderly inmate. In this regard, as can be noted from Table 2, 11 Heads/ Managers of old age homes have reported that they only admit those who are able to pay the required institutional charges whereas 4 institutes are essentially for those who are destitute, have no one to care for and, have no means of economic support. What is surprised to note from Table 2 is the criterion that the person must be able to take care of self (84 percent or 21 institutes) and that the person must be free from any diseases and must be in good physical and mental health (20 institutes). Discussion on this aspect with Heads of the institutes revealed that, as they are not equipped to look after ailing inmates. In fact, they reported that the

Table 2: Percentage Distribution of the Old Age Homes by their Intake Capacity,

Admission Criteria, Actual Strength and Requirement for such Homes Among the Elderly, Gujarat, 2003

Criteria Intake capacity of old age home Upto 25 inmates 26-50 51-100 100+ Norm to accommodate specific number of elderly men and women Only for men Only for women Equal numbers of both sex More men than women More women than men No specific norm Criteria for admitting an elderly person At least 55 years old At least 60 years old Able to take care of self Free from any diseases/No infectious diseases/good physical and mental health Able to pay institutional charges/ able to support self economically For those who are destitute/have no one to care for/have low income Religious affiliation Demand for accommodating the elderly in the home Unable to meet the demand Able to meet the demand Total number of elderly admitted in the home 25 or less 26-50

Number of institutions (in percent) 24.0 (6) 40.0 (10) 28.0 (7) 8.0 (2)

4.0 (1) 8.0 (2) 12.0 (3) 12.0 (3) 4.0 (1) 60.0 (15) 24.0 (6) 76.0 (19) 84.0 (21) 80.0 (20) 44.0 (11) 16.0 (4) 12.0 (3)

72.0 (18) 28.0 (7) Male 64.0 (16) 24.0 (6) Female 76.0 (19) 12.0 (3) Total 48.0 (12) 32.0 (8)

51-100 100+ None (No male/female inmate)

- (0) 4.0 (1) 8.0 (2)

8.0 (2) - (0) 4.0 (1)

16.0 (4) 4.0 (1) - (0)

old age homes do not have staff to even look after those elderly who may require hospitalization and in such circumstances the Heads are forced to ask family members to take the elderly away from the institute. The Heads of the institutes regretted that they could not admit any person who could not look after himself /herself but they were helpless to do anything as they did not have the required staff and other funds to look after ill inmates. It is also evident from Table 2 that religious affiliation is the other criterion reported from only three of the old age homes. The fact that there is a big demand for such old age homes is evident from Table 2, as 18 out of 25 Heads have reported that they are unable to meet the demand and some of them have a long waiting list of people seeking admission. Only 7 old age homes are able to meet the demand. Finally, Table 2 provides information about the actual numbers of men, women and total elderly living in the 25 selected institutes. As can be seen from Table 2, 48 percent of old age homes have twenty five or less elderly, 32 percent have between 26 and 50 elderly while the remaining i.e. 20 percent have more than fifty inmates. The sex wise pattern of distribution indicates that three fourths of the institutes have 25 or less women, 12 percent have 26 to 50 women, and 8 percent have between 51 and 100 women. One intuitional head has reported that they do not any women. On the other hand almost two thirds of the institutes have 25 or less men, about one-fourth have between 26 and 50 men and 4 percent have more than 100 men. Two of the institutional heads have reported that they do not have any men living in the old age home (Table 2).

Facilities and Service Provision


As all the old homes in the study are residential in nature they are expected to have all the facilities and services that are necessary for daily living. An assessment of these aspects, presented in Table 3, indicates that 92 percent (23 homes) of the old age homes have their own kitchen with cook and helpers, or rely on facility of the trust/hospital with which they are attached. Only two of the selected old age homes do not have kitchen facilities and inmates have to manage by eating food that is available outside. It may be noted that one of these homes has just been established and therefore does not have enough inmates while the other is used more like a destitute home and the elderly, many of whom work in the city come to the home only at night to sleep. The picture with regard to other facilities and services such as laundry, sweeping and mopping and cleaning of utensils, reveals that in many of the homes, staff that is employed by the institute does all these tasks. For example, laundry is done by paid staff of the institute in 11 homes, cleaning of utensils in 13 homes and 16 heads have reported that sweeping and mopping is done by staff employed for the purpose (Table 3). Of the remaining, eight heads of old age homes have reported that inmates wash their own clothes, 2 have reported about the provision of a washing machine whereas 4 have reported that

inmates use the facility of washer-man (dhobi). The cleaning of utensils and sweeping and mopping in some of the institutes is done by the elderly. As can be seen from Table 3, in 36 percent of the institutes (9 old age homes), the staff of the institute does the sweeping and mopping of the common Table 3: Percentage Distribution of Old Age Homes by Various Service Provision and Facilities, Gujarat, 2003 Services & Facilities Kitchen facility Own kitchen with cook and helpers Kitchen of main trust/hospital No kitchen facility Medical facility Full-time doctors Part-time doctors Hospital facility of trust No regular visit of doctor/no health facility Nursing staff Available Not available Laundry facility Washing machine Washer man (dhobi) Self (by inmates) Paid staff of institute Cleaning of utensils Done by paid staff of institute Done by paid staff partially (inmates are expected to clean utensils used by them for meals) No kitchen facility (eat out) Sweeping and Mopping Done by paid staff completely Done by paid staff partially (inmates are expected to clean their rooms) Provision of entertainment None Yes: TV/Radio Library Newspapers/Magazines Number of institutions (in percent) 80.0 (20) 12.0 (3) 8.0 (2) 20.0 (5) 24.0 (6) 20.0 (5) 36.0 (9) 28.0 (7) 72.0 (18) 8.0 (2) 16.0 (4) 32.0 (8) 44.0 (11) 52.0 (13) 40.0 (10) 8.0 (2) 64.0 (16) 36.0 (9) 16.0 (4) 84.0 (21) 95.2 (20) 52.4 (11) 47.6 (10)

Katha, bhajans and other


religious activities Trips to religious places such as Dakor, Ambaji, Shreenathji Movies/Picnics

57.1 (12) 66.7 (14) 9.5 (2) Contd. Number of institutions (in percent) 76.0 (19) 24.0 (6) 50.0 (3) 50.0 (3) 50.0 (3) 12.0 (3) 88.0 (22) 100.0 (22)

Services & Facilities Facilities for sports and games None Yes: Volley ball Carrom Playing cards Managing the death of an inmate

i) Experience of death of inmate

ii) Procedure followed in the event of death iii) Action taken if informed person does not come
Last rites performed by institute according to persons religion Not experienced such a situation Inform relatives/Inform referee mentioned on the application form

No inmate has died at the old age home Experienced deaths of inmates

90.9 (20) 9.1 (2)

areas whereas the inmates are expected to clean their own rooms. Similarly, in 40 percent (10 institutes) of the old age homes, the inmates are expected to clean the utensils they use for eating while the staff of the institute cleans the utensils used for cooking and preparing meals (Table 3). The picture with regard to medical facility indicates that 20 percent of the old age homes studied have access to hospital facility of the trust they are managed by, another 20 percent have full-time doctors and 24 percent (6 institutes) have parttime doctors. The remaining 36 percent (9 homes) do not have any health facility or regular visit of a doctor (Table 3). Managers of institutes, which did not have any medical facility, were therefore asked about the arrangements they made in the event that an inmate required medical attention. Some of the heads reported that they have contact with private doctors who are immediately called and others

stated that inmates have contact with their own doctors whom the institute would call if needed. Nursing staff is available in only seven of the old age homes studied which means that the majority do not have this facility making it difficult, as discussed earlier, to care for the sick or ailing elderly. The provision of facilities for recreation sports and games and entertainment was explored next. As can be seen from Table 3, 16 percent of the old age homes (4) do not have any facility for entertainment while as high as 76 percent (19) do not any facilities for sports and games. Institutes, which have facilities for entertainment, have indicated the availability of TV/radio (95 percent), library (52 percent), organizing trips to religious places (67 percent), organizing religious activities such as katha, bhajan (57 percent) and the availability of newspapers/magazines (48 percent). Regarding the availability of various facilities for sports, indicated by just 6 (24 percent) of the old age homes, three each have reported about the provision of games such as carrom, cards and volley ball (Table 3). Finally, Table 3 presents information regarding the management of death of an inmate. As can be noted, three of the managers reported that not a single person had died at the old age home since its establishment. When those who had experienced death of an inmate (22 institutes), were asked to state the procedure normally followed in the event of a death of an inmate, cent percent of the managers (22 institutes) stated that they informed the relatives or the referee mentioned on the application form. In the event the person informed did not come to claim the body, the last rites were performed by the institute according to the persons religion, as reported by 91 percent of managers (20) of the institutes, while the remaining two managers stated that they had not faced a situation where the informed persons had not come.

