University of Ghana http://ugspace.ug.edu.gh COLLEGE OF HUMANITIES UNIVERSITY OF GHANA CARE OF THE AGED IN CONTEMPORARY GHANA BY ANGELINA OPOKU YEBOAH (10483823) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF ARTS IN SOCIAL POLICY STUDIES JULY, 2019. University of Ghana http://ugspace.ug.edu.gh i University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to the Almighty God who has brought me this far. I also dedicate it to my parents Mr and Mrs Yeboah and all my siblings Eunice, Angela, Francisca, Sandra and Francis. MAMA, once again, WE MADE IT. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My utmost thanks go to the Almighty God for making this work and my stay in Legon a wonderful and a successful one once again. Indeed, thou hast brought me thus far. I will also like to render extreme appreciation to my supervisor, Dr. Charles Ackah, Director of the Centre for Social Policy Studies, University of Ghana for his time, guidance and constructive criticisms and helping to make this work a success. I express my profound gratitude to my family; Mr and Mrs Emmanuel Yeboah, Eunice, Angela, Francisca, Sandra and Francis for their love, understanding and encouragement. To you guys, I say you are amazing and together we have done it once again to the glory of God. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Table of Contents DECLARATION ..................................................................... Error! Bookmark not defined. DEDICATION ................................................................................................................... i ACKNOWLEDGEMENT .................................................................................................. iii TABLE OF CONTENTS .................................................................................................... iv LIST OF TABLE(S) ......................................................................................................... vii ABSTRACT .................................................................................................................. viii CHAPTER ONE ............................................................................................................... 1 INTRODUCTION ............................................................................................................. 1 1.1 Background .............................................................................................................. 1 1.2 Problem Statement ......................................................................................................... 4 1.3 Objectives ........................................................................................................................ 5 1.4 Research Questions ......................................................................................................... 6 1.5 Significance of The Study ................................................................................................. 6 1.7 Limitations of The Study .................................................................................................. 6 1.8 Organization of The Study ............................................................................................... 6 1.9 Conclusion ....................................................................................................................... 7 CHAPTER TWO .............................................................................................................. 8 LITERATURE REVIEW ..................................................................................................... 8 2.1 Introduction .................................................................................................................... 8 2.2 The Process of Ageing ...................................................................................................... 8 2.3 Challenges of Ageing ....................................................................................................... 11 2.3.1 Health Challenges ......................................................................................................................... 12 2.3.2 Socio-Economic Challenges .......................................................................................................... 13 2.4 Caregiving ....................................................................................................................... 16 2.4.1 Traditional Caregiving Arrangements ........................................................................................... 17 2.4.2 New and Emerging Forms of Caregiving Arrangements in Ghana ................................................ 19 2.4.3 Other Support Systems ................................................................................................................. 21 2.5 Quality of Life ................................................................................................................. 22 2.6 Modernization and its Ramifications on Ageing and Caregiving ...................................... 23 2.7 Concepts ......................................................................................................................... 24 2.7.1 Ageing ........................................................................................................................................... 24 2.7.2 Elderly or Aged ............................................................................................................................. 24 2.7.3 Caregiving ..................................................................................................................................... 25 iv University of Ghana http://ugspace.ug.edu.gh 2.7.4 Normative Values ......................................................................................................................... 25 2.7.5 Quality of Life ............................................................................................................................... 25 2.8- Conclusion ..................................................................................................................... 25 CHAPTER THREE .......................................................................................................... 26 METHODOLOGY .......................................................................................................... 26 3.1 Introduction ................................................................................................................... 26 3.2 Research Design ............................................................................................................. 26 3.3 Phenomenology ............................................................................................................. 26 3.4 Research Area ................................................................................................................. 27 3.5 Target Population ........................................................................................................... 29 3.6 Sampling Technique ........................................................................................................ 30 3.7 Sample Size .................................................................................................................... 30 3.8 Methods of Data Collection ............................................................................................ 31 3.8.1 Data Handling and Analysis .......................................................................................................... 31 3.9 Ethical Consideration ...................................................................................................... 32 3.10 Conclusion .................................................................................................................... 32 CHAPTER FOUR ........................................................................................................... 33 PRESENTATION OF FINDINGS ...................................................................................... 33 4.1 Introduction ................................................................................................................... 33 4.2 Demographic Characteristics of Study Participants ......................................................... 39 4.3 Norms and Expectations of Care among The Elderly ....................................................... 40 4.4 Old and new caregiving Arrangements ........................................................................... 42 4.6 Experiences of care and quality of life among the elderly ................................................ 46 4.7 Challenges Faced by Caregivers working with the elderly ................................................ 47 4.7.1 Challenges at The Institutional Level ............................................................................................ 47 4.7.2 Challenges Faced by Family Caregivers ........................................................................................ 48 4.8 Sources of Support for the Elderly ................................................................................... 49 4.8.1 Formal Support ............................................................................................................................. 49 4.8.2 Informal Support .......................................................................................................................... 50 4.9 Discussion of Findings ..................................................................................................... 51 4.10 Norms and Expectations of Care among The Elderly ...................................................... 51 4.11 Old and New Caregiving Arrangements ......................................................................... 53 4.13 Experiences of Care and Quality of Life among the Elderly ........................................... 57 4.14 Challenges Faced by Caregivers working with the Elderly .............................................. 58 4.14.1 Challenges Faced at the Institutional Level ................................................................................ 58 4.14.2 Challenges Faced by Family Caregivers ...................................................................................... 59 4.15 Sources of Support ........................................................................................................ 60 v University of Ghana http://ugspace.ug.edu.gh 4.15.1 Formal Support ........................................................................................................................... 60 4.15.2 Informal Support ........................................................................................................................ 60 CHAPTER FIVE ............................................................................................................. 62 SUMMARY OF FINDINGS, RECOMMENDATIONS AND CONCLUSION ............................. 62 5.1 Introduction ................................................................................................................... 62 5.2 Summary of Findings ...................................................................................................... 62 5.3 Recommendations .......................................................................................................... 64 5.4 Conclusion ...................................................................................................................... 65 5.5 Summary ........................................................................................................................ 66 REFERENCES ................................................................................................................ 67 APPENDIX: INTERVIEW GUIDE ..................................................................................... 74 vi University of Ghana http://ugspace.ug.edu.gh LIST OF TABLE(S) Table 4. 1: Demographics ................................................................................................... 39 vii University of Ghana http://ugspace.ug.edu.gh ABSTRACT The population of Ghana and the world at large is not only growing but it is also greying. This increase in the number of senior citizens has come with its accompanying challenges and this has placed it on the world’s agenda. The growing number of older persons in Ghana, a country which valued norms of reciprocity and filial piety, has brought about new forms of elder care because of the decline in extended family support. This research project used qualitative methodology specifically in-depth and semi-structured interviews with older residents of Mercy Home and members of Help Age to understand the normative values and expectations of what constitutes quality care for the elderly and how caregiving affects quality of life. It explored the perceptions of both caregivers and the elderly about emerging forms of caregiving arrangements. Challenges faced by caregivers in providing quality care for the elderly was also explored. Findings from the study revealed that older persons expect caregivers to assist them with activities of daily living. Participants cited disability status, location of children, finance, values and availability of caregivers as factors determining caregiving method adopted. All participants believed caregiving impacts quality of life. Additionally, challenges faced by caregivers ranged from financial to emotional and physical. This study contributes to literature by providing qualitative insight into the normative values and expectations of older persons. viii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background The Ghanaian population is not only increasing in number but it is also greying. For instance, the 2010 Population and Housing Census estimated the Ghanaian population 60years and above to be 1.6million which signifies a more than seven-fold increase since the 1960 census which was 213,477 (Ghana Statistical Service, 2010). In 2000, older persons aged 65years and above constituted 5.3% of the Ghanaian population (Ghana Statistical Service, 2010) and this signified an increase from 4.0% in 1984 (Ministry of Employment and Social Welfare, 2010). By 2050, it is estimated that this proportion will rise to 15% (World Bank, 2000). The Ghana National Ageing Policy states that the oldest old, that is, those who are 85 years plus is the fastest growing group of the older population in Ghana (Ministry of Employment and Social Welfare, 2010). The proportion of the female elderly population is 56% as compared with 44% of the males. Again, 54% of the elderly population resides in rural areas with 46% in urban centres (Ministry of Employment and Social Welfare, 2010). Ageing populations are becoming a common feature of the world. The growth in the elderly population around the world is a testimony of improved health care and nutrition, education, reduction in infectious and parasitic diseases among others (Mba, 2010). In the developed world, the transition process leading to an ageing population has taken place over the span of about a century (Angel & Angel, 1997) giving ample time to prepare and cope with the increased numbers of elderly people (Mba, 2004). In Africa, this transition process is rather occurring quickly (Mbamaonyeukwu, 2001) and this has led to some ageing crisis including; poverty, developmental challenges; health challenges; and gender issues (Ministry of Employment and Social Welfare, 2010). 