Financial, Infrastructural and other Problems Experienced In Management of Old Age Homes
The management and ensuring good service provision can be affected by inadequate staff, infrastructural facilities, funds and by the inter-personal relations among the inmates and between the managers and the inmates. Information was therefore sought from managers of the old age homes regarding the types of problems faced by them in ensuring smooth functioning of the institute. As can be noted from Table 4, two-fifths of the managers (10 institutes) have stated that they do not face any problems in providing various services in their old age homes, indicating that three fifths of them do face some problem. The various problems reported are inadequacy of staff (8 institutes), unable to provide care for those elderly requiring hospitalization reported by 4 institutional heads/managers and lack of discipline among inmates and their resentment in carrying out the tasks assigned to them (Table 4).

With regard to financial problems, 11 heads/managers of the selected institutes reported that they did not face any problem whereas an equal number stated that the grant was inadequate to meet the various expenses (Table 4). Four managers of the old age homes opined that the charges fixed for the inmates was insufficient, three of them felt that the funds for medical care were inadequate and two of them reported about the problems of delay in receipt of grant from the government (Table 4). Infrastructural facilities were found adequate in a little over half of the old age homes studied as reported by 13 institutional managers. Five respondents have reported about the inadequacy of space to accommodate more numbers of elderly as the demand for such homes, they feel, is growing. Inadequate staff (reported by 4 respondents), inadequate water and electricity Table 4: Percentage Distribution of Old Age Homes by Type of Problems Faced in Smooth Functioning of their Institute, Gujarat, 2004 Type of problems faced in smooth functioning of the old age home on the following aspects Service provision No problem faced Inadequate staff Unable to care for inmates who require prolonged hospitalization Lack of discipline among inmates and do not like to do assigned work Others Funds No problem Inadequate grant to meet expenses Charges paid by inmates are insufficient Inadequate funds for medical care Delay in receipt of grant from government Others Infrastructural facilities No problem Inadequate space to meet the growing demand Inadequate staff Inadequate water, electricity supply Building requires repair Others Dealing with relatives of inmates No problem Number of institutions (in percent)* 40.0 (10) 32.0 (8) 16.0 (4) 12.0 (3) 20.0 (5) 44.0 (11) 44.0 (11) 16.0 (4) 12.0 (3) 8.0 (2) 20.0 (5) 52.0 (13) 20.0 (5) 16.0 (4) 12.0 (3) 8.0 (2) 8.0 (2) 96.0 (24)

Relatives demand special privileges Other problems No other problem Staff is poorly motivated to work due to inadequate salary * Percentages may add to more than 100 due to multiple responses.

4.0 (1) 80.0 (20) 20.0 (5)

supply (3 respondents) and the inability to carry out much needed repairs of building (such as paint work, leaking roofs, uprooted floor tiles etc) reported by 2 heads were the other problems related to infrastructural facilities.

In addition to the above aspects, the heads were also asked whether they encountered problems in dealing with the relatives of the inmates or faced any other problems in managing the old age homes. All except one institutional head reported that they did not face any problems in dealing with relatives and 20 of them also did not have any other problems (Table 4). The only problems reported by one respondent were that sometimes relatives, especially those known to a member of the trust, demanded special privileges. Among other problems, the low motivation of the staff due to the inadequate salary was the only problem reported by 5 respondents (Table 4). This affected the way they carried out their tasks and also affected the service provision for the elderly. Finally, the managers of the institutes were asked about their own satisfaction and how satisfied they perceived the elderly were with the service provision in the old age homes. The opinion about the managers own satisfaction is almost equally divided with 14 of them expressing satisfaction and 11 reporting dissatisfaction (Table 5). The various reasons reported for feeling satisfied were that the required infrastructural facilities are available (6 respondents) and that they are able to provide good services to the elderly (6 respondents). Among the dissatisfied group, the paucity of funds for medicines and better health and medical care was the major reason reported by 73 percent (8 respondents) of heads. This was followed by the lack of funds for various purposes such as for accommodating disabled persons, providing clothing to the elderly and for appointing adhoc staff for maintaining the cleanliness of the old age homes (Table 5). Two of the managers each have mentioned about the lack of space to meet the growing demand for accommodation and luck of funds for constructing building. Inadequate water supply and the high expectation of the elderly, which the managers are unable to meet, were reported by 1 institutional head each.

The perception of the managers regarding satisfaction of the elderly with the service provision in the old age homes, also presented in Table 5, shows that the majority of them, 19 out of 25, have reported in the affirmative, indicating that according to them, the inmates are satisfied. The major reasons reported for this were that food is available at nominal or no cost. (12 respondents), good accommodation, all the required care is provided and adequate time available for the elderly to carry out their religious activities (7 managers each), the availability of medical care (6 respondents), personal safety and security of the elderly at the old age home (4 managers) and the companionship of age mates (2 respondents). Those managers who perceived that the elderly were dissatisfied (6 respondents) reported the following reasons. Sixty percent attributed this to general dissatisfaction among the elderly with all the services provided (Table 5), followed by 1 respondent each who reported about the lack of vehicle facility at the institute which prevented then from taking out the elderly on excursions and day trips, the unhappiness of the elderly with the food provided and the difficulty the elderly faced in mobility in multi-storeyed buildings which did not have a lift (Table 5).

Table 5:

Managers Satisfaction and Inmates Satisfaction with the Various Services Provided in the Old Age Homes as Perceived by the Manager of the Institute, Gujarat, 2003 Opinion of the managers Number of institutions (in percent) 56.0 (14) 44.0 (11) 42.8 (6) 42.8 (6) 14.3 (2) 72.7 (8) 27.3 (3) 18.2 (2) 18.2 (2) 9.1 (1) 9.1 (1)

Reasons for satisfaction

(a) Satisfaction of the Manager of the Institution Yes No Able to provide good services to the inmates Have all the needed facilities Others

Reasons for dissatisfaction

Inmates need better health medical care/need funds for medicines Need more funds to accommodate disabled persons/provide clothing/appoint adhoc staff for cleanliness of home Need more space to meet growing demand Requires fund for building Inadequate water supply Unable to meet expectation of inmates (b) Whether inmates are satisfied

Reasons for satisfaction


Food at nominal or no cost Good accommodation Adequate time for religious activities All the required care is provided Medical care is available Personal safety and security at the old age home Companionship of age mates Dissatisfied with all the services at the Home Inmates are unhappy with the food Difficulty of mobility in multi-storied building No vehicle facility

Yes No

76.0 (19) 24.0 (6) 63.2 (12) 36.8 (7) 36.8 (7) 36.8 (7) 31.6 (6) 21.1 (4) 10.5 (2) 60.0 (3) 20.0 (1) 20.0 (1) 20.0 (1)

Reasons for dissatisfaction

II. Perspectives of the Elderly Living in Old Age Homes As described earlier, a sample of 114 elderly men and 119 elderly women living in the 25 old age homes selected for the study were interviewed to obtain their views and feelings about institutional living arrangements, their satisfactions and dissatisfactions with the same and their attitudes regarding children (especially sons) as old age security in a changing familial value system.