1 University of Ghana http://ugspace.ug.edu.gh Care giving is a very important aspect in the life of the elderly. “Caregiving is characterized by attention to the needs of others” (Hermanns & Mastel-Smith, 2012). There are 2 main systems of long-term care for the elderly; informal care providers such as the unpaid family members and formal care providers, such as nursing aides, home care assistants and other paid care workers. Most care delivered to older people in Ghana is unpaid care provided by family members, mainly women, and is sometimes supplemented by the labour of formal caregivers. “While not all longevity is associated with ill health and increased need for care provision, the proportion of the population that is living longer means that more people will need support and care as they move to end of life” (Boggatz & Dassen, 2005). Long term care is mostly family based in Sub Saharan Africa because of norms of reciprocity and also due to grave lack of formal care replacements or enough funds to afford other formal care alternatives. “Indications of increased use of formal care, especially among urban older people in the Arab region are emerging” (Hussein & Ismail, 2017) and this phenomenon is also seen to be rising steadily in Ghana. Age and ageing as a process are socially and culturally defined (Ennuyer, 2002), implying “old age can be a privilege in a given space and time whereas it can lead to social exclusion in another” (Lagace, Charmarkeh & Grandena, 2012, p412). In countries in the global North where individuality and autonomy are of high esteem (Bourbonnais & Ducharme, 2010), ageing is seen as a disadvantage whereas countries of the Southern hemisphere which place more importance on interdependence and filial piety (Lagace et al, 2012) make people have a positive view of ageing. Studies on the perception of ageing in Sub-Saharan Africa revealed that traditional Sub-Saharan African societies are rather gerontocratic and seniors continue their autonomy through the practice of initiation rites, esoterism and oral transmission of knowledge and traditions and the propensity for the older group to live with their children still remains robust (Devisch, Makoni & Stroeken, 2002; 2 University of Ghana http://ugspace.ug.edu.gh Attias-Donfut & Gallou, 2006; Lagace et al., 2012; Echeta & Ezeh, 2017). Thomas (1983) and Diop (1989) explain that although the aged in sub-Saharan Africa are still thought of as vital pillars of the community, their experience, knowledge and wisdom are more and more challenged by younger generations. Such threats to traditional social ties can be partly attributed to the impact of modernization, globalization and formal education (Cohen & Menken, 2006). Ghana, the country under study is a country in sub-Saharan Africa undergoing massive social change. In Ghana according to the Ghana National Ageing Policy (Ministry of Employment and Social Welfare, 2010), older men and women remain active participants in community matters, politics and cultural life at the community level in the rural areas (where more than 70 % of the population live). The older generation are still regarded as the custodians of culture and tradition in rural setting and play active roles in the traditional chieftaincy system (politics) and cultural life. Contrarily, in the urban areas their roles are gradually being wind-swept by the contemporary institutions of urbanization and there is currently no mechanism in place to address that. According to the Ministry of Employment and Social Welfare, (2010), in the past older persons were accorded a notable place in the society, but social change resulting from urbanization, migration and other global issues have affected traditional norms in recent times. The focus of this study was to examine the normative values and expectations of what constitutes quality care for the elderly and how the care the elderly receives affects their quality of life all from their perspective. It also sought to explore the perceptions of both caregivers and the elderly about the new forms of caregiving arrangements adopted in recent times to complement the efforts of the family. The study also sought after understanding challenges faced by caregivers in providing quality care for the elderly. 3 University of Ghana http://ugspace.ug.edu.gh 1.2 Problem Statement Caregiving for the aged is a very essential aspect of their lives. Studies have shown that members of the family are important sources of home caregiving for those senior citizens who are not able to take care of themselves (Stone, Cafferata & Sangl, 1987; Freedman, Soldo & Wolf 1997). Currently, family support for the elderly has reduced (Aboderin, 2004; Mba, 2004; Kwankye, 2012). The idea of an erosion of the extended family dates back to early sociological analyses of family structure (Ogburn & Tibbits, 1933; Ogburn & Nimkoff, 1955). For instance, Freedman, Soldo and Wolf ‘s (1997) study revealed that demographic trends will modify the size and statuses of families in ways that will impede families’ ability to be the main agent of community-based elder care. What is more, the United Nations Organization (UNO) in 1982 was driven by the fear that without formal support structures in most developing countries, the decline of family support would lead to a crisis in the support of elder persons (Aboderin, 2004), and this later manifested in the resulting International Plan of Action on Ageing (IPAA) (Sen 1994; UNO 1982). Mba’s (2004) study in Ghana revealed that modernization and urbanization, has weakened the traditional solidarity network. Specifically the extended family system is collapsing, leaving older people with little or no means of support. This has put Ghana’s fast growing number of older people in a precarious condition possible to perpetuate poverty (Mba, 2004). Considering the fact that the extended family support system is rapidly declining (Kwankye, 2012), there is the need for “the timely development of policy responses to secure the well-being of older people” (Aboderin, 2004, p). There is an increasing body of research on the aged in Ghana. For example, Kwankye’s (2012) study on the health and economic implications of growing old in Ghana in 2012; Mba’s (2004) study on population ageing and poverty in rural Ghana; Ayernor’s (2012) study on diseases of ageing in Ghana and Tawiah’s (2011) study on population 4 University of Ghana http://ugspace.ug.edu.gh ageing in Ghana: a profile and emerging issues to mention but a few. Notwithstanding the increasing number of studies, the experiences, expectations and values of the elderly with regards to the care they receive from the perspective of male and female elderly Ghanaians have not been fully explored. Taking on older persons using family care and institutional care as a means of analysis, this study seeks to explore and understand the expectations of the elderly on the meaning they ascribe to the care they receive, emerging long term caregiving arrangements, and investigate how the care they receive improves their quality of life from the lenses/perspectives of the elderly who receive the care. Similarly, there are limited studies on emerging caregiving arrangements for the elderly in Ghana. Fewer studies exist on institutional care for the aged in Ghana, domiciliary caregiving and NGO assistance for the aged. This study seeks to also explore emerging alternative caregiving arrangements for the aged in Ghana and how the aged who receive the care perceive the care they receive. It also seeks to understand the general perception of the elderly and caregivers on these new forms of care that are emerging in the country. 1.3 Objectives The main objective is to investigate the normative attitudes, values and expectations on what constitute quality care for the elderly and explore the perceptions of people on emerging alternative long-term caregiving arrangements. 1. investigate the normative values and expectations on what constitute quality care for the elderly. 2. Explore the views of the elderly on how the care they receive affects their lives. 3. To explore the perceptions of the elderly and caregivers on emerging alternative long-term caregiving arrangements. 5 University of Ghana http://ugspace.ug.edu.gh 1.4 Research Questions 1. What are the normative attitudes, values and expectations on what constitute quality care for the elderly? 2. What are the views of the elderly on the effect of the care they receive on their life? 3. What are the perceptions of the elderly and caregivers on emerging long-term caregiving arrangements? 1.5 Significance of The Study Findings such as challenges faced by caregivers and the elderly will inform policymakers about the gaps in existing policies. The findings can also be used by policymakers in reviewing existing policies or when designing new policies. This research will go a long way to fill a gap in literature on the new forms of elder care and also inform researchers of other areas worthy of study. 1.7 Limitations of The Study The study adopts qualitative methodology leading to the use of a few participants. This gives a clear indication that conclusions drawn cannot be generalised due to the small number of study participants. However, the study still gives an idea and helps in understanding how the elderly in Ghana are being cared for in their everyday lives and helps to get a clear picture of whether their expectations are being met. 1.8 Organization of The Study The study is arranged into five (5) chapters: • Chapter 1 introduced the study by discussing the background, objectives, problem statement and its significance. • Chapter 2 contains the literature review. Here, information is given about other scholarly work in the field of ageing and also provides a conceptual framework within which the study will be understood. 6 University of Ghana http://ugspace.ug.edu.gh • Chapter 3 contains the methodology. Information is given about the given about the research area, research design, the target population, the sampling technique that will be used to collect data and the data collection procedure. It expands more on the research method used, the reasons for such and its significance. • Chapter 4 contains presentation and discussion of findings. Findings are discussed using themes generated from the objectives. • Chapter 5 concludes and make recommendations to policymakers and future researchers. 1.9 Conclusion This chapter discussed the background of the study, problem statement, objectives, significance of the study and also defined the key concepts in the study. Findings of this study will be beneficial to academia since it will add to knowledge and stimulate further research as well as informing policymakers about gaps in existing policies and making recommendations on the way forward. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents the literature review and theoretical framework on ageing and caregiving. Using relevant scholarly articles on ageing and caregiving, the section synthesized literature on the following themes: the process of ageing; challenges of ageing; caregiving; and modernization and its ramifications on caregiving. The chapter provides a theoretical framework within which the study was understood. 2.2 The Process of Ageing “Ageing is a broad concept that includes physical changes in the bodies of individuals over adult life, psychological changes in human minds and mental capacities, and social changes in how humans are viewed, what humans can expect, and what is expected of humans” (Atchley & Barusch, 2004, p. 4). Ageing is biologically and socially defined. As a biological component, most evolutionary biologists define ageing as an age- dependent or age-progressive decline in intrinsic physiological function, leading to an increase in age-specific mortality rate and decrease in age-specific reproductive rate (Promislow & Bronikowski, 2006; Flatt & Schmidt, 2009; Bronikowski & Flatt, 2010; Fabian & Flatt, 2011). According to Flatt (2012), ageing leads to a steady decrease in mental and physical capacity resulting in high risk of diseases and death. Age and ageing as a process according to Ennuyer (2002) are socially and culturally defined which implies that old age can either be a privilege in one place while leading to social exclusion in another (Lagace et. Al 2012). People are born into societies and socialized based on the customs and traditions of that society. People’s social world 8 University of Ghana http://ugspace.ug.edu.gh therefore has a great impact on their lives, ageing inclusive. Beyond this and other biological factors as well, ageing can also be associated with life transitions such as retirement, relocation to more appropriate housing and the death of family and/or friends (World Health Organization retrieved from www.who.int//ageingandhealth on 01/06/2019). The manner in which elderly people are valued differs by culture (Holmes & Holmes, 1995) and per se culture change has a significant effect on respect for the elderly (Simic, 1990; Streib, 1987 cited in Sung, 2004). For older persons, some necessities include care, food, shelter, healthcare, security, respect, among many others. All these determine the quality of life of the elderly. Studies (for instance, Cohen-Mansfield, Ejas & Werner, 2000; Noelker & Harel, 2000; Sung, 2004) have found out that respect is a necessity to elderly persons and plays a key role in determining their quality of life and maintaining their status and dignity. Africans value filial piety (respect for parents and grandparents), reciprocity and cooperation (Oppong, 2006). For countries of the global South, significance is given to interdependence and norms of filial piety (Lagace et al, 2012) which enables people to have a more positive view of ageing. Studies (for instance, Devisch, Makoni & Stroeken, 2002; Attias-Donfut & Gallou, 2006; Lagace et.al, 2012; Ncube, 2017) on perceptions of ageing in Sub-Saharan African societies revealed that traditional societies in Sub-Saharan Africa value ageing in the comfort of familiar surroundings. The societies are gerontocratic so seniors can maintain their authority through the practice of initiation rites, esoterism and oral transmission of knowledge and traditions. The elderly in Sub-Saharan Africa are seen as a repository of knowledge and serve as the custodians of the norms and customs of their society. This knowledge is believed to have been gained through experience in their life course. The propensity for the older age group to live with their children still remains strong. 9 University of Ghana http://ugspace.ug.edu.gh In countries of the Northern hemisphere, individuality and self-rule are extremely valued (Bourbonnais & Ducharme, 2010) thus making ageing a disadvantage. Studies such as Lagace et al (2012) and Palmore’s (1999, 2001, 2004) have identified the adverse beliefs and outlooks towards both the ageing process and the senior citizens who symbolize the process. Butler (1969) conceptualized such views and thoughts under a concept known as ageism. Ageism involves marginalizing and denying older persons of their privileges (Lagace et al, 2012). Ageism has resulted in stereotypes of ageing which involves expectations about how people at or above a certain age should act without regard for individual differences (Dionigi, 2015). Stereotypes faced by the elderly could be positive (wealthy and wise), negative (disease, being alone, reliance and poor physical and mental effectiveness) or neutral and they are continually changing over time and across contexts (Dionigi, 2015). A study by Lagace et al (2012) of elder Somalis living in Canada found out that the elderly Somalis described the loss of social status as you age as the most difficult issue they have to deal with in Canada and other western countries. This is because unlike sub-Saharan Africa where seniors could maintain their autonomy through practices of initiation rites and esoterism, the elderly in the western world are more vulnerable to society. “Here (in Canada), you just sit in coffee shops, back home (Somalia) you become an elder” (Lagace et al, 2012, p12). This is evidence that in such a cultural context ageing is seen as a disadvantage, a process which many people want to avoid. With regards to ageing in Ghana, the Ghana National Ageing Policy, 2010 states that older persons are continually involved in community issues and are still regarded as the custodians of culture and tradition in rural areas (where more than 70 % of the population live). Contrarily, in the urban areas, their roles are declining due to urbanization and there 10 University of Ghana http://ugspace.ug.edu.gh is presently no means in place to tackle that (Ministry of Employment and Social Welfare, 2010). 2.3 Challenges of Ageing The sharp rise in the numbers of elderly population have received overwhelming interest because of the notion that costs to society and families will intensify with the increasing number of dependent older people (Aikins, Aryeetey, Amendah, Nonvignon & Nortey, 2017). In the developed world, the demographic transition leading to an ageing population has taken place over a long time (Angel and Angel, 1998) giving sufficient time to plan and manage the increase (Mba, 2004). In Africa, particularly Ghana, this transition is occurring quickly (Mbamaonyeukwu, 2001). This according to the Ghana National Ageing Policy has led to some ageing crisis including; poverty, development and health challenges and gender issues (Ministry of Employment and Social Welfare, 2010). Aside these, the status older people were accorded in traditional Ghanaian society is also declining. This challenge is attributed to how social change has affected the traditional norms according to the Ghana Ageing Policy (Ministry of Employment and Social Welfare, 2010). Currently, older persons in Ghana are increasingly showing signs of poverty, neglect and loneliness. Also worthy of mention is the fact that ageing affects male and female differently in physiological and social ways. Apt’s (1996) study found out that social neglect affects mostly women who are overburdened with widowhood rites and responsibilities, caregiving and social and cultural discrimination. Older persons, especially women are mostly discriminated against on the basis of gender stereotypes (ibid).. Another challenge of ageing has to do with needing of care. Levinson (2008) states the elderly need care as their personal activities get limited by developmental challenges resulting in degeneration of health, disability, frailty and incapacity for self-care. 11 University of Ghana http://ugspace.ug.edu.gh In the proceeding paragraphs, information will be given on some health, and economic challenges of ageing. 2.3.1 Health Challenges Health is defined by the World Health Organization (WHO) as a complete state of physical, mental and social wellbeing of an organism and not just the absence of infirmities. For an individual to be able to participate fully in the community, their state of health is very significant. With regards to the rapid increase in the population aged in Ghana, interrogations have been made as to whether health services and social protection programmes are well advanced to meet the needs of the elderly (Kwankye, 2012). The health of the aged is also closely linked to other life activities such as retirement, death of loved ones and physical and social environment. An ageing population will require increased access to specialized geriatric healthcare services, social protection programmes and income security. Common conditions in older age include hearing loss, cataracts and refractive errors, dementia, diabetes, high blood pressure, back and neck pain, osteoarthritis, depression among many others and people may experience several of these conditions at the same time. Most of these conditions are known as geriatric syndromes because they usually tend to occur later in life. In 2006, the World Health Organization (WHO) projected that illnesses related with ageing such as Parkinson’s disease, Alzheimer’s and other forms of dementia accounted for 6.3% of disability while Alzheimer’s and other forms of dementia alone accounted for 12% of neurological disorders (Kwankye, 2013). Ghana is faced with the weight of fighting against evolving and re-evolving communicable diseases such as HIV/AIDS, tuberculosis and malaria, with the swelling risk of non- communicable diseases. According to the Ghana Ageing Policy, older women are at a high risk to disability due to differences in life expectancy and gender inequalities over the life 12 University of Ghana http://ugspace.ug.edu.gh course (Ministry of Employment and Social Welfare, 2010). With a growing population, Ghana is not only confronted with these sicknesses but also health professionals are fast ageing with only a few specialized to serve the elderly in the country (Kwankye, 2013). With regards to access to health care services, studies in Ghana (for instance Banga, 1993; Apt & Grieco, 1995; Darkwa, 1999) revealed that people who stay in rural areas have poorer well-being and lesser access to healthcare services and may encounter social, traditional and ecological blockades which stops them from using healthcare services, as compared to people in urban areas. Policies that assist the elderly with regards to healthcare in Ghana is the National Health Insurance Scheme. With the National Health Insurance Scheme (NHIS,) the healthcare needs of older Persons 70 years and above on the scheme is covered without payment of premium and it was introduced to ensure increased access to health care for older persons in Ghana. 2.3.2 Socio-Economic Challenges A large number of the Ghanaian population are engaged in informal work and therefore are not likely to contribute and benefit from formal social security programmes or pension scheme. Those in the formal sector who also contribute to formal social security programmes retire with not much as pension allowance due to inflation thereby leading to poverty and as a result most resort to informal jobs after retirement. Large numbers of senior citizens keep working into their old age until their health deteriorates and prevents them from continuing to work. Recent United Nations Population Division (2003a) calculations have shown that among the world’s major areas, Africa has by far the highest proportion of economically active people among those aged 65 or older. Due to the decline in the extended family support and high standard of living, sometimes with even regular remittance from children, most Ghanaian elderly still have to work till they die. The population of Ghanaians who are aged 65+ constitute 1.28 of the total 13 University of Ghana http://ugspace.ug.edu.gh population of the country. Male elders 65+ constitute 0.57 whereas female elders aged 65+ constitute 0.71 of the total population. According to GLSS 6, the percentage of the elderly 65+ who are economically active is 0.73 which is comprised of 0.36% males and 0.37% females (Ghana Statistical Service, 2014). This affirms the earlier assertion that most Ghanaians work till death. Women experience the effect of extreme poverty and continue to remain among excluded groups (Ministry of Employment and Social Welfare, 2010). For females, especially older women, much of their labour is unpaid, subsistence and domestic (often caring) work (Oppong, 2006). According to the Ghana National Ageing Policy, women also face difficulties acquiring assets and lack access to opportunities that produce wealth (Ministry of Employment and Social Welfare, 2010). Older persons are often deprived access to employment opportunities and are often among the primary staff to be targeted during periods of cutbacks. This makes it difficult for older persons to be engaged in active service with the resulting effect being poverty. Meanwhile, only a very small minority are in formal retirement programs or receive state pensions. Most old people work in agriculture and have no protection whatsoever in old age, other than from their families (Kasente, 2000; Oppong, 2006). Local and International Policies The care for the elderly in contemporary Africa began with the assumption that as societies westernise and extended families give way to nuclear families, care for the aged by the family declines. This led to the enactment of the International Plan of Action on Ageing (IPAA) in 1992 by the United Nations (UN) with the aim of developing policy responses to secure the well-being of people as they age and it subsequently led to the enactment of the Madrid Plan of Action on Ageing (MIPAA) which was adopted in 2002. 14 University of Ghana http://ugspace.ug.edu.gh The ratification of these instruments incurred obligations on all member states of the United Nations to adopt policies in line with the goal and objectives of the instruments. In line with these conventions the Government of Ghana passed the 1992 Constitution and specifically the Ghana National Ageing Policy in 2010 to address the multiple discriminations against older people, particularly women who are usually discriminated against on the basis of gender through the implementation of programmes and projects in consonance with policy recommendations. Some of these programmes include the Livelihood Empowerment Against Poverty (LEAP) programme. It is a non-contributory social transfer for some elderly persons. In Ghana, the LEAP programme involves cash transfer geared towards assisting caregivers. It targets extremely poor households with at least one eligible member who is either caring for an orphan or a vulnerable child, or an elderly or disabled person who is unable to work. Household selection is done at community-level by the Community LEAP Implementation Committees (CLICS) and verified centrally by a proxy means test. Households receive a cash transfer every 2 months based on the number of eligible members within the household capped at 4 per household. All members of participating households receive free enrolment in the NHIS (Ministry of Employment and Social Welfare, 2010). Transfers are done physically in the community permitting sensitization (Roelen, Delap, Jones & Chettri, 2016). As part of the benefits of LEAP, older Persons (65 years and above) without productive capacity in Ghana are given conditional and unconditional cash transfer on bi-monthly basis. In addition, the National Health Insurance Scheme (NHIS) is a programme also aimed at improving the well-being of people in Ghana including older persons. The NHIS covers the healthcare needs of older Persons 70 years and above on the scheme without payment of premium. It was also introduced to ensure increased access to health care for 15 University of Ghana http://ugspace.ug.edu.gh older persons in Ghana. Then, lastly the National Pension Scheme is also a programme aimed at assisting Ghanaians specifically older persons. The National Pension Scheme developed a three-tier pension system to capture the 84 per cent informal economy in Ghana, where majority of older persons operate. 2.4 Caregiving Caregiving is a very important aspect in the life of the elderly. Caregiving involves attention to the needs of people (Hermanns & Mastel-Smith, 2012). Sociologists define caregivers as unpaid workers such as family members, friends, and neighbours There are 2 main systems of long-term care for the elderly. These include informal care providers such as the unpaid family members and formal care providers, such as nursing aides, home care assistants and other paid care workers. In many countries, family play a crucial role in caring for the aged. While not all ageing is accompanied by ill health and need for care, the fraction of the population that is ageing implies people will need care as they move to end of life (Hussein & Ismail, 2017). Many factors determine the decision regarding who the elderly lives with and this includes migratory status of the elderly, availability of children and resources, sex, family size and marital status, financial and health status of both the elderly and their relations, and shared experiences (Ncube, 2017). In Sung’s (2004) study of young Koreans and Americans, findings were evident that elders perceive caregiving as a form of respect. Care, to the elderly includes attention, care, assistance with activities of daily living and maintaining contact with them. Financial assistance and companionship are signs of care, which are also essential (Van der Geest, 2002). Some of the most common activities for which elderly people need help include grocery shopping, taking a bath, washing, and going to the toilet. 16 University of Ghana http://ugspace.ug.edu.gh Most care delivered to older people in Ghana is provided by family members, mainly women (younger spouse/ wife) and/or extended family members, and supplemented by formal caregivers (Boggatz & Dassen, 2005). Notably, gender determines who gives care and who receives the same (Schatz & Seeley, 2015) and most often women (wife/children) are the ones who provide care. According to the Ghana National Ageing Policy, in Ghana, older women are mostly the primary caregivers. (Ministry of Employment and Social Welfare, 2010). Studies (Echeta & Ezeh, 2017; Nortey et al, 2017) have documented the psychological, social and health consequences that caregivers of elderly populations face which include; offspring of senior citizens are trapped in the difficulty of trying to raise their own children, live their lives and cater for their parents who are old. These challenges have provided an impetus to the development of social policies to support caregivers in some countries. 2.4.1 Traditional Caregiving Arrangements Growing old does not only come with health challenges but also leads to making choices about who and where to live, largely influenced by culture and values (Papalia, Olds & Feldman, 2011). Long term care is predominantly family based in Sub Saharan Africa (Lagace et al, 2012) because of culture and also due to critical lack of formal care alternatives. Traditionally, the family provided support for the aged including income security and long term caregiving. Family plays a very crucial role in caring for the elderly and people who are vulnerable in many LMICs including Ghana (Nortey et al, 2017). These family caregivers are expected to assist their older relatives with performing activities of daily living including cleaning, washing, feeding, running errands, preventing falls and elderly abuse. Reliance on families alone to provide long-term care culminates in inconsistent care quality and places a particularly heavy burden on females (Dovie, 2019). Studies for instance the Ghana 17 University of Ghana http://ugspace.ug.edu.gh National Ageing Policy (Ministry of Employment and Social Welfare, 2010); Kavanaugh, Stamatopoulos, Cohen and Zhang (2016); Nortey et al (2017) and Bassah, Ubenoh and Palle, (2018) have proven that this care arrangement is currently undergoing changes as a result of; weakening of the extended family, migration in all its forms (rural-urban migration, out-country migration), urbanization, inadequate support from government and general global economic challenges. Moreover, WHO (2017) believes this form of care may be unsustainable due to the increasing number of the elderly. According to Coe (2016), people are by middle class households in some areas of Ghana whereas some urban households hire carers through commercial agencies to assist the elderly. The works of carers are often supplemented by house helps. The employment of people to supplement the effort of relatives in taking care of their elderly is a proof of how most families are suffering in taking care of their elderly. This phenomenon clearly increasing in the Arab region as well according to Hussein and Ismail’s (2017). This implies that the rising number of the elderly has led to a new type of elder care in societies who traditionally valued norms of reciprocity (Coe, 2016). The reality of poverty and the diminished adequacy of material and family support has reinforced the concern and call for policy responses and underlined the need for old age economic security policies (Apt, 1997; Aboderin, 2000). The Ghana National Ageing policy adopted in 2010 aims at strengthening family and community care for the elderly by enhancing their abilities. The policy seeks to encourage families to develop plans and incorporate in these plans strategies to support their older members (Ministry of Employment and Social Welfare, 2010). Despite the challenges faced by family caregiving, the family still serves as a safety net for the old and vulnerable. Critics of the modernization theory have stressed that families and family support are not breaking down but are adapting to new socio-economic realities, 18 University of Ghana http://ugspace.ug.edu.gh with the broad cultural values of intergenerational support remaining intact (Heslop, 1999; Aboderin, 2004). As a result, many countries are developing policies that encourage family or community-based care for aged people. New forms of care that have arisen in recent times to supplement the efforts of the family will be discussed in the proceeding paragraphs. 2.4.2 New and Emerging Forms of Caregiving Arrangements in Ghana Ageing populations have become a common feature of the world and it is placing new demands on societies to provide comprehensive systems for long-term care at home, in communities or institutions (Dovie, 2019). These new forms of care are not without challenges. According to Okoye (2014), elderly abuse has arisen due to lack of government intervention and the weakened extended family. Some elders are abused and sometimes lose their money and other precious things to hired workers (ibid.). These new forms of caregiving methods include; 2.4.2.1 Home Care by professional carers Home care according to Boerma, Kroneman, Hutchinson and Saltman (2012) refers to assistance provided by professionals in the homes of the elderly. This type of domiciliary/live-in caregiving method is popular in the United Kingdom and USA. Coe’s (2016) study in Ghana revealed this occupation of carers is often confused with house helps and nurses. The increasing care agencies signify a growing commercialization of care. In Ghana, carers with a “carer” credential earned by completing either a Health Assistant Training (HAT) or Health Assistant Clinical (HAC) are employed into the homes of the elderly to provide care for them. They are most often assisted by house-helps. What distinguishes carers from house helps is their remuneration, biomedical training and their supervision and management by an outside agency. Private nursing services currently is a luxury because of its expensive nature so those who patronize these services are either 19 University of Ghana http://ugspace.ug.edu.gh wealthy themselves or have wealthy children footing the costs. This form of caregiving relatively small since most Ghanaians cannot afford the costs that come with it. 2.4.2.2 Non-Governmental Organizations The engagement of philanthropic institutions in development is far from new (Youde 2013; Nally & Taylor 2015). Another growing form of elder care in Ghana is the springing up of non-governmental organizations that assist the elderly. Some of these organizations in Ghana include Help Age Ghana, the Akrowa Aged-Life Foundation, Ripples Health Care, Society for the Aged Ghana, and Aged Help Foundation Ghana. Government cannot solve challenges of ageing alone due to the increase in the population of older persons and as such NGOs have played a key role in bringing to the forefront the socioeconomic and health problems of older people and helping to find solutions to them (Shawney, 2003). Information and literature about the activities of NGOs who assist the elderly in Ghana is limited. 