Background Characteristics of the Elderly Inmates


The socio-economic background characteristics of the elderly men and women residing in the selected old age homes are presented in Table 6. It is evident from this table that more than half of the inmates (55 percent) are living in private institutions with more women (60 percent) than men (51 percent) choosing to live in private old age homes than government aided ones. The recency of choosing institutional living can be noted from the fact that a little over three-fourths of the elderly (76 percent) had reported their duration of stay at the old age home as less than six years (Table 6). Table 6 further shows that about 7 percent of the elderly had reported that they had been residing at the institution for more than 11 years. With regard to the age distribution, it can be noted that about 61 percent were above the age of 69 years, 32 percent were between 60 and 69 years while the remaining 7 percent were less than 60 years old. No significant differences in this

age structure were noted between elderly men and women (Table 6). The background characteristics further reveal that about 29 percent of the elderly men as against 8 percent of the elderly women had never married. Table 6 also reveals that the proportion of widows was much higher (64 percent) than widowers (35 percent) while 30 percent of men and 21 percent of women were found to be currently married. Table 6 further reveals that 16 percent of the currently married elderly were living with their spouse at the old age home while 12 percent were not living with their spouse. The educational characteristics indicate that about one fifth of the elderly did not have any education, thirty percent had reported primary educational attainment, and another 9 percent had completed middle school while about 8 percent had completed college or university education. Between men and women, more men than women were found to have been educated (Table 6). The low educational attainment of the elderly is also reflected in their last occupation. As can be noted from Table 6, only 2 percent of the elderly men had been engaged as executives or were in some white collar profession, about 23 percent of men and 13 percent of women had either worked as school teachers/clerks or other related service groups, about 44 percent of men and 14 percent of women were either labourers in agricultural or non-agricultural occupation or were class IV servants (Table 6). Among women, two-fifths of them had been housewives, about 2 percent had been engaged in carrying out a business and four percent were skill workers such as tailors, embroiderers. The picture with regard to their current occupation indicates that the majority of men (97 percent) and women (94 percent) were not pursuing any occupation. More women (6 percent) than men (3 percent) reported that they were gainfully occupied. Some of the women were helping in certain

Table 6: Background Characteristics of Elderly Inmates Living in Old Age Homes in Gujarat, 2003

Characteristics Type of old age home Government aided Others Sex of the inmates Male Female Age of the inmates < 60 years 60-64 years 65-69 years 70-74 years 75 years & above Marital status Never married Currently married Widow/Widower Divorced/Separated Educational attainment Illiterate Pre-primary Primary Middle High school Higher secondary College & above Last occupation Professional/Executive Clerk/School teacher & related service groups Business Skill worker Housewife Labourer Class IV servants/non-agricultural job Landlord/Cultivator Unemployed

Percentage distribution Male Female Total 49.1(56) 50.9(58) 6.1 14.0 19.3 28.9 31.6 28.9 29.8 35.1 6.2 10.5 11.4 39.5 13.2 9.6 5.3 10.5 1.8 22.8 6.1 15.8 16.0 28.1 5.3 6.2 40.3(48) 59.7(71) 8.4 16.8 13.4 22.7 38.7 7.6 21.0 63.9 7.6 31.9 10.9 37.8 4.2 3.4 5.9 5.9 13.4 1.7 4.2 40.0 3.4 10.9 0.8 23.5 44.6(104) 55.4(129) 48.9(114) 51.1(119) 7.3 15.5 16.3 25.8 35.2 18.0 25.3 49.8 6.9 21.1 11.2 38.6 8.9 6.4 5.6 8.2 0.9 18.0 3.9 9.9 21.4 8.6 19.3 3.0 15.0

Contd.. Characteristics Percentage distribution Male Female Total

Present occupation Not working/Unemployed 97.4 94.1 95.7 Engaged in some gainful occupation 2.6 5.9 4.3 Religion Hindu 90.4 89.9 90.1 Christian 3.5 3.4 3.4 Parsi 2.6 4.2 3.4 Jain 3.5 2.5 3.0 Independent source of income Yes 43.8 42.9 43.3 No 56.1 57.1 56.7 Residing at the old age home with spouse Yes 15.8 16.8 16.3 No 18.4 5.9 12.0 Never married/Not currently married 65.8 77.3 71.7 Duration of stay at the old age home < 1 year 16.7 11.8 14.2 1-2 27.2 28.6 27.9 3-5 31.6 37.0 34.3 6-10 19.3 13.4 16.3 11-15 1.7 5.0 3.4 16+ 3.5 4.2 3.9 Type of family Nuclear 25.4 20.2 22.7 Joint 46.5 59.6 53.2 Lived alone 28.1 20.2 24.0 Place of stay where lived for most of the life City/Town 81.6 78.2 79.8 Village 18.4 21.8 20.2 Total 100.0(114) 100.0(119) 100.0(233) tasks of the old age home e.g. cooking, cleaning for which they were paid some salary. Among men, the nature of their occupation was tailoring/ stitching. The picture with regard to their current economic condition further reveals that only about 43 percent of the elderly have an independent source of income either in the form of pension or savings interest which means that more than half of them are without any financial security (Table 6).

Finally, the background characteristics regarding familial and urban/rural traits, reveal that a little over half of the elderly (53 percent) had lived in a joint family, while about 23-24 percent each had either lived in a nuclear family or had lived alone, prior to coming to the old age home. Sex differentials on this aspect can be seen as more women (60 percent) than men (47 percent) had lived in a joint family. Equal proportions of women had lived alone or in a nuclear family (20 percent each) while more men (28 percent) had reported that they had lived alone. The urban characteristic of the elderly is clearly noted as almost 80 percent had lived in a city/town for most of their lives. However, as about one-fifth of the respondents reported that they had spent a major part of their lives in villages, information about such institutions has reached villages in the proximity to towns and cities.

Services and Facilities


This section describes the services and facilities available for the elderly living in the selected old homes, the expenses incurred by them for accommodation and other services and how they meet these expenses. The section also looks at the circumstances of the elderly which influenced them to decide in favour of institutional living. The results on these aspects are presented in Tables 7-9. This section at the first place presents information on the type of facilities and services available within the old age homes for the elderly. Information on this aspect is summarized in Table 7. With regard to the nature of accommodation, the majority of the inmates i.e. 86 percent share a room between 2-3 persons (52 percent) or between 4-6 persons (34 percent). Just 5 percent of the inmates each is provided with single room accommodation or double room for couples while 3 percent of the inmates reported that they share a room with seven or more persons share a room. As regards the availability of furniture/fixtures in the room, most of the inmates (88-93 percent each) reported the availability of beds with mattress and pillows, cupboards and fans, although less than two-fifths reported the availability of table/chair. About 62 percent of the inmates have bathroom/toilet facility, either western style, or Indian style which is attached to the room. More women (71 percent) than men (53 percent) have reported about this type of facility. The remaining inmates reside in homes with shared bathroom/toilet facilities. Three fourths of the inmates reported that homes provide all meals including morning and afternoon tea, breakfast, snacks, lunch and dinner while almost all the remaining (24 percent) reported that they are provided just lunch, dinner and tea but no snacks. One percent of the inmates reported that the home does not provide any meals (Table 7) and the inmates eat out. While the majority of the inmates (79 percent) are satisfied with the quality of the meals, the remaining are not satisfied with the meals as it does suit their health or for other reasons (Table 7). Regarding availability of medical facility, 45 percent of the women and one fourth of the men have reported that all medical facilities are available free of cost,

about 17-18 percent of the men and women each reported that they have doctors who are available full time whereas 25 percent of the women each reported about the availability of either part-time doctors or hospital facility of the trust managed homes. Lack of health facility or no regular visits by doctor was reported by 13 percent of the elderly women and 28 percent of the elderly men (Table 7). Thus, some form of medical facility is available for most of the elderly in the institutions. The next aspect explored, with regard to facilities and services in the various old age homes, was about the availability of entertainment and Table 7: Type of Services and Facilities Provided in the Old Age Homes: Inmates Perspective, Gujarat, 2004