2.4.2.3 Institutionalization An institutional care denotes a place of residence for older adults who require continual nursing care and have significant difficulty in relation to coping with the essential activities of daily living (ADLS) (Dovie, 2019). Institutional care includes, for example, help with everyday routines, rehabilitation, support and guidance, recreational activities and health care or treatments (www.hel.fi//institutionalcarefortheelderly retrieved on 4/04/2019). Ageing does not only come with a decline of physical strength and health; it behoves the elderly and their families to make decisions on living arrangements and social support systems. Such living arrangements include institutionalization (care homes). In Ncube’s (2017) study in Zimbabwe, he pointed out that indigenous Zimbabweans value ageing in the comfort of familiar people and surroundings. Therefore, according to Tran (2012), institutionalization invokes in elderly people negative feelings of regret, 20 University of Ghana http://ugspace.ug.edu.gh powerlessness, guilt and neglect. Dhemba and Dhemba (2015) therefore believe institutionalization of elderly Africans is shunned and is only adopted as a last resort. The family is still expected to care for their elderly in Africa. Van der Geest (2002) notes that formally organized services for the elderly did not exist in Ghana as of 2002 because there was no single institution for care of elderly people. The only facilities that were available in Accra and perhaps a few other places were day care centres where elderly people could meet each other and pass time with games and other activities. In Egypt according to Boggatz and Dassen (2005), institutional homes are concentrated in the cities reflecting a greater need for institutional support there, as it is where the traditional social network has changed most. Reasons for staying in care homes include the feeling of being a burden, lack of family care, family problems, loneliness, lack of affection and fear of illness (Boggatz & Dassen 2005). 2.4.3 Other Support Systems There is limited emphasis on family caregiving and support to the elderly because it lies outside the market economy (Nortey et al, 2017). Family members usually support older persons through remittances (ibid.). In as much as family support is declining, many older people get a substantial part of their maintenance from their children (Oppong, 2006). The GLSS 6 revealed remittances to parents are the second highest aside remittances to children in both rural and urban localities (Ghana Statistical Service, 2014). From the survey, female parents in urban localities receive a greater proportion of remittances (38.3%), followed by their rural counterparts (27.7%). The survey further revealed parents who are males in urban areas receive a greater proportion of remittance (21.6%) than their male counterparts in the rural areas (10.1%). In total, remittances to male parents constitute 16.2% of all household income whereas that of female parents constitute 34.4% of all household income (Ghana 21 University of Ghana http://ugspace.ug.edu.gh Statistical Service, 2014). It is believed that female parents or older women receive higher remittance because they live with and nurture their grandchildren. The Ghana Livelihood Empowerment against Poverty (LEAP) Programme is a social assistance program for elderly persons aimed at providing financial support for them. Beneficiary households receive a cash transfer every 2 months based on the number of eligible members within the household capped at 4 per household. All members of participating households receive free enrolment on the NHIS. As part of the benefits of LEAP, older Persons (65 years) and above without productive capacity in Ghana are given conditional and unconditional cash transfer on bi-monthly basis. It is aimed at shielding some older persons and caregivers from the harsh economic climate. 2.5 Quality of Life In the promotion of health and the general wellbeing of people, the notion of quality of life, how to ensure and enhance it cannot be taken for granted. Quality of life for older people has taken centre stage in theory and empirical research, though there has not been a specific focus in these studies (Vaarama, Pieper & Sixsmith, 2008; Quality of Life Research Unit). Researchers have been unable to focus on specific aspects of quality of life due to its broad and subjective definition. This is an indication of the fact quality of life cannot be accurately measured or determined using a single approach or a single set of criterion. Therefore, any attempt to persuade all for the acceptance of a single definition and a skewed measurement or determination will be an imposition and hence an imperialistic disposition. The study seeks to bring to bear unique conception and determination of quality of life among indigenous Africans. The subjective nature of quality of life and its measurement opens it to many definitions reflecting various positions and orientations. According to Accordino, Rosenthal 22 University of Ghana http://ugspace.ug.edu.gh and Freund (2000), “quality of life refers to a general feeling of wellbeing and overall satisfaction with current aspects of one’s life” (p. 354). This definition takes into consideration feelings of individuals and groups of people whose quality of life is under evaluation. This position has been reflected by Lepage (n.d.) that quality of life is linked to happiness, freedom and standard of living of people and that quality of life must always reflect personal needs, expectations and requirements of citizens. These conceptions of quality of life reflect the individual person’s urge for personal satisfaction, wellbeing and happiness. Although, there is a difficulty in defining quality of life in terms of wellbeing and satisfaction, what is clear is the fact that quality of life must be determined by the individual’s orientation, that is, the values, culture, and view of life. Quality of life can therefore be accurately determined when the assessment or measurement is done by the citizen using yardstick defined by the individual or the citizen. Reinhard, Given, Petlick, & Bemis (2007) have argued that the lack of adequate knowledge by caregivers can hamper quality care by leading to accidental harm of care recipients and carers. 2.6 Modernization and its Ramifications on Ageing and Caregiving Modernization and ageing theory argue that the status and support of the elderly weaken as societies westernise and as extended families become nuclearized (Aboderin, 2004). The idea of an erosion of the extended family dates back to early sociological analyses of family structure (Ogburn & Tibbits, 1933; Ogburn & Nimkoff, 1955). For instance, Freedman, Soldo and Wolf (1997) claimed that demographic developments will modify the families’ ability to continue serving as the main source of long-term care for the elderly. What is more, the United Nations Organization (UNO) in 1982 was concerned that in the absence of formal support structures in most developing nations, the decline of family care would result in a crisis in supporting the increasing numbers of the elderly (Aboderin, 23 University of Ghana http://ugspace.ug.edu.gh 2004). Care provision by kin members is strained because potential caregivers also being the most productive age-group of 21 to 49 (UN, 2015) are mostly employed and overburdened with responsibilities. With more women who do the caregiving entering the labour force, the support from family is declining. This has led to a growing demand of other forms of caregiving arrangements to supplement traditional caregiving methods. The ageing and modernization theory describes what is happening in the western world and explains reasons for the decline in family support. An impact of this theory to the aged is that it has clearly proved persuasive enough to grab the attention of policy makers and has helped to put the situation of the aged on both national and international agenda and discourse. “Its claims provided justification for directing resources to design programmes to assist the elderly. The prediction coupled with rapid aged population growth led to the adoption of the International Plan of Action on Ageing (IPAA) by the United Nations in 1982. This policy necessitated the timely development of policy responses by countries to secure the continued well-being of older people” (Aboderin, 2004, p 31-32). 2.7 Concepts 2.7.1 Ageing Ageing process also known as “normal ageing represents the universal biological changes that occur with age and are unaffected by disease and environmental influence” (World Health Organization, 1999). Ageing is influenced by biological and social factors such as care. 2.7.2 Elderly or Aged Definition of aged is a more country and gender specific term with “the age of 60 or 65, which is roughly equivalent to retirement ages in most developed countries been said to be the beginning of old age” (WHO, 2002). The United Nations (UN) define the aged with a cut of 60years. “The aged is defined as persons aged 60years and over” (Mba, 2002). This 24 University of Ghana http://ugspace.ug.edu.gh definition was employed for the study. Categorization of the aged are; 60-74-young old; 75- 84-old; 85+ oldest old. The term aged or elder will be used interchangeably and will denote parents, grandparents, elderly relatives, and older persons in general. 2.7.3 Caregiving “Caregiving is characterized by attention to the needs of others” (Hermanns & Mastel-Smith, 2012). The Oxford Dictionary defines caregiving as the activity or profession of regularly looking after a child or a sick, elderly or disabled person. From the study, care for the elderly includes but not limited to respect, assistance with activities of daily living and financial and emotional support. Most elderly female participants had been caregivers. 2.7.4 Normative Values Normative is defined by the dictionary as establishing, relating to, or deriving from a standard or norm, especially of behaviour. Values according to the dictionary is the regard that something is held to deserve; the importance, worth, or usefulness of something. Normative values here refer to the standard or norm that people regard as useful or important to them. For most elderly Ghanaians who value aging in the comfort of their homes, institutional care is frowned upon. For others, any form of care is valued. 2.7.5 Quality of Life The World Health Organization (WHO) defines Quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns. Quality of life is also the standard of health, comfort and happiness experienced by an individual or group. 2.8- Conclusion In conclusion, this chapter reviewed scholarly articles on ageing and provided a theoretical framework which is the modernization theory in which the work can be situated. 25 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction In this chapter, information is given about the research area, research design, the target population, the sampling technique that will be used to collect data and the data collection procedure. It expands more on the research method used, the reasons for such and its significance. 3.2 Research Design This study sought to explore and understand the views of the elderly on the meaning they ascribe to the care they receive. It also sought to discover the perceptions of the elderly and caregivers on emerging caregiving arrangements for the elderly in the country. As a result of this, a qualitative research design was used for the study. According to Zhang and Creswell (2013), a qualitative design is a way of studying and making clear the meanings individuals or groups give to a social or human problem. A qualitative research enables one to gain comprehensive information on the experiences of participants to gather data in their settings, analyse the data inductively and for explanations of the meanings of the data (Creswell, 2017). For the purpose of this study, the phenomenological approach in qualitative research was used. 3.3 Phenomenology Phenomenology is a qualitative research inquiry method argued for by sociologists such as Marx Weber among others. According to Creswell (2017), phenomenological research is a design of inquiry in which the researcher describes the lived experiences of individuals about a phenomenon as described by participants. The focus of phenomenology 26 University of Ghana http://ugspace.ug.edu.gh is on the individual experiencing the phenomena (Green & Thorogood, 2009). Phenomenology was suitable because the study endeavoured to understand the values and expectations older persons associate with quality care for themselves. It also explored their views and that of caregivers on emerging alternative caregiving arrangements for the elderly. This means the lived experiences of participants needed to be explored. Therefore, the study adopted phenomenology to be able to explain the views of participants experiencing the phenomenon. Giorgi and Giorgi (2003) argue that phenomenology involves using interviews to gather descriptions of participant’s lived experiences, their written or verbal responses. By reason of this, in-depth interviews were used for the study to gain information from participants of the study. The phenomenological approach enabled elderly participants to narrate their views and perceptions on what they deemed as quality care. It also gave caregivers the opportunity to expatiate on the caregiving method adopted and the reasons for such. In order to avoid researcher biases, researcher’s preconceived thoughts, views and perceptions were kept in check so as not to interfere with the findings of the study as suggested by Finlay (2008). Furthermore, recommendations by participants on what could be done to mitigate the crisis of old age in Ghana to improve the quality of life of life of the elderly in the country has been captured in the study. 3.4 Research Area The study was undertaken in Accra located in the Greater Accra Region of Ghana. Accra is the capital town and largest city of Ghana covering an area of 225.67km2 with an estimated urban population of 2.27million as of 2012. Accra is surrounded by towns such as Nsawam in the Eastern region, Kasoa in the Central region and Tema. Accra serves as the Greater Accra region’s economic and administrative hub. Due to this, there are many 27 University of Ghana http://ugspace.ug.edu.gh migrants in Accra for work, tourism and trade among many other reasons and this has led to a high population in the city. Accra’s population is estimated to be a youthful one. Rural- urban migration has seen many people migrating to Accra alone leaving their extended families behind. This has led to a reduction in the extended family support since migrants mostly do not have their kin present to assist them. The Ghana Living Standards Survey (GLSS 6) identified the aged male between the ages of 60-64 as constituting 0.7% of the population of Greater Accra Metropolitan Assembly whereas the females aged 60-64 constituted 1.165% of the population in Accra. The population of the elderly 65 and above was estimated to be 1.5% for males and 1.6 for the females in the Greater Accra Metropolitan Assembly (Ghana Statistical Service, 2014). The study was conducted in Accra because of proximity and its easy accessibility to the researcher. Also, there are different forms of caregiving alternatives for the elderly in Accra including; institutional care for the aged, NGO assistance for the aged, domiciliary/live-in care and lastly care provided by kin members which is more predominant in Ghana. All the other forms of caregiving provision have become pronounced indicating family constraint in caring for their aged. Accra is also a cosmopolitan city which has almost every ethnic group in Ghana as a resident. This will give a clear picture of what is happening in the country relative to different ethnic groups. The Ghana Living Standards Survey 6 (GLSS 6) revealed the ethnic composition of the Greater Accra Metropolitan Assembly as being comprised of, Akan-34.5%; Ga Dangme-30.8%; Ewe-20.7%; Guan 3.0%; Gurma- 1.8%; Mole-Dagbani-5.4%; Grusi-1.0%; Mande-0.5%; All others 2.3% (Ghana Statistical Service, 2014). With many migrants in Accra, the situation of migrant elders’ will be brought to bear. The study was conducted in Achimota and Sakumono all located in Accra. Achimota was considered for the study due to the presence of a non-governmental organization (NGO) 28 University of Ghana http://ugspace.ug.edu.gh for the elderly known as Help Age Ghana. Help Age served as an entry into the community. Help Age Ghana is a non-governmental, non-religious and non-profit making organization with its head office at Osu, Accra. It was established in 1988 to promote the prospects of older persons in the Ghanaian society. Help Age Ghana has formed volunteer groups in 22 communities to pay the elderly people in those communities’ regular visits and assist them in the performance of their house chores. The organization organizes regular medical check- ups for the elderly and also pay the medical bills of those whose medication are not covered by the National Health Insurance Scheme. Help Age Ghana has a number of 30 registered members living within the community of Achimota. Members of Help Age at Achimota meet biweekly on Tuesdays at the Achimota Presbyterian church. Sakumono was also considered for the study due to the presence of an institutional home for the elderly known as Mercy Home Care for the Aged. It is an institution that was established because many Ghanaians in the diaspora had unsettling feelings mostly concerning aged parents who had been left behind. Despite regular remittances, they still believed their aged parents were not being given the proper care they deserved. This led to the establishment of the Mercy Home Care Centre by Mrs. Mercy Adarkwa with the assistance of Stefan and Susan Hess and many others as a home care facility just as is commonly found in Europe and the US. Mercy Home Care Centre offers professional health care to the aged in Ghana. The Home had a total staff of 10 and 32 resident older persons as at the time of the study. 3.5 Target Population The target population for this study were elderly persons living in Achimota in Accra who are members of Help Age Ghana and residents of Mercy Home Care for the Aged in Sakumono. Participants with the relevant characteristics were used for the study in order to gain first-hand unadulterated information from them. Some elderly persons in Achimota 29 University of Ghana http://ugspace.ug.edu.gh employing family caregiving and some caregivers for the elderly were also interviewed in order to gain information about their sources of support and also alternative caregiving arrangements they have resorted to. 3.6 Sampling Technique For this study, non-probability sampling technique was used. Non-probability sampling refers to the technique in which some units of the population have zero chance of selection or where the probability of selection cannot be accurately determined (Bhattacherjee, 2012). The non- probability sampling techniques which were used are Purposive Sampling and Snowball sampling techniques. Purposive sampling ensures the selection of units with direct reference to the research questions being asked. Purposive sampling technique was used to spell out the inclusion and exclusion criteria of study participants. For inclusion in the study, participants were expected to be members of Help Age or residents of Mercy Home or adopting domiciliary or family care. The other inclusion criteria was that older participants had to be 60 years and above. Snowball sampling technique was also used because the researcher was unable to identify family caregivers and older persons employing domiciliary care. The researcher asked participants to recommend older persons in the community who fit the inclusion criteria. Some family caregivers were recommended by a participant who was a member of Help Age after her interview. A carer at Mercy Home recommended her older landlady at Achimota employing domiciliary care. 3.7 Sample Size The total number of participants used for this study was 29 comprising 8 male and female elders who were members of Help Age in Achimota, 8 male and female residents of Mercy Home Care, 2 carers of Mercy Home Care, the Administrator of Mercy Home Care, 30 University of Ghana http://ugspace.ug.edu.gh 3 family caregivers in the community, 5 elderly persons in the community and 2 care nurses. This sample size was chosen because the study is a qualitative study which is interested in the information received rather than the number of participants involved in the study. Crouch and McKenzie (2006) asserts that qualitative studies focus on meaning than making generalizations. In order to be included in this study, a participant was required to be able to speak either Twi, Fante or English. 3.8 Methods of Data Collection Data was collected through face-to-face explorative interviews (semi-structured) conducted by the researcher in Achimota and Sakumono respectively. Interviews were used to gain in-depth information on the topic. Interview guides were used during the interviews. The interviews were unstructured and involved open ended questions aimed at eliciting information about the topic from participants. Interviews were recorded with participant’s consent and transcribed afterwards. The language spoken during the interviews were either Twi, Fante or English and the estimated time for each interview was mostly around thirty (30) minutes. 3.8.1 Data Handling and Analysis The data analysis method that was employed for the study was thematic analysis. Thematic analysis was chosen as a method of data analysis because it allows flexibility and depth in exploring the feelings, meanings and understandings of participants (Braun & Clarke, 2006). The deductive approach of thematic analysis was employed for the study. It involves analysing the data with preconceived themes based on theory or literature. Here, the themes were influenced by the objectives of the study, theory and literature review. Reoccurring and similar codes were interrogated in how they relate to each other and then grouped into the already identified organizing themes. 31 University of Ghana http://ugspace.ug.edu.gh Audio files were kept for safe keeping on a computer and transcribed afterwards. Firstly, recorded audio files will be transcribed in English. This will be done several times to ensure consistency and accuracy. Data was then grouped under themes and analysed. 3.9 Ethical Consideration Ethics is a disciplined attempt to justify particular values, or set of values, and to understand what kinds of conduct embody or promote these values (Bunton & Macdonald, 2004). The following ethics were adhered to; 1. Informed consent- all participants received and signed an informed consent form before interviews were conducted. 2. Voluntary participation and harmlessness- participation in this study was by free will and not coercion. Participants who were not willing to take part in the study were not coerced to do so. 3. Confidentiality- this was ensured through the use of pseudonyms. Pseudonyms is defined as a fictitious name used when a person performs a particular social role. 4. Avoided plagiarism- every article or work used has been correctly cited or referenced. 5. Disclosure- information about the study was provided to potential participants before data was collected to enable them to decide whether or not they wished to participate in the study. 3.10 Conclusion To sum it up, this chapter sought to expound on the method used for conducting the research and its usefulness. It also gives readers information about the locality where the research was conducted and the population which served as participants. 32 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR PRESENTATION OF FINDINGS 4.1 Introduction This chapter presents the data analysis and findings of the study. Data was analysed according to themes generated from the objectives of the study. The findings are grouped under main themes which are; norms and expectations of care among the elderly, old and new caregiving arrangements, experiences of care and quality of life among the elderly, challenges faced by caregivers working with the elderly and sources of support. 33 University of Ghana http://ugspace.ug.edu.gh 4.2 Demographic Characteristics of Study Participants Table 4. 1: Demographic of Participants SEX Number of participant Average Marital status Part played in the study Mercy Help Family Nurses caregivers ages married separated widowed single elderly Family Care home age care care caregiver nurse Male 5 3 1 1 2 44-88 5 4 2 1 10 1 1 Female 3 5 2 1 6 26-84 2 11 4 11 2 4 Source: field data, 2019. 39 University of Ghana http://ugspace.ug.edu.gh The table (Table 4.1) above presents the demographic characteristics of the twenty- nine participants used for the study. Out of the total number of 29 participants, 21 of them were elderly persons aged between 63years and 88years. The average age of the elderly participants was 75.9 with the youngest elderly participant aged 63years and the oldest elderly participant aged 88years. Among the 21 elderly persons, 11 were females and 10 were males. The eldest female participant was aged 84years while the youngest was aged 65years with the average of the female elderly participants being 76.9 whereas the eldest male participant was aged 88years and the youngest was 63years. The male participants had an average age of 74.5. Of the total number of elderly participants, 13 were widowed, 4 were married, and 4 were separated. It is worthy to mention that all the 11 older women who participated in the study were widowed. A good number of the elderly participants had no senior high school education (61.9%), and a few had senior high school education or better (38.1%). Participants from Mercy Home constituted 37.9%, participant from Help Age constitute 27.6% with participants in the community constituting 34.5%. Out of the 8 caregivers who participated in the study, 6 were females and 2 were males. The age range of the 8 caregivers was between 26 and 55 with the average being 35.6. Most of the caregivers were females (75%) and a good number had attained a senior high school certificate or better (75%) and a few had little or no education (25%). Only 3 of the caregivers were married, 1 was separated and the remaining 4 were single. 4.3 Norms and Expectations of Care among The Elderly Older persons’ expectations of what constitute quality care was assessed by asking the question “what do you think should go into quality care for the elderly or what are your expectations on what constitute quality care for the elderly”? Out of the 21 elderly participants interviewed, all 21 expected caregivers to assist them with activities of daily living including running errands, cooking, cleaning, washing clothes, assisting to take a 40 University of Ghana http://ugspace.ug.edu.gh shower, and accompanying them to hospital appointments. Elderly participants also expected caregivers to assist them financially since none benefitted from any social assistance program. Even though not all elderly participants (28.2%) had caregivers, they expressed awareness of the possibility of needing caregivers in the near future. Their expectations will be for caregivers to assist them meet their daily needs when the time comes. A number of the female elderly participants (63.7%) had been caregivers of elderly persons before and this shaped their expectations on what should go into quality care for the elderly. This is what an elderly woman who had been a caregiver to her late mother had to say; “I expect my caregiver to cook for me, clean after me, take me to the hospital, do the house chores and run errands for me. dieting, dressing and cleanliness is important. When I was my mother’s caregiver, whenever she was quiet, I realized she was thinking and worrying so I engaged her in a conversation to cheer her up. It helped her to forget she was worried.. It always worked. Respect is also very important. Sometimes when I wanted her to do something for instance taking a bath, she will say no. I do not force her in such situations and after some time she will now agree to do what she said she will not do. Respect is key. I expect my future caregiver to do the same for me” (Obaa, elderly person and former caregiver). Also, most importantly, there was a general concern about listening, respect and obedience. All elderly participants expect not only their caregivers but all young people to accord them respect because of their age. Most elders stressed on respect and placed emphasis on generational gap which has resulted in the younger generation according elders with little to no respect in recent times. This is what a participant in Mercy Home had to say; “caregivers should listen to the residents because there’s a peculiarity with every resident. When I say they should listen, what I mean to say is that when a resident says my leg hurts, don’t say I don’t see it so it means it doesn’t hurt. Listen and know what to do about it. Most of them don’t listen and it is bad. I also expect them to be respectful because if you respect me you will obey me and do what I want you to do. 41 University of Ghana http://ugspace.ug.edu.gh This younger generation, you people do not respect and you think we talk too much but it is not like that” (Uncle Kwesi, Mercy Home). Elderly participants also expected support from government since most of them were not eligible for any pension because they were employed in the informal sector. Most of the elderly continued to work even in their old age due to this. Participants (33.3%) who were formerly employed in the formal sector also complained of insufficient pension. Of all the participants, 23.8% participants were still economically active because of little to no support from the government or family. Out of the 21 elderly participants from Mercy Home, 75% were bedridden and could not engage in any economic activity. Most depended on their relatives to meet the cost of care. None of the 21 elderly participants benefited from LEAP as at the time of the study. With regards to support from the government, an elderly participant had this to say; “in my view I expect the government to assist us because we need their support. Many of us do not get any income so we expect the government to assist us financially. My pension is even less than 400gh; what can I do with such amount for a whole month. I am even lucky I earn some pension, some elderly people do not even get some. Look at how much I earn, how can I even afford institutional care because I heard it is very expensive. The government has to really assist us” (Mr. Amoah, Help Age). 4.4 Old and new caregiving Arrangements Growing old comes with decisions about caregiving arrangements. From the study, choice of caregiving arrangements is not only determined by the older person but also by health, finances, availability of caregiver, location of children and the expectations of the care recipient. All 8 elderly participants at Mercy Home care initially used family home caregiving before settling for institutional care. A significant discovery made was that about 95% of participants from Mercy Home had either lived abroad before relocating to Ghana 42 University of Ghana http://ugspace.ug.edu.gh or have their children abroad. This is what some participants had to say about reasons for their choice of caregiving method. “Initially when I came back from the US after staying there for 40years, I was staying in the house and some relatives were taking care of me because my daughters are still in the US. I realized there are some things your own kids or family will not do for you when you are in the house. From my experience, your own relatives steal from you a lot, believe me, they do. Here (Mercy Home), anything wrong with you they take care of it, like wiping you up, giving you a bath and others. They don’t complain and they keep your belongings safe. when I was in the house, my phone was stolen 5 times, my relatives also inflated prices of goods. So when my daughter recommended institutional care I gladly accepted” (Uncle Kwesi, retired pharmacist, Mercy Home). “We were initially using home caregiving. My elder brother (marital status- separated) was with her in the house when she was strong before she had the stroke. After she was discharged from the hospital we tried managing it ourselves but it was very difficult because we had to change diapers and do so many things. We realized combining caregiving with other things became difficult. So her only daughter who is in the US proposed we use a care home instead and it was then that someone introduced me to mercy home. She has been at Mercy Home for about 3years now” (Papa Arkoh, nephew/caregiver of an older person at Mercy Home Care) An 84-year-old female participant who is employing both family care and nurses care due to her health also had this to say; “I have had only two home nurses and that was after my son’s death in December, 2018. I had high blood pressure and was admitted at the hospital. After I was discharged, the doctor prescribed insulin injection because I have diabetes as well. Knowing I cannot do the injection myself, I had to look for an agency who have home care nurses to assist me that is why my daughter in US paid for these 2 nurses to take care of me. They run shift. With the house chores, my granddaughter and my late sister’s daughter assist me. They sweep, cook, run errands, and assist me in any way possible.” (Awo). 