Type of services and facilities


Type of accommodation Single room Double room for couple 2-3 persons per room 4-6 persons per room 7 or more persons per room Furniture/fixtures in the room Bed with mattress and pillow provided Cupboards/Lockers to store personal belongings for each person Chair/table provided Fans (ceiling/pedestal) provided Common cupboards Bathroom/toilet facility Attached with room, western style Attached with room, Indian style Shared, western style Shared, Indian style Type of meals All meals including breakfast, lunch, dinner and tea twice Only lunch, dinner and tea but no snacks No provision of any meals Quality of meals Satisfied with all meals No special food for people with health problem Not very satisfied No provision of any meals No comment/cant say Entertainment/Recreation facilities

Percent distribution+
Men
5.3 6.1 52.6 31.6 4.4 93.9 87.7 42.1 83.3 5.3 42.1 10.5 16.7 47.4 73.7 25.4 0.9 79.8 11.4 16.7 0.9 -

Women
5.0 5.0 50.4 37.0 2.5 92.4 87.4 35.3 92.4 7.6 44.5 26.9 18.5 31.9 77.3 21.9 0.8 79.0 1.7 16.8 0.8 1.7

Total
5.2 5.6 51.5 34.3 3.4 93.1 87.6 38.6 88.0 6.4 43.3 18.9 17.6 39.5 75.5 23.6 0.9 79.4 6.4 16.7 0.9 0.9

Television Library Newspapers/Magazines Religious activities (katha, bhajan, satsangh, religious discourses etc.) Trips to religious places (such as Ambaji, Dakor, Shreenathji) Movies/hotels/picnics (once a year or occasionally) Others None

65.8 48.2 36.8 49.1 29.8 3.5 8.8 15.8

72.3 44.5 42.9 53.8 36.1 7.6 9.2 5.0

69.1 46.4 39.9 51.5 33.0 5.6 9.0 10.3

Contd
Type of services and facilities Medical facility Doctors full time Doctors part time Hospital facility of trust No regular doctors visit/No health facility All medical services are free Consultation of the doctor is free but medicine charges are borne by inmates Others Services for personal needs Men 17.5 18.4 23.7 28.1 23.7 18.4 Percent Women 16.8 25.2 25.2 12.6 45.4 16.0 4.2 distribution+ Total 17.2 21.9 24.5 20.2 34.8 17.2 2.1

(a) Facility for washing clothes


Use washing machine at the institute Clothes washed by staff of institute Use services of washerman (dhobi) Wash own clothes Utensils cleaned by staff (completely) Utensils cleaned by staff (partially) Utensils cleaned by inmates 5.3 36.0 0.9 57.8 36.0 43.0 21.0 36.0 47.4 16.6 2.5 31.9 2.5 63.1 31.9 51.3 16.8 31.9 58.8 9.3 3.9 33.9 1.7 60.5 33.9 47.2 18.9 33.9 53.2 12.9

(b) Facility for cleaning utensils

(c) Facility for sweeping/cleaning room

Sweeping/cleaning done by staff (completely) Sweeping/cleaning done by staff (partially) Sweeping/cleaning done by inmates Ways of meeting/maintaining contact by inmates with children/relative/friends living outside the institute Relatives can come and meet at fixed timings No restrictions of any type on visit/ relatives can come and meet any time

40.4 31.6

42.0 30.3

41.2 30.9

Inmates can go outside with permission Keep in touch by telephone Total

43.0 1.8 100.0(114)

35.3 2.5 100.0(119)

39.1 2.1 100.0(233)

+ Percentages may add to more than 100 because of multiple responses.

recreation facilities. As evident from Table 7, the majority of the old age homes (90 percent) have some form of facilities or organised activities for the recreation of the elderly. The availability of television is reported by 70 percent of the elderly women and men, 46 percent have reported about the availability of library facility whereas newspapers/magazines have been reported by 40 percent of the women. Organised activities such as religious activities (bhajans, religious discourses, satsangh have been reported by half of the elderly inmates. In addition, about one third of them have reported that they are also taken on short trips to places of religious importance such as Dakor, Ambaji or Shrinathji. Interestingly, occasional visits to movies/hotels or being taken on picnics have also been reported by about 6 percent (4 percent of men and 8 percent of women) of the elderly. This is indeed encouraging as such outings are likely to promote greater interaction between the elderly as well as increase their exposure to the world outside. Information on the provision of facilities for the fulfillment of other basic personal needs, such as laundry, cleaning of utensils, cleanliness of rooms, also presented in Table 7, reveals that two thirds of the elderly reported that they wash their own clothes, 19 percent reported that they clean the utensils used by them and 13 percent stated that the sweeping and cleaning of the institute including their rooms is done by them. On the other hand, 34 percent of the elderly have reported that the staff of the old age homes carries out all these activities and they do not have to do anything. A fairly large proportion of the elderly reported that the staff of the institute washes the cooking utensils (47 percent) and sweeps the common areas of the institute (53 percent), whereas they have to wash the utensils used by them for eating and sweep and mop their rooms themselves (Table 7). Finally, Table 7 provides information on the arrangements made by the institute so that the elderly can meet or maintain contact with their family and friends. As evident almost two fifths of the elderly each have reported that their relatives can visit the old age home at fixed times everyday or that they themselves can go out to visit with the permission of the Superintendent or that there are no restrictions of any type and the relatives of the inmates can visit the old age home at any time. The next aspect was about payment made for accommodation and other services by the elderly in the old age homes. As can be seen from Table 8, about 48 percent of the respondents have reported that they have to pay for accommodation and other services while the rest do not have to incur any expenses towards institutional living. Even in government-aided institutions almost two fifths have

stated that they paid towards accommodation and other services as against 55 percent of the respondents in private homes. Of those who reported about having to pay for accommodation, 39 percent in government aided and 34 percent in private institutions paid less than Rs.200/- per month while 29 percent in government aided homes made a payment of Rs.600/- to Rs.800/- per month and another 20 percent paid more than Rs.800/- per month. On the other hand, 34 percent of the inmates in private institutions paid Rs.200/ to Rs.600/ per month, although more than 20 percent reported about paying more than Rs.1000/- per month. Information on amount of monthly personal expenses incurred (bus fares, alms/temple) indicates that about one-fifth of the respondents had reported that they did not have any personal expenses while two-fifths had reported that they spent less than Rs.100/- per month on their own needs. About 11 percent stated that their personal expenses were about Rs.400/- or more while the remaining 28 percent spent about Rs.100/- to Rs.400/- per month.

Table 8: Percentage Distribution of Elderly Inmates by Various Expenses Incurred by them for Institutional Living, Gujarat, 2003
Percent of inmates
Government aided Private All Institutions

Type of expenses at the old age home Whether payment made for accommodation and other services Yes No Amount of monthly payment made to the institute (in Rupees) < 200 200-400 401-600 601-800 801-1000 1001-1600 1601+ Total Amount of monthly personal expenses (in Rupees) No personal expenses <100 101-200 201-400

39.4 60.6 39.0 2.4 9.8 29.3 9.8 9.7 100.0(41) -

55.0 45.0 33.8 12.7 21.1 2.8 7.0 11.3 11.3 100.0(71) -

48.1 51.9 35.7 8.9 17.0 12.5 8.0 10.7 7.1 100.0(112) 20.6 39.9 16.3 12.0

401-600 601+ Source of money for meeting various expenses at the institute Own savings/investment/pension Assistance from children Assistance from relatives Current earning/gainful occupation Individual donors/visitors/neighbours Trust/Trustee Total

9.0 2.1 42.2 16.6 26.7 7.5 7.5 7.5 100.0(233)

Regarding the source of money for meeting various expenses at the institute, the major sources reported, which are presented in Table 8, are personal savings/investments or pension (42 percent), followed by assistance from relatives (27 percent) and assistance from children (17 percent). About 8 percent each have reported that their main sources are either from their current earnings or, assistance from neighbours, individual donors or visitors to the institute or assistance from the trust or trustee of the old age home (Table 8). The fact that assistance from relatives rather than children is reported by a greater proportion is due to the fact that some of the elderly had not married and therefore had no children. Further, some had no children despite being married while a few reported that their children did not give them any monetary assistance.