43 University of Ghana http://ugspace.ug.edu.gh With regards to the perceptions of the elderly on emerging caregiving arrangements, all participants on one hand agreed that institutional care is foreign to Ghanaians because it is not part of the culture while on the other hand accepting it’s importance of helping older persons who would have otherwise not gotten caregivers. A good number of participants (71.4%) rejected the idea of living in a care home. In as much as they agreed care homes are not bad due to presence of professional carers, their preferred choice of caregiving method was home care. They also believed reasons for institutionalization include absence of caregivers, health, troublesome nature of some older persons, and lastly availability of children. This is what some participants had to say; “I have heard about care homes but all I know is that care homes are in the western countries. My daughter in US works with a care home so she tells me stories about it. I do not want to stay in a care home. I have so many people at my disposal from my village in Kwahu willing to be my caregiver. With that said I’m not saying it should be discouraged or it is bad. The society is changing we have become enlightened and I think it is helping those who do not have relatives to take care of them or those whose children are busy” (86-year-old participant from Achimota). “care homes are not bad because some people do not have people to take care of them. Also, I heard the carers are trained so they have knowledge of what they are doing which is mostly not the case in family caregiving because caregivers are not trained. But I still feel my children can provide quality care for me because I know how I have trained them so they will be happy to take good care of me. Some older people are troublesome making it difficult for their children to live with them.. I have taken care of them during their infancy so it shouldn’t be difficult for them to take care of me. I will stay home as I am doing now for them to look after me” (Abray, 88-year-old member of Help Age). Some participants (28.6%) also viewed care homes as better than home caregiving and as such preferred the former. This decision was attributed to the quality of care in care homes because of professional carers; unavailability of family caregivers; and presence of 44 University of Ghana http://ugspace.ug.edu.gh other older persons (companionship) in the care homes. Other reasons include safety of personal belongings. For instance participants believed money is safer in the care homes than in the house. Also, the carers do not complain during personal care which is not the case in home caregiving. Some participants explained; “I think institutional care is good and left to me alone I would have chosen institutional care to home care giving because there will be other older persons around. Also if my children are busy they will not get time to take care of me if I’m home. Some of our children don’t have time so if you stay in the house you will be lonely and end up thinking a lot which is not good. You might not get anyone to assist you so you may not eat the right food. All these can let you die early” (Ogray, member of Help Age). “I think institutional care is good because the carers are trained so they check our vitals every morning. I have been here for three years and I like it here. My properties are also safe here because no one will touch it. To go back home forever, no. I won’t go back again. I was with them but they brought me here so I won’t go back. I will rather want to visit occasionally only when they come for me. For instance, they sometimes come for me during occasions like Christmas and Easter. They bring me back when the festivities are over. I want to be here permanently” (76-year-old retired Medical Doctor, Mercy Home Care) Some participants also preferred day-care services for the elderly where they meet during the day and go back home rather than care homes where they have to stay far away from home. They preferred the day-care services because there were other older persons around to interact with and also because it does not demand relocation. This is what some participants had to say about day-care services; “I will rather prefer the one that they go in the morning and come back home in the evening (day-care services) since it will be in this town. The activity will help take my mind off my worries. I have lost 3 of my children within the past 3years so I worry and think a lot. The other time my daughter in Ada told me to be dressing up and I told her with this worrying how can I dress up and just sit there, I mean, there is no 45 University of Ghana http://ugspace.ug.edu.gh point in it. Meeting and spending time with other old people will be fulfilling” (Grandma Araba, 82years, Achimota). “we the elderly these days sometimes most of us complain about the lifestyle of our children. They don’t listen to us. Sometimes you want someone to talk to and they won’t have time for you that’s why I even joined Help Age so that occasionally I will get people to talk to. We meet once every two weeks and when we meet here we also converse in our own style and laugh” (Uncle J, member of Help Age). 4.6 Experiences of care and quality of life among the elderly In assessing if the quality of care older persons receives affect their quality of life, all participants were asked the question “in your view, do you think the care an older person receives affects his or her life”? All 29 participants answered in the affirmative with some older persons who had been caregivers before using their caregiving experiences to expatiate more on how quality of care affects the quality of life of older persons. Participants admitted that even though quality of life cannot be attributed to only one factor, care for the older person plays a very important role in improving or decreasing the quality of life of an older person. This is because they believed if the care an older person receives is good, that is, all activities of daily living are assisted with, medication is provided and there is companionship, it translates into happiness and long life. However, if the care received is substandard, that is, medications needed are not provided, no companionship, activities of daily living are not assisted with, the older person will worry which can lead to death. Some participants had this to say; “Quality of care is very key. If you take good care of them they live longer, if you do not, they die early. When I was taking care of my mother, we were staying in a rented accommodation and when we were evacuated I took her to them. They couldn’t take good care of her so she died shortly afterwards. I knew she would have lived longer if she was with me. She died because they could not give her good care like I used to” (Auntie Ama, older person and former caregiver). 46 University of Ghana http://ugspace.ug.edu.gh “good care prolongs the care recipient’s life span. I say this because of my sister’s mother in-law who I stayed with in Aburi. When someone grows old and you do not pay attention to them, it is really difficult. She grew so old we had to carry her to the bathhouse and she even had dementia so she was very troublesome. Despite that we still treated her with respect and gave her the care due her and so she really grew older. If you do not take care of them well, worrying can send them to their grave and you the caregiver will forever live with the guilt” (Auntie Mariama, older person and former caregiver). “I believe the quality of care elderly persons receive impact their lives. When they are happy with the care they receive you realize that they do well. When it comes to medication, if they don’t have good care they are given wrong medication and all these end up affecting them” (Sister Yaa, caregiver). Participants were convinced that the care received impacts quality of life. The care in terms of food, medication, attention and others have a direct bearing on the quality of life enjoyed by older persons. Good care translates into happiness and satisfaction contributing positively to their overall quality of life. The absence or inadequacy of basic necessities including food, medication and attention can culminate into neglect which negatively affect quality of care. This can lead to untimely death in the long run. 4.7 Challenges Faced by Caregivers working with the elderly 4.7.1 Challenges at The Institutional Level At the institutional level both Mercy Home and Help Age had various challenges. Information about challenges was gained through asking participants of Help Age whether they are satisfied with what Help Age does for them. All 8 participants of Help Age expressed dissatisfaction citing reasons such as; been given medication which are close to expiration, and also insufficient food and toiletries given to them. Staff of Mercy Home also complained about their remuneration which they classified as their main challenge. Looking at the number of hours they work daily and number of older persons they have to take care 47 University of Ghana http://ugspace.ug.edu.gh of, staff complained bitterly about the 500 Ghana Cedis they received as monthly remuneration and indicated it as a disincentive. “our pay is very bad. We take care of about 30 to 35 people but they give us meagre salary. Even those who do home service for just one person earn more than us. We are paid 500gh monthly which is very little looking at the work we do” (Ann, 26year old carer at Mercy Home Care). “….due to their old age they sometimes make it difficult for us. If you do not take care you might retaliate. Some of the residents are troublesome so they make our work very difficult. I’m also not very much satisfied with the salary. Our salary is not good at all looking at the work we do. Our work is very difficult” (Gifty, 27- year-old carer at Mercy Home). “I am not satisfied with what Help Age does for us. What they do is not enough. The rice they give us occasionally is even just 2cups and most often I don’t even get some because they will tell you it wasn’t enough. This is what happens all the time. The last time too they brought some medicines and when I checked it was close to expiry so I assumed that is the reason why they gave them to us. At least they can give us 5kg rice, a little sardine and mackerel as members because I heard they have funders. It will really help us” (Auntie Afia, member of Help Age) 4.7.2 Challenges Faced by Family Caregivers Family caregivers of the elderly who were interviewed expressed challenges faced in taking care of their elderly were mostly financial, emotional and physical. This is what some had to say; “…..I live at Mamprobi and drive all the way to Sakumono just to visit her. It is not an easy thing and the fact is if I don’t do such thing the nurses over there will also relax in taking care of her so I try to do that to put them on their toes. Even that when I get here there are times that I still see some things wrong and I have to actually talk to them about it. It has not been easy financially as well. You can imagine paying 750gh monthly and also spending money on medication, taking her for hospital appointments and buying groceries. Roughly if you put all together it is 48 University of Ghana http://ugspace.ug.edu.gh getting to 1500gh-2000gh every month. It’s really difficult” (Papa, 44-year-old family caregiver with relative at Mercy Home Care.) “Combining taking care of her and my 2 children as well is difficult. It is hard but when I take them to school at dawn, she would not be awake by that time so by the time I come back around 8:30 she will be awake for me to take care of her. Sometimes she is worrisome that’s the only problem I have with her” (Aba, 30-year- old family caregiver at Achimota) 4.8 Sources of Support for the Elderly 4.8.1 Formal Support None of the 21 elderly participants received support from the government as at the time of the study. None benefited from the Livelihood Empowerment against Poverty (LEAP) programme and most participants (75%) did not know about the existence of the programme. The only support some participants (28.6%) received was their pensions because they were in formal employment during their working years. “aside my pension pay I don’t receive any money from the government so it is my children who support me because my pension is also not enough” (Pierre, member of Help Age). “I don’t even get pension allowance because I was a casual worker. The little money they gave me when I was leaving the job has also gotten held up at the bank (GN Bank) so I don’t even have access to it. The government should help us because life is very difficult” (Auntie Ama, former casual worker at the Accra Metropolitan Assembly). All the participants expressed a need for government to support them in very diverse ways. A participant had this to say; “I feel the government has to support us financially because we are suffering. The government also needs to get us geriatric hospitals and doctors in Ghana because Ghana hasn’t got those facilities yet. We don’t have specialized health care services to see the real problem of the aged because the doctors are mostly general 49 University of Ghana http://ugspace.ug.edu.gh practitioners but when we grow old like that we have problems with our system paa so we need specialized doctors. So we need the geriatric doctors to come and take care of us because when we go they just give us paracetamol but the real problem is there so the government has to come in and assist us because we the aged have peculiar problems” (Uncle Kojo, Help Age). 4.8.2 Informal Support All participants received support from either their children, in-law, church, and sometimes benevolent organizations (for example Help Age but the support is just for their members). Most participants (47.6%) expressed that the financial support received from their family members especially children was minimal and as such some participants (28.6%) had to continue working to supplement it. A participant had this to say; “My church members and sometimes my in-law give me a little money or foodstuff because of my age. Periodically, Help Age gives us a little rice and toiletries. My other children sometimes send me foodstuffs and a little money but the money I get from them is not enough so I still work. I sell rubbers on a table in front of my daughter’s house so that I can get something small” (an 83-year-old member of Help Age). Some older persons (33.3%) who receive pension also stated that they support themselves most of the time with occasional support from their children or relatives. Participants (37.5%) who were pensioners and received good pension stated they hardly depended on their children. Some of the pensioners who were participants had this to say; My children fund part of the cost of staying in the care home and I pay for the rest. I have a good pension and I receive disability benefits from the US where I stayed and worked for 40years as a pharmacist. So basically, financially I mostly depend on myself and no one else but I receive some support from my daughters some times. I do not receive support from the Ghana government” (Uncle Kwesi, retired Pharmacist). 