Circumstances which Influenced the Decision for Institutional Living


An exploration of the reasons for choosing institutional living provides glimpses of lives of the elderly in present day Gujarat under changing familial values. This aspect is further discussed a little later in the report. As evident from Table 9, the major reasons for choosing to live in an old age home are due to own or spouses ill health or disability or not having anyone to take care of them (45 percent), nominal or no cost for the fulfillment of basic needs (38 percent), to avoid familial conflict (especially with children) or for peace of mind and to be cared for in a better way (34 percent each). Two other reasons, which indicate the physical and psychological state of the elderly are lack of physical space for of the elderly who live with children and grandchildren or that they did not want to be a burden on family members (19 percent) and to be able to live a life of dignity and self respect (11 percent) which the elderly felt they did not enjoy by staying with married children. No major differences are noted on this aspect between the elderly men and elderly women respondents.

A related issue explored was the person or persons who were instrumental in the decision of the elderly to seek institutional care. Almost three fourths of the men and a little over half the women reported that it was their own decision to live in an old age home (Table 9). A further 45 percent of women and 21 percent of men reported about the role played by relatives in helping them decide on institutional living as a better option over familial living. Neighbours or friends have been instrumental in case of 30 percent of men and 9 percent of women while children have played a role in the case of 22 percent of women and 8 percent of men (Table 9). Regarding information about the source of knowledge about the old age home where the elderly are residing, neighbours/friends/relatives have been reported as the major source (55 percent), followed by the respondents own contact with the institute or that the institute was of repute and therefore was known to them (Table 9). Mass media and social workers have played minimal role in creating adequate awareness in this regard.

Table 9:

Percentage Distribution of Elderly Inmates by the Circumstances which Made them Opt for Institutional Living, the Persons Instrumental in this Decision Making and their Source of Knowledge About the Old Age Home they Chose to Live in, Gujarat, 2003

Decision making for institutional living Circumstances that influenced the decision for institutional living To be cared for in a better way Due to familial conflict/For peace of mind Did not want to be a burden on family members/lack of physical space Due to own/spouse ill-health or disability/have no one to take care of self For companionship All basic needs are taken care of at a reasonable cost/free To live a life of dignity/live with self respect Others Persons instrumental in the decision Self Children Relatives Neighbors/friends Social worker Religious leader Trustee of old age home Others Source of knowledge about the old age home Own contact with institute/wellknown institute Children Media (Newspapers/Magazine/Radio/ T.V. Religious leader/organization Trustee Neighbors/friends/relatives

Percent distribution+
Men 30.7 32.5 15.8 42.1 7.0 42.1 11.4 8.8 73.7 7.9 21.1 21.9 6.1 1.8 1.8 3.5 16.7 0.9 9.6 8.8 6.1 54.4 Women 37.8 35.7 21.0 47.1 2.5 34.5 10.1 10.1 52.1 21.8 45.4 9.2 4.2 3.4 17.6 11.8 0.8 7.6 3.4 55.5 Total 34.3 33.9 18.5 44.6 4.7 38.2 10.7 9.4 62.7 15.0 33.5 15.5 5.2 0.9 0.9 3.4 17.2 6.4 5.2 8.2 4.7 54.9

Family doctor Social worker/employer etc. Cannot say Total

2.6 4.4 0.9 100.0(114)

4.2 100.0(119)

1.3 4.3 0.4 100.0(233)

+ Percentages may add to more than 100 because of multiple responses.

Health and Illness Management


Health and illness are important concerns in old age. Visual, auditory, dental and mobility problems, weakening of muscles, loss of appetite, anemia, sleeplessness, and minor gastric disorders are some of the common afflictions of ageing. In this regard, the study has explored the various health problems or illnesses experienced by the elderly at the time of the interview. Data on this aspect is presented in Table 10. As is evident, while the list of varied types of illnesses or health problems is fairly long, the proportion of elderly currently suffering from some of them is not very large. In fact, about 14 percent of the elderly men and women have reported that they do not have health problem or illness. The major health problems reported by the respondents are arthritis/joint pain (50 percent), followed by visual problems (31), back pain (29), anemia/weakness (21) and sleeplessness and mobility (20 percent each). About 17 to 19 percent have reported auditory problems, hypertension, muscular weakness and lapses in memory. Asthma and respiratory problems have been reported by 14 percent while cataract has been mentioned by 13 percent. Gastric problems/acidity and constipation, which are often more associated among the elderly due to weakening of the alimentary system, are reported by just 3 percent each of the respondents (Table 10). Sex wise differentials can also be noted from Table 10. Overall, 89 percent of the elderly women have reported at least one current health problem or illness as against 83 percent of elderly men. Problems of back pain, mobility and joint pain/arthritis are noted more among women (38,24 and 57 percent respectively) than among men (20,17and 43 respectively). Anemia/ weakness has been reported by 28 percent of the women as against 13 percent of men. Sleeplessness and hypertension each were reported by 24 percent of women and by 13 and 24 percent of men respectively. Asthma/respiratory problems have been reported by a greater proportion of elderly men (20 percent) as compared to 8 percent of women. Thus, it seems that morbidity among women during old age is relatively more than among the men. The aspect on health and illness was further explored with regard to treatment seeking, for those reporting a health problem or illness. This information, which is presented in Table 11, looks at treatment for current illness as well as that, which occurred, in the recent past. Of those who had reported a current health problem, about 28 percent of them had not sought any treatment for the same. The majority of the remaining had resorted to allopathic treatment (64 percent), followed by ayurvedic (9 percent) and homeopathic (7 percent) treatment, while about 3 percent had resorted to home remedies (Table 11). The results on

treatment taken for illness in the recent past (one week, one month and one year prior to the survey) also indicate that of those elderly who had such an illness/health problem, the majority (90 to 95 percent) had sought treatment. Finally, the opinion of the elderly about their health in general was sought. As can be seen from Table 11, about 23 percent considered themselves to be very healthy while 62 percent felt they were fairly healthy. It is heartening to note that no major sex differentials are noted on this aspect of health and illness management, indicating that both men and women equally are seeking treatment for their health problems.

Table 10: Experience of Various Health Problems Reported by Elderly Inmates at the Point of Survey, Gujarat, 2003

Current health problem/illness


None Visual Cataract Auditory Dental Mobility Arthritis/Joint pain Weakness of muscles Back pain Anemia/Weakness Loss of appetite Sleeplessness Lapse in memory Depression Speech difficulty Partial paralysis Respiratory/Asthma Urinary Prostate Hernia Hypertension Low blood pressure Cardiac Diabetes Gastric/acidity Constipation Skin disease Others

Percent distribution+
Men
17.5 29.8 12.3 19.3 15.8 16.7 43.0 15.8 20.2 13.2 5.3 15.8 18.4 0.9 2.6 2.6 20.2 7.0 3.5 3.5 13.2 3.5 9.6 7.9 1.8 2.6 0.9 3.5 114

Women
10.9 31.9 14.3 16.8 18.5 23.5 57.1 21.8 37.8 27.7 9.2 23.5 16.8 10.1 5.0 0.8 8.4 6.7 1.7 24.4 6.7 8.4 8.4 4.2 3.4 1.7 9.2 119

Total
14.2 30.9 13.3 18.9 17.2 20.2 50.2 18.9 29.2 20.6 7.3 19.7 17.6 5.6 3.9 1.7 14.2 6.9 2.1 2.6 18.9 5.2 9.0 8.2 3.0 3.0 1.3 6.4 233

Total number of inmates


the respondents.

+ Percentages add to more than 100 because of reporting more than one illness/health problem by

Table 11: Treatment Availed by Inmates for their Current and Past Health Problems/Illness, Gujarat, 2003 Percent distribution Women

Treatment for current & past illness


Type of treatment for current health problems/ illness No treatment taken Treatment currently availing: Allopathy Ayurveda Homeopathy Home remedies Total Illness during the recent past and its treatment Illness during last one week Treatment taken Illness during last one month Treatment taken Illness during last one year Treatment taken Inmates opinion about their health in general Very healthy Fairly healthy Not healthy Total Number of respondents

Men

Total

27.7 63.8 12.8 6.4 2.1 100.0*(94)+

27.4 64.2 5.7 6.6 3.7 100.0*(106)+

27.5 64.0 9.0 6.5 3.0 100.0*(200)+

7.9 88.9 14.0 93.8 14.9 94.1

8.4 90.0 17.6 95.2 28.6 94.1

8.2 89.5 15.9 94.6 21.9 94.1

23.7 61.4 14.9 100.0 114

21.8 61.3 16.8 100.0 119

22.7 61.4 15.9 100.0 233

* Percentages may add to more than 100 due to multiple responses. + Includes only those who are currently availing treatment for their health problems.

Psycho-emotional and Social Aspects of the Elderly Living in Old Age Home The final aspect studied provides an idea of the psychological, emotional and social aspects of the elderly living in old age homes as reflected by their satisfactions and dissatisfactions with various services provided and the advantages of such institutional living arrangement as against the disadvantages as well as their sense of isolation (being away from children and family) or whether such an arrangement provides the much needed comfort, solace and companionship of agemates and the freedom to pursue their own activities without constraints. This section ends with an exploration of the opinions of the elderly regarding children as old age support and who they feel should care for the elderly, in the context of changing familial values. Findings on these varied but related issues are presented in Tables 12-14.

Satisfaction with Service Provision


As is evident from Table 12, the majority i.e. 86 percent of the elderly respondents has reported their satisfaction with the various services provided in the old age homes. The major reasons reported for expressing satisfaction are because of good services and good behaviour of the staff (58 percent), food being palatable and wholesome (32), accommodation being satisfactory (27), and they have the freedom to pursue and participate in religious activities (15). A few have also mentioned about the good medical facility available at the institute (10 percent) and that the entertainment and library facilities are also good (2 percent). In addition, about 5 percent have stated that they have to be satisfied with the services as they have no choice and that they have accepted and are resigned to this way of living (Table 12). This last view is also voiced by a large majority of those who expressed their overall dissatisfaction with various services in the old age homes. As can be seen from Table 12, about 14 percent of the elderly had expressed their dissatisfaction out of which 58 percent stated that they felt this way as they had no choice but to live here and had therefore resigned themselves to this way of life. A few among this group also refused to gave any comments and were found to just turn away from this line of questioning, indicating the pain they felt with such an arrangement. The other reasons reported for dissatisfaction were the inadequacy of basic facilities of light, fan, entertainment and staff (16 percent), followed by food not being to their liking or not suiting their health (13 percent) and loss of freedom to live the way they want and restrictions in their movements because of the rules of the institute (10

percent). Just 3 percent have expressed their dissatisfaction with medical and health care facilities provided (Table 12).

Table 12: Satisfaction and Dissatisfaction Expressed by the Inmates with the Services Provided at the Old Age Homes, Gujarat, 2003 Satisfaction/Dissatisfaction with the services Satisfied with services Not satisfied with services Reasons for satisfaction
All services are good/good behaviour of the staff Services are free/at low cost Food is good/wholesome food/find food suitable Accommodation satisfactory Good medical facility/medical care is good Have freedom/facility to participate in religious activities Entertainment/library facility is good Have no choice/have to be satisfied with services/accepted the way of living

Percent distribution of Inmates 85.8 14.2 57.5 14.0 31.5 26.5 9.5 15.0 1.5 4.5 100.0* 9.7 12.9 9.7 3.2 16.1 58.1 100.0*

Total Reasons for dissatisfaction


Have no freedom to live the way want/have to follow institutes rules/restriction in movement Food does not suit health/food is not good Accommodation is not adequate/lack of space/sharing room with other inmates who are not like-minded or not accommodative Not satisfied with medical/health care service Basic facilities like light, fan, staff to clean utensils & clothes and entertainment are inadequate No comment/No other option but to live here/resigned to circumstances

Total

* Percentages may add to more than 100 due to multiple responses.

Advantages and Disadvantages of Institutional Living


Regarding the various advantages and disadvantages of living in an old age home, presented in the Table 13, it is noted that mental well being associated with institutional living (33 percent) and all basic needs taken care of by good and caring staff (49 percent) are the major advantages reported. It is interesting to note from Table 13 that a much higher proportion of elderly men (40 percent) than elderly women (25 percent) have stated that they consider the stress free environment, peace of mind and absence of conflicts (with children) as the major

Table 13: Opinions and Attitudes Regarding Institutional Living Expressed by Inmates , Gujarat, 2003 Percent distribution Women Total
3 25.2 47.9 12.6 21.8 14.3 5.0 10.9 6.7 100.0* 58.8 8.4 19.3 4 32.6 49.4 15.9 18.9 13.3 2.6 12.0 7.7 100.0* 63.5 6.4 17.6

Opinions / Attitudes
1 Advantages of institutional living Stress free environment/ no conflicts/ peace of mind Looked after very well/all needs taken care of /services of low or no cost / staff is good and caring Free from responsibility of maintaining a household at this age Can pursue religious activities as desired Company of other age-mates Personal security/safety No choice/have no one to care for us/can not look after self Cannot say

Men
2 40.4 50.9 19.3 15.8 12.3 13.2 8.8 100.0* 68.4 4.4 15.8

Total
Disadvantages of institutional living No disadvantages Have to live according to institutes rules/ it is like living in a jail Away from family and relatives/feeling of being isolated/minimum interaction with out side world Inadequate medical care/lack of cleanliness of rooms, bath-rooms and toilets Sharing accommodation with unknown people Food is not suitable/palatable Loss of self respect/living on charity/ institutional living is painful Cannot say/no comments/dont want to say

2.7 1.8 2.6 8.8 100.0*

0.8 5.0 4.2 4.2 5.9 100.0*

1.8 2.6 3.0 3.4 7.3 100.0*

Total
Given a choice, preferred place of stay/ arrangement in ones old age Old age home With family

60.5 32.5

58.8 31.1

59.7 31.8

Either arrangement, depending on the circumstances

7.0 100.0*(114)

10.1 100.0*(119)

8.6 100.0*(233)

Total

1 Reasons for preferring old age home For self respect/peace of mind/away from familial conflict/more freedom/this is the best option at this age Lack of affection in family/no familial support Lack of economic support Do not want to be a burden on any one Have no one to take care/absence of close family members Fulfillment of all needs/requirement/do not have to depend on any one Can pursue religious activities without disturbance/can live our life of Sanyansin (Sainthood) Other (such as company of others/low cost of need fulfillment)

2 44.9 26.1 8.7 14.5 24.6 30.4 5.8 7.2 100.0*(69) 73.0

3 37.1 25.7 8.6 10.0 24.3 28.6 10.0 2.8 100.0*(70) 70.3

4 41.0 25.9 8.6 12.2 24.5 29.5 7.9 5.1 100.0*(139) 71.7

Total
Reasons for preferring familial living Home is home/it is more comforting/you are with your own people/can share joys and sorrows together/better to die in presence of family members Have rights over family members/no obligations It is more respectful to live in family Can live as we wish/easy to adjust with own family members/have freedom To enjoy grandchildren/great feeling to live with grandchildren No substitute for home in old age

10.8 5.4 8.1 2.7 10.8 100.0*(37)

8.1 10.8 10.8 2.7 10.8 100.0*(37)

9.5 8.1 9.5 2.7 10.8 100.0*(74)

Total
Reasons for those who would opt for either (old age home or family) arrangement, depending on the circumstances Individual should stay where they have self-respect Being bachelor/spinster/having no family or children, can not opine/might have no option If there is no income/economic support,

37.5 12.5 -

25.0 33.3 8.3

30.0 25.0 5.0

then institutional living is better If children are affectionate and take care, then one should opt for familial living, otherwise old age home/if there is no conflict in the family, then familial living is better Others

37.5

33.3

35.0

Total
1 Whether inmates feel lonely living in an institute away from children and relatives Yes No Cannot say Reasons for feeling lonely in the institute away from children and relatives (Yes group) It is natural to miss children and family/ feel isolated from social life Have brought up children with love and care and would like to be with them Affection and care of children is absent/ despite ill treatment by children we miss them Others

12.5 100.0*(8)

8.3 100.0*(12)

10.0 100.0*(20)

2 17.5 81.6 0.9

3 26.1 73.9 -

4 21.9 77.7 0.4

65.0 15.0 25.0 5.0 100.0*(20)

45.2 29.0 25.9 6.4 100.0*(31)

52.9 23.5 25.5 5.9 100.0*(51)

Total
Reasons for not feeling lonely in the institute away from children and relatives (No group) Dont miss children because they have no love or respect for us/they are selfcentered We are in contact with children and relatives/ children and relatives come to visit us and we can also go to visit them Have no close family/used to living alone, not having married Have come to terms with our life/have made our life/this is our home Have made friends here/have company here Staff takes care of us/staff is good to us/services and facilities are good Have freedom to do what we want

11.8 6.5

14.8 12.5

13.3 9.4

10.8 14.0 30.1 8.6 19.4

8.0 18.2 31.8 11.4 13.6

9.4 16.0 30.9 9.9 16.6

Living with spouse Cannot say

Total
Whether the inmates are happy about their stay in the old age home Very happy Happy Some what happy Not happy Not at all happy Cannot say

8.6 7.5 100.0*(93)

1.1 4.5 100.0*(88)

5.0 6.1 100.0*(181)

Total

29.8 33.3 30.7 3.7 1.8 0.9 100.0*(114)

26.0 37.0 33.6 1.7 1.7 100.0*(119)

27.9 35.2 32.2 2.6 1.7 0.4 100.0*(233)

* Percentages may add to more than 100 because of multiple responses. advantages, probably indicating that women may have been better able to cope with the emotional upheavals of familial living. For women, the proportion reporting the freedom to pursue religious activities as desired (22 percent), is a little more than the same reported by the men (16 percent), again indicating the basic difference between the sexes on their interests and pursuits. Not surprisingly, almost equal proportions of the men and women (48-51 percent) have reported that they consider the low or no cost of services/all their basic needs being taken care and being well looked after to be the major advantages of living in an old age home. In addition, almost equal proportions (11-13 percent) have also reported that such a living arrangement is of benefit to them as either they cannot look after themselves or they have no one to take of them. In fact, this is, on a way, a forced choice, as reported by this proportion of the elderly respondents (Table 13). With regard to the perceived disadvantages of living in an institute, 64 percent of the elderly (68 percent men and 59 percent women) do not consider any disadvantages with such an arrangement. The feeling of isolation living away from family and friends and the outside world, in general, is the major disadvantage reported by 18 percent of the elderly. Other disadvantage, which arises out of the restrictions, as reported by about 6 percent, is that they feel they are living in a jail and the resentment they feel having to live according to the rules of the institute. Surprisingly, more women (8 percent) than men (4 percent) have reported this loss of freedom as a disadvantage of living in an old age home (Table 13). Some of the other disadvantages reported by about 2-3 percent each of the elderly are the lack of cleanliness of accommodation, bathrooms and toilets, sharing accommodation with unknown people, unsuitable food and the loss of self respect and the feeling of living on charity (of such an arrangement) which causes than pain. The respondents were therefore asked about their preferred living arrangement. As evident from Table 13, three-fifths of the elderly men and women (60 percent) have reported that they would choose to stay in an institute, 32 percent

reported that they would prefer to stay with family and the remaining opined that either institutional or familial living arrangements would be acceptable to them, depending on the circumstances, i.e. if they have someone who would look after them they would prefer to live with family, otherwise institutional arrangement, is better. Among the reasons reported for preferring institutional living arrangement the major ones reported are for self-respect/ peace of mind/absence of familial conflict (41 percent), followed by fulfillment of all basic needs/requirements and not having to depend on the whims of family members (30 percent), lack of familial affection and support (26 percent) and absence or no close family members to take care of them as reported by 25 percent of the elderly (Table 13). Among about 32 percent of the elderly who had opined that given a choice they would prefer to live with family members in their old age, the major reason reported by as high as 72 percent of them, being the feeling of comfort and belongingness with ones own children, being able to share the joys and sorrows together and finally the sense of security of dying in the presence of loved ones. About 10-11 percent each have also reported about the rights they can exercise over family members, the respect they would have (in society) living with family members and the ease of adjusting with ones own family than with strangers. Of those who stated that either arrangement would be acceptable, depending on the circumstances, about 35 percent reported that familial living arrangement is preferable if children are affectionate, take care of older parents and there is no conflict between the two generations, while 30 percent of the elderly reported that a person should stay wherever they have self respect. Another 25 percent stated that since they had not married and had no children, they were not in position to voice their opinion (Table 13). To further understand the emotional state of the elderly, the respondents were asked whether they felt lonely living away from their children and the reasons for the same. An overwhelming 78 percent replied in the negative indicating that they did not feel lonely living in an institute (Table 13). A closer examination of the reasons for expressing this view reveals that about 31 percent said that they have made friends at the old age home, about 17 percent reported that they now have the freedom to do what they want, while 16 percent stated that they have come to terms with their life and consider the institute as their home now (Table 13). About 9 percent have stated that they are in touch with their children and relatives and they visit each other while an equal proportion reported that they do not experience loneliness as they had no close family and were used to living alone before coming to the old age home. Once again, the void created by the absence of close family members is filled by the good care taking provided by the staff of the institute as reported by 10 percent of the elderly respondents (Table 13). While more than four-fifths have stated that they do not feel loneliness living away from children, their answers and justification, however, reflect an artificial

armour which they have created around themselves to protect against the emotional pain meted out by children. Only 22 percent of the elderly admitted that they did experience loneliness living away from their children. Among this group, 53 percent replied that it was natural to miss children and that living in an institute isolated them from social life. Another 26 percent stated that despite the ill treatment meted out by children (the elderly being forced to live in an institute), they missed them and their love and affection. The remaining almost one fourth of the respondents reported that since they had invested emotionally in the upbringing of children, they would like to spend their life with them. (Table 13). All these reasons reflect the pain that is associated with the severing of the strong familial bond that these elderly parents are experiencing in the last stage of their lives. An overall indicator of the emotional state of the elderly can finally be assessed from their response to how happy they are about their stay in the old age home. As revealed from Table 13, about 63 percent of the respondents are very happy or happy while 32 percent are somewhat happy. Just 4 percent expressed the view that they are not happy with this living arrangement while less than 1 percent reserved their opinion on this aspect.