50 University of Ghana http://ugspace.ug.edu.gh “I pay for the cost of staying in Mercy Home. My brother has access to my ATM card so he goes to withdraw the money for me and I use it to pay. I receive a good pension so I am able to pay for anything I want. I do not depend on my children or anybody because I have enough money” (retired medical doctor). Some caregivers who were participants also indicated that they often do not receive help from other external sources. “We don’t get any other support from anywhere apart from what my cousin (her daughter) and myself (her nephew) put together. Once in a while when any family members visit, they usually bring some biscuits and drinks and that is all. When we talk about the finances, it is just the two of us” (Papa, caregiver of an older person at Mercy Home). Both caregivers and the elderly encounter challenges that makes caregiving very difficult. Financial challenge is at the core of these challenges. The absence of financial support puts huge burden on both caregivers and elderly and makes cost of care higher. The support received in the form of groceries and toiletries are insufficient in assisting the elderly. 4.9 Discussion of Findings 4.10 Norms and Expectations of Care among The Elderly Quality care means different things for different people. For the elderly, quality care relates to the availability of fundamental services and behaviour that give them comfort. In Sung’s (2004) study of young Koreans and Americans, findings revealed elders consider care as a kind of respect. Care, to the elderly includes attention; concern; taking care of them when they are ill; doing housekeeping for them; maintaining contact with them; spending time with them; and caring by living together with them. This study discovered that participants expected their caregivers to assist them with activities of daily living including running errands, cooking, cleaning, washing clothes, assistance with personal care, accompanying them to hospitals and administering medication. These are some of the most common activities for which frail elderly persons need the help of others. According to Bassah et al (2018) family caregivers are expected to 51 University of Ghana http://ugspace.ug.edu.gh assist their older relatives with performing activities of daily living including cleaning, washing, feeding, running errands and preventing falls and elderly abuse. This finding is in sync with the expectations of the study participants. These elderly people are content when they get assistance with their activities of daily living because, to them, that is all they need to survive and be comfortable. For the elderly in Ghana, their greatest burden is to meet their basic needs because of the absence of social assistance programs and so once these needs are met, their major challenge is solved. Even though not all elderly participants had caregivers, they expressed awareness of the possibility of caregivers in the near future as they become frail. During that time, they expect caregivers to assist them meet their daily needs. As Levinson (2008) noted, the elderly need care as their personal activities get limited by developmental challenges resulting in degeneration of health, disability, frailty and incapacity for self-care. Additionally a number of the female elderly participants had been caregivers of elderly persons prior and it shaped their expectations of quality care for the elderly. The elderly also expected financial assistance and support from government, their children, family members and non-governmental organizations. All activities of daily living are made possible with money and since there is not much social assistance programs for the elderly, there is an overly dependence on informal support systems. Just as Van der Geest (2002) revealed, helping the elderly financially and providing company are tokens of care, which are indispensable. Also, most importantly, there was a general concern about listening, companionship, respect and obedience. All elderly participants expect not only their caregivers but all young people to accord them respect because they are senior citizens. Most elders stressed on respect and placed emphasis on generational gap. They argue generational gap has resulted in the younger generation according elders with little or no respect in recent times. Oppong 52 University of Ghana http://ugspace.ug.edu.gh (2006) notes that many older people now feel a sense of declining status, a loss of respect, and relative deprivation and increasingly, old age per se no longer commands respect. In traditional Igbo setting according to Echeta and Ezeh (2017, ). just as other Sub-Saharan societies, honor was attached to old age so the aged felt privileged while the young looked forward to ageing. Parents educated their children to value and respect elderly. These roles are rapidly changing and as such older participants of the study expect the younger generation to accord them respect. In conclusion, the expectation older persons have of their caregivers borders on reciprocity. Those who worked hard for their children are sure they will receive respect and care from them because they laid a good foundation in their early life. 4.11 Old and New Caregiving Arrangements Choice of caregiving arrangements is not only determined by the care recipient but by certain conditions including finance, availability of caregiver, location of children and the expectations of the care recipient. According to Papalia et al. (2011), growing old calls for decisions about who and where to live; and this is greatly influenced by cultural traditions and values. All participants in this study either used home care, institutional care, day-care services or employed carers to assist them in their homes. Reasons for employing these caregiving arrangements included; disability status, location of children, finance, values and availability of caregivers. Thirteen participants who employed family caregiving attributed it to the availability of caregivers and their values. Just as Echeta and Ezeh, (2017) noted caregiving becomes less stressful when the children live together with their parents because they can perform it themselves or supervise those who do it on their behalf. In situations where they do not stay together they provide paid house helps or stewards to look after their parents. Female children in particular visit their parents from time to time to supervise the caregivers (ibid.). Most of the participants who employed family care were 53 University of Ghana http://ugspace.ug.edu.gh taken care of by either their children or family relatives. Their children (both male and female) were able to provide care for them because they lived in the same environment. Those whose children were not present to provide care for them paid people including house helps, relatives and nurses to assist their older persons under their supervision. Eight of the elderly participants used institutional care and were residents of Mercy Home care at Sakumono. All of them initially used family caregiving before settling for institutional care. Care homes are now emerging in Ghana. Van der Geest (2002) noted formally organized services for the elderly did not exist in Ghana as at the time of his study. There was no single institution for care of elderly people. The only facilities that were available in Accra and perhaps a few other places were day care centres where elderly people could meet each other and pass time with games and other activities (ibid.). Currently, there are a number of institutional care homes for the aged in Ghana specifically Accra which is now contrary to Van der Geest’s (2002) findings. It was noted from the study that all elderly participants at Mercy Home had a disability which they explained they developed when they aged. Uwakwe and Modebe (2007) recognized that the family caregivers find it difficult to cope with disabled elderly ones due to immense care demands coupled with their job burdens. This may partly explain why all the elderly participants at Mercy Home were disabled. Family caregivers who are financially able resort to institutional care to ensure their elderly relatives get good care. Reasons participants adopted institutional care included; health conditions, unavailability of family caregivers, location of children and the feeling of being a burden. According to Boggatz and Dassen (2005), the Ministry of Social Affairs in Egypt found the following as reasons people stayed in a care home: the feeling of being a burden, lack of family care, family problems, feeling lonely, lack of affection, and fear of illness. Abd el Ghany (1986) also found that loneliness was the residents main reason for staying in care homes, especially 54 University of Ghana http://ugspace.ug.edu.gh for males. Women, however, reported health reasons to a greater extent than men for their admission (ibid.). Contrary to this, findings from this study prove that not only women, but men as well reported health conditions as reasons for their institutionalization. None of the elderly participants in Mercy Home cited loneliness as a reason for institutionalization. An institutional care denotes a place of residence for older adults who require continual nursing care and have significant difficulty in relation to coping with the essential activities of daily living (ADLS) (Dovie, 2019). There is little information about institutional care for the aged in Ghana but most care homes are located in Accra, the capital city of Ghana. Care homes are mostly owned by private individuals with some being supported by donors including non-governmental organizations. In Ghana, as stated earlier, institutional homes are mostly found in Accra and this finding correlates with the findings of Boggatz and Dassen (2005) who found out that in Egypt institutional homes were concentrated in the cities which may reflect a greater need for institutional support in the cities, as it is where the traditional social network has changed most. Accra as a cosmopolitan city has many migrants as residents leading to a decline of the traditional social network. This has resulted in families resorting to institutional homes for the care of their older persons in instances where they cannot provide care themselves. According to Azer and Afifi (1992) some institutional homes in Egypt had an indication of overcapacity and the explanation was that only 8.8% of their sample had ever heard of care homes and also some of their study participants also rejected staying in such a place. Similarly, Mercy Home had a total population of 32 elderly persons which is an under capacity because the facility can accommodate more than 50 people. This may be explained by the fairly new nature of care homes in Ghana. Additionally, majority of older participants rejected the idea of staying in a care home. Just as Boggatz and Dassen (2005) found out, this can be attributed to the prevalence of family care in the country. 55 University of Ghana http://ugspace.ug.edu.gh With regards to the perceptions of the elderly on emerging caregiving arrangements, all participants on one hand agreed that institutional care is foreign to Ghanaians because it is not part of the culture while on the other hand accepting it’s significance of helping older persons who would have otherwise not gotten caregivers. According to Coe (2016) the increasing number of elderly in the world has brought about new forms of caregiving in societies who traditionally valued norms of reciprocity. Notwithstanding, a good number of participants rejected the idea of staying in care homes or using paid workers. Most participants preferred family caregiving and as such expressed disappointment should other caregiving methods be employed. Nwoke (2014) argue that some older persons find it difficult to cope with outsiders making it difficult to use paid workers. Some elderly who had been nursing the idea of their children looking after them in old age felt unfulfilled. Many closed in and felt lonely even though they have people to attend to them (ibid.). Some participants cited the troublesome nature of some older persons, unavailability of family caregivers and unavailability of children as reasons for institutionalization. Some participants preferred care homes over family care. From the study, reasons stated for this decision are; professional carers translate into quality care, unavailability of family caregivers and presence of other older persons (companionship) in care homes. In Echeta and Ezeh (2017), a respondent, who resides in a care home stated loneliness as a reason for admission. They indicated they are well fed and there’s companionship. This finding is synonymous with the findings of this current study. Participants stated they are well fed and there’s companionship reducing loneliness. Another reason for preference of institutional care include safety of personal belongings. For instance money is safer in care homes than in the house. Contrarily, Okoye (2014) finds that some elders may be abused or lose their money and other precious things to hired workers. Due to strict supervision by family and care home managers, staff of institutional homes as well as hired workers are 56 University of Ghana http://ugspace.ug.edu.gh mostly unable to steal from or abuse older persons. Furthermore, participants stated carers do not complain during personal care unlike family caregivers. Some participants also preferred day-care services for the elderly where they meet for some time and go back home rather than care homes where they have to relocate. They preferred the day-care services because of companionship and also because it did not demand relocation. Some also preferred hired carers to assist them in their homes and they gave reasons as not having to relocate, easy supervision by family members and being able to maintain close contact with their family. 4.13 Experiences of Care and Quality of Life among the Elderly Quality of life has to do with an individual’s perception of their position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns. Quality of life is also the standard of health, comfort and happiness experienced by an individual or group. In assessing if the quality of care older persons receives affect their quality of life, participants agreed quality of life was not dependent on one factor but caregiving is essential in improving or decreasing the quality of life of an older person. Some older persons who were previously caregivers explained from their experience that quality care translates into long life of the care recipient. Participants believed good care that is, assistance with activities of daily living, administration of medication and companionship impacts positively on the quality of life of the elderly. The lack thereof could lead to unhappiness and untimely death of the older person. According to Lepage (n.d.) quality of life is linked to happiness, freedom and standard of living of people and that quality of life must always reflect personal needs, expectations and requirements of citizens. Participants were convinced that the care they receive impacts on the quality of life because at their age, care is a necessity and as such care received goes a long way to 57 University of Ghana http://ugspace.ug.edu.gh influence their life. The care in terms of food, medications and attention has a direct effect on their quality of life. This quality of care has a consequence on how long care recipients live and the satisfaction they reap. When efforts in care makes them happy, it contributes positively to their quality of life. The absence or inadequacy of food, medication and attention negatively affect quality of care. 4.14 Challenges Faced by Caregivers working with the Elderly 4.14.1 Challenges Faced at the Institutional Level At the institutional level both Mercy Home and Help Age had various challenges. Help Age provides assistance for the elderly by providing them with toiletries, medications, food, and entertainment. Staff of Help Age interviewed stated they had volunteers who went around assisting the elderly with their household chores but upon interactions with members of the Achimota branch disagreed. All participants of Help Age expressed dissatisfaction in the assistance received from the organization citing reasons such as; given medications close to expiration, insufficient food and toiletries. Staff of Mercy Home also complained about their remuneration which they classified as their main challenge. Looking at the number of hours they worked daily and number of older persons they have to take care of, staff complained bitterly about the 500gh they receive as monthly remuneration and stated it is a disincentive. Even though not explicitly stated by staff, Mercy home had low staffing and as such the workload on the staff was high. The finding is consistent with Changala, Mbozi and Kasonde-Ng’andu (2016) who found that institutional homes in Zambia were understaffed and as such the workers were overstretched and could not provide adequate care for the elderly. There was no training by the care home for staff. All carers had an HAC/HAT certificate which implies all of them had basic knowledge in health and care of older persons but the lack of training is considered a challenge because training is important for caregivers. 