Table 14: Opinions of the Inmates Regarding Children as Old Age Support and Who Should Care for the Elderly in the Context of Changing Familial Values

Opinion Whether the elderly agree with the view that children are the main support for parents in old age Yes No Cannot say Total Reasons for considering children as main support in old age (Yes group) Parents have given birth to children/ children are expected to support parents/ why else do people have children It is a tradition/customary for children to look after elderly parents When children are young parents look after them, so in old age children should care for their ageing parents Only sons are expected to support parents in old age, but not daughters

Percent distribution
Men Women Total

67.5 28.9 3.5 100.0(114) 57.3 37.7 5.2 -

58.0 41.2 0.8 100.0(119) 63.7 31.9 4.3 2.9

62.7 35.2 2.1 100.0(233) 60.3 34.9 4.8 1.4

Others Cannot say

Total Reasons for not considering children as main support in old age (No group) Children have become selfish/want to live 30.3 their own lives without responsibility of parents/ children forget sacrifices made by parents In pursuit of economic and professional 6.2 growth children dont want to care for the elderly God is our only support 12.1 Son may be willing but daughter-in-law may 9.1 not be willing to look after the elderly If parents have money, only then children will 21.2 look after them in old age Others 15.2 Cannot say 12.1 Total 100.0*(33) Who should care for the elderly in the context of changing traditional family values and ties The elderly themselves 13.2 Son(s) 41.2 Daughter(s) 2.6 Both sons and daughters 26.3 Government Spouse 39.5 Cannot say 7.0 Total 100.0(114) * Percentages may add to more than 100 because of multiple responses

3.9 100.0*(77)

2.9 100.0*(69) 38.8

1.4 2.1 100.0*(146) 35.4

12.2 20.4 12.2 6.1 12.2 6.1 100.0*(49) 6.7 45.4 4.2 23.5 34.5 3.4 100.0(119)

9.8 17.1 11.0 12.2 13.4 8.5 100.0*(82) 9.9 43.3 3.4 24.9 36.9 4.7 100.0(233)

Are children still considered the main support for ageing parents?
In view of the fact that many of the elderly respondents living in the old age homes are doing so despite having children of their own, whom they had probably expected would care them in their old age, it was thought pertinent to find out whether they still consider children as the prime support in old age. As evident from Table 14, a large proportion of the elderly, 63 percent reported that they still consider children to be the main support in old age. Among this group, three fifths of the respondents reported about the reasons such as it is natural for children to look after ageing parents, it is expected role/duty of children to care for parents and is the main reason why people have children. Another 35 percent replied that it is customary for children to look after parents. These reasons reflect the values adhered to by ageing parents who invest heavily in children for securing a better future when they themselves are unable to fend for themselves. Table 14 also shows that 35 percent of the elderly men and women reported that they do not consider

children to be their main support in old age. Their reasons for expressing this view indicate their pain and feelings of betrayal by children. As can be noted from Table 14 about 35 percent reported that children have become selfish and do not want the responsibility of ageing parents. About 17 percent opined that only God is their support, 12 percent indicated a reason which points to the greed and selfishness of children i.e. that children will only look after parents if the latter had money while 11 percent reported that the son may be willing to look after the elderly parents but the daughter-in-law would not like this responsibility. In view of these responses, the elderly were therefore asked who they feel should care for them in the context of changing traditional family values. It is interesting to note from Table 14, that children still feature largely in the care of ageing parents since 43 percent reported that sons should care for the elderly and 25 percent felt that both sons and daughters should take care of the elderly. About 37 percent reported that the spouse should care for them, probably forgetting that the spouse is also getting old or that one of them would probably die earlier than the other. Surprisingly, not a single respondent has voiced the role of the government in providing the much needed support in the care of this group of the population, whose numbers are going to increase in the future.

SUMMARY AND CONCLUSIONS The present study was undertaken with the overall objective of understanding the existing institutional facilities available for the care of the elderly and to obtain the perspectives of the elderly men and women living in old age homes regarding institutional living, in the state of Gujarat. A sample of 25 old age homes, government aided and NGO managed, from various parts of Gujarat was selected to obtain information on institutional facilities from the managers of these homes. A further sample of 233 elderly men and women (about 9-10 from each home) was also drawn to obtain perspectives of the elderly. Interviews with the managers of the old age homes has revealed that a little over half of the old age homes have been in existence for more than 15 years while just five institutions are relatively new as they had been established during the last 5-6 years. All the surveyed homes are residential in nature and since most of them are NGO supported, their major source of funding is either through individual donors or by the trust that has established them. Almost fifty percent of the homes surveyed either do not charge anything for accommodation and other services from inmates or waive the charges for those who cannot pay, less than half require compulsory full payment from all inmates whereas just two managers reported that they charge a nominal amount from the inmates. The intake capacity of the homes varies from 25-100 and more and most of

them accommodate both men and women. Very few homes are for only men or only women. The results of interviews with the heads/managers of the old age homes has also revealed that they are unable to meet the growing demand for old age homes as reported by more than two-thirds of the institutional heads. Furthermore, despite charging the elderly for accommodation and other services, the institutions are not adequate with respect to various services and staff for care taking due to inadequacy of funds. Yet another important limiting feature of the old age homes surveyed, pertains to their criteria for admitting an elderly person. Majority (fourfifths), of these institutions, do not admit the elderly who have any diseases, especially infectious diseases, are unable to take care of themselves or are not in good physical and mental health. In fact, this is the group most likely to be in need of good health and medical care. Regarding the difficulties of managing such an institute is the inadequacy of funds for medical care and other service provision as well as in employing sufficient number of staff for care of the elderly. The perspective of the elderly living in old age homes sheds light on their socio-economic and other characteristics and attitudes towards institutional living. It is noted that the majority are not highly educated, particularly elderly women, and were in lowly paid jobs with meager savings to meet their requirements during their old age. The background characteristics further reveal that about 29 percent of elderly men and 8 percent of elderly women had never married. The proportion of widows was much higher (64 percent) than widowers (35 percent). With regard to their familial background, it is interesting to note almost one fourth of the elderly had lived alone prior to coming to the old age. Among them, more men (28 percent) than women (20 percent) had reported that they had lived alone. The picture with regard to living arrangements in the old age homes shows that the majority of the elderly have to share a room and toilet facilities with other age mates in the institute, which often causes conflict among them. Some have also reported on the dissatisfaction with the quality of meal provided. Regarding experience of health problem or illness, the results indicate that the majority i.e. 86 percent have reported the common problems of ageing such as failing eye-sight and hearing, arthritis, dental problems, weakness, sleeplessness, lapses in memory, asthma, hypertension, problems in mobility and back pain. Relatively more women (89 percent) than men (82 percent) have reported about a current health problem. There opinions regarding satisfactions and dissatisfactions with the various services indicates that the majority are satisfied with the services provided and with the care taking of the staff. Among the reasons for choosing institutional living arrangements, the absence of close family and relatives to take care of them coupled with their own ill health or that of their spouse is the foremost reason reported by the elderly. This is, in fact, further supported by their background characteristics wherein 18 percent of

the elderly had never been married, while about 57 percent were either widowed or divorced. Most startling are the results, which indicate that the demand for institutional living arrangements in the face of weakening traditional familial support has increased as grown-up children find it difficult to simultaneously care for their own children and ageing parents. This virtually compels the elderly to move out of the care of the family to such impersonal arrangements, where they are struggling to make a new meaning of their lives, seek solace and comfort in age mates, adjust to the discipline of institutional living and to unfamiliar living arrangements including the peculiarities of age mates. Such familial conflicts as a cause for choosing institutional care finds confirmation from the fact that more than fifty percent of the elderly had been living in a joint family before coming to the old age home. In addition, about one third have reported that they choose such an arrangement due to familial conflict, about 11 percent stated that such an arrangement enabled them to live a life of dignity and self respect and a little less than one-fifth had chosen institutional living as they did not want to be a burden on family members. Finally, the results suggest that while the physical ties of the elderly men and women with their adult children have weakened or snapped completely, their psychological and emotional bond with them remains strong. This is reflected by the fact that more than sixty percent of the elderly living in old age homes still adhere to the view that children are the main support for parents in old age. It is therefore a sad reflection that these expectations of the elderly for the care and comfort from their children remain unfulfilled. The results therefore suggest that the state should be prepared to meet the need for good institutional living arrangements for the elderly as the demand for such care is likely to rise in the future. Simultaneously, some sort of counseling services will also need to be developed and incorporated in the larger programmes for the elderly to address their psychoemotional health in addition to the service provision for their physical health.

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