58 University of Ghana http://ugspace.ug.edu.gh According to Changala, Mbozi and Kasonde-Ng’andu (2016) not much had been done to train staff of care homes in Zambia on how to care for the aged and that caregivers had been asking for capacity building and training. 4.14.2 Challenges Faced by Family Caregivers Family caregivers of the elderly expressed challenges faced as financial, others were emotional whereas some were physical. Other challenges family caregivers faced included combining taking care of their children, going to work as well as taking care of their older relatives. According to Echeta and Ezeh, (2017) and Nortey et al, (2017), studies have documented the psychological, social and health consequences that caregivers of elderly populations face which includes offspring of senior citizens caught in the problem of trying to raise their own offspring, live their lives and take care of their elderly parents. This has resulted in most caregivers having to relocate to new cities and having to resign from their jobs in order to be able to take care of their older relatives. Lack of training is also another challenge identified. None of the family caregivers who participated in the study had undergone training or skills development. According to Kamwengo (1999) many caregivers in both the community and care homes lack skills and knowledge for effectively working with and for the aged. This reduces their ability to effectively take care of older persons. Lastly, most caregivers complained that the care recipients were troublesome and as such needed constant attention which made care provision very difficult for them. Financially, none of the caregivers received assistance from the government. Cost of caregiving was either shared amongst the children of the care recipient or sometimes borne by the caregiver which exacerbates challenges. Most caregivers complained about the cost of providing care. 59 University of Ghana http://ugspace.ug.edu.gh 4.15 Sources of Support 4.15.1 Formal Support None of the elderly participants received support from the government as at the time of the study. None benefited from the Livelihood Empowerment against Poverty (LEAP) programme and most participants did not even know about the existence of the programme. The only support some participants received was their pensions. Participants who received pensions were a few because the Ghanaian population is predominantly engaged in the informal sector. Oppong (2006) and Kasente (2000) agrees only a very small minority of the elderly are in formal retirement programs or receive state pensions. Most old people work in agriculture so have no protection in old age, other than from their families. Those who were in the informal sector received no support from the government and either depended on relatives or had to continue working to make ends meet. According to Apt (1993) policy makers have been unsuccessful in developing welfare programs to cater to the needs of those operating in the informal sector. The non-existence of formal institutions and pension programs to support the elderly will make them more vulnerable and prone to social problems, especially, after retirement. Elderly destitution is therefore becoming an increasing problem in urban Ghana (ibid.). Currently, pension schemes have been designed to accommodate workers in the informal sector but at the time of this study, none of the participants benefited because they were not contributors. 4.15.2 Informal Support All participants received support from either their children, in-law, church, and sometimes benevolent organizations (for example Help Age but the support is just for their members). The support was sometimes financial, emotional, assisting to perform activities of daily living. According to Bassah et al (2018) family caregivers are expected to assist their older relatives with performing activities of daily living and preventing falls and 60 University of Ghana http://ugspace.ug.edu.gh elderly abuse. More generally, they play a role in the physical, emotional and sometimes financial assistance of older family relatives who cannot care for themselves. Most participants expressed that financial support received from family members especially children was minimal. Some participants had to continue working to supplement it. A sizable percentage of retired Ghanaian workers look for employment opportunities to enable them deal with the economic hardships (Okraku, 1985). Notwithstanding, many elderly persons get their maintenance from their children. Oppong (2006) states many poor parents do get a significant part of their maintenance from their children. Nortey et al, (2017) agrees one major means usually adopted by family members to provide supports to older persons is the use of remittances. According to GLSS 6 remittances to parents are the second highest aside remittances to children in both rural and urban localities (Ghana Statistical Service, 2014). Echeta and Ezeh, (2017) found that some families make regular contributions of money and foodstuff monthly for the upkeep of their older relatives. 61 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY OF FINDINGS, RECOMMENDATIONS AND CONCLUSION 5.1 Introduction The chapter provides a summary of the entire study. Based on the results, conclusions are made on the identified challenges faced by the participants and coping mechanisms which are adopted to ensure survival. Suggestions by way of recommendations are made to mitigate the identified challenges faced by caregivers and elderly persons. 5.2 Summary of Findings Findings from the study revealed that all participants expected their caregivers to assist them with activities of daily living including running errands, cooking, cleaning, washing clothes, assistance with personal care, accompanying them to hospitals and serving them their medication which are some of the most common activities for which frail elderly persons need the help of others. Even though not all elderly participants had caregivers they expressed awareness of needing caregivers in the near future as they became frail. They expected future caregivers to assist them meet their daily needs during that time. The elderly also expected financial assistance and support from government, family and non- governmental organizations. Additionally, there was a general concern about listening, companionship, respect and obedience. All elderly participants expect not only their caregivers but all young people to accord them respect by reason of their age. From the study, all participants either used family care, institutional care, day-care services or domiciliary care. Reasons for employing any of the above caregiving methods include; disability status, location of children, finance, values and availability of caregivers. Most of the participants who employed family care had their children or some family relatives as caregivers. Their children were able to provide care for them because they lived 62 University of Ghana http://ugspace.ug.edu.gh in the same environment. Those whose children were not present to provide care for them paid people including house helps, relatives and carers to assist their older persons under supervision. Some elderly participants also used institutional care and were residents of Mercy Home care. All of the residents previously used family caregiving before relocating to the care home. Majority of the elderly participants at Mercy Home were disabled implying caregivers might have found it difficult combining the demands of caregiving with their own families and as such resort to care homes. The reasons for choosing institutional care by respondents included; health conditions, unavailability of family caregivers, location of children and the feeling of being a burden. Participants were convinced that the care received impacts on the quality of life. Care is a necessity during old age therefore care received either influences their life positively or negatively. Care in terms of food, medication and attention has a direct effect on their quality of life. This quality of care has a consequence of how long care recipients live and the satisfaction they reap. When efforts in care makes them happy, it contributes positively to their quality of life. The absence of or inadequacy in the nature of food, medication and attention negatively affect their quality of care. All participants of Help Age expressed dissatisfaction in the assistance received from the organization citing reasons such as; given medication close to expiration, and insufficient food and toiletries. Remuneration was the main challenge of the staff of Mercy Home. Mercy home had low staffing leading to huge workload on the staff. The lack of training for caregivers is a challenge because training is important for caregivers. Family caregivers of the elderly expressed challenges faced as financial, emotional and physical. Some of the challenges family caregivers faced included combining taking care of their children, going to work as well as taking care of their older relatives. None of the family caregivers who participated in the study had undergone training. Lastly, most 63 University of Ghana http://ugspace.ug.edu.gh caregivers complained that the care recipients were troublesome and needed constant attention which made care provision very difficult. None of the elderly participants received support from the government or benefited from the Livelihood Empowerment against Poverty (LEAP) programme and most participants did not even know about the existence of the programme as at the time of the study. The only support some participants received was their pension. Participants who received pensions were a few because the Ghanaian population is predominantly engaged in the informal sector. All participants received support from either their children, in-law, church, and sometimes benevolent organizations. The support was sometimes financial, emotional and assistance to perform activities of daily living. Most participants expressed that the financial support received from their family members especially children was minimal. Some participants had to continue working to supplement it. Notwithstanding, many elderly persons got their maintenance from their children. 5.3 Recommendations Based on the findings from this study, it is hoped that the following recommendations if adopted, would help improve the life of caregivers and older persons. Findings indicate minimal government assistance for older persons. The Government of Ghana needs to borrow a leaf from countries with advanced welfare schemes for older persons to supplement the existing schemes. This will go a long way to better lives of the elderly. From the study, most older persons received no support from the government and had to continue working which sometimes affect their health negatively. Welfare programs should also get to the older population who need it. In other words, political capture, nepotism and bribery should be avoided in order for the impact of these welfare programs to be felt by the elderly persons who they are intended for. 64 University of Ghana http://ugspace.ug.edu.gh Findings from the study revealed that there are no government owned care homes. Considering the increasing number of older persons in the country and the weakening of the extended family system, it is essential for the government to establish such homes to absolve older persons without caregivers. Government owned care homes may be relatively cheaper than privately owned care homes due to subsidies. This will make it affordable for most people. Training opportunities for caregivers both family and institutional is necessary to improve the care older persons receive. From the study, caregivers had no training which inhibits the quality of the care provided. On the job training and skills development is important for caregivers in order to provide quality care for the elderly. There is the need to train caregivers in simple physiotherapy, nutrition and counselling in order to be able to understand care recipients and provide quality care for them. These trainings will increase the knowledge of caregivers and provide them with requisite skills that will enhance their abilities in taking care of their older ones. Sensitization of the elderly about the new forms of alternative long-term caregiving arrangements so that they will be more receptive to it when they are employed. There should be public education of older persons about the advantages of these new forms of caregiving arrangements in order for them to not allow cultural norms and values prevent them from using it. Findings of the study indicated that care homes were understaffed and staff were underpaid which served as a demotivation to them. Owners of care homes should work on staffing and remuneration in order to provide quality care for older persons. 5.4 Conclusion This research revealed that Ghanaians who previously valued ageing in the comfort of their homes currently employ other forms of caregiving including the use of paid workers, 65 University of Ghana http://ugspace.ug.edu.gh carers and care homes. Even though not all participants wanted to employ most of these new forms of caregiving methods, they showed awareness of their importance. Older persons believed that the care received impacts their quality of life and as such when they receive good care, they lived longer and when the care received is not good, it affects them negatively. Findings from the study showed that older participants received no support from the government aside the pensions of those who were in formal employment. Older persons depended on support from their children, relatives, and other informal support systems to make ends meet. Others also had to continue working because the support received from their family was minimal. 5.5 Summary Ageing populations are now a common feature of the world and Ghana is not an exception. The older population has increased in number and this can be attributed to improved health, nutrition, and improved technology which has resulted in increased life expectancy. This increasing number of older persons has come with it accompanying challenges of ageing including the health challenges and socio-economic challenges. The increasing number of older persons has brought about new forms of elder care in societies who previously valued ageing in their homes in the midst of their children. The traditional support systems for the elderly which is the extended family is weakening in recent times and this has brought about new forms of care including the use of paid workers and institutionalization. Institutional care for the aged is on the increase now because of the unavailability of caregivers for elderly persons, location of children of older persons and their health status. Both family caregivers and caregivers in old people’s homes encountered several challenges which were mostly financial. None of the older participants or caregivers received support from the government. Support for older persons was mostly informal and most times older persons had to work to supplement it. 66 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abd el Ghany (1986) cited in Boggatz, T., & Dassen, T. (2005). Ageing, care dependency, and care for older people in Egypt: a review of the literature. Journal of clinical nursing, 14, 56-63. Aboderin, I. A. G. (2000). Social Change and the Decline in Family Support for Older People in Ghana: An Investigation of the Nature and Causes of the Shifts in Support (Doctoral dissertation, University of Bristol). Aboderin, I. (2004). Modernisation and ageing theory revisited: current explanations of recent developing world and historical Western shifts in material family support for older people. Ageing & Society, 24(1), 29-50. Accordino, M. P., Rosenthal, D. A. & Freund, R. (2000). Effects of treatment participation on quality of life of elders with serious mental disability. Psychiatric Rehabilitation Journal. Vol 23 (4); pp. 352-358 Ageing, W. H. O. (1999). Ageing: Exploding the myths (No. WHO/HSC/AHE/99.1). Geneva: World Health Organization. Angel, J. L., & Angel, R. J. (1998). Aging trends–Mexican Americans in the Southwestern USA. Journal of Cross-Cultural Gerontology, 13(3), 281-290. Apt, N. A., & GRIECO, M. (1995). Aging in Africa: toward a redefinition of caring. An Aging Population, an Aging Planet and a Sustainable Future, 1. Apt, N.A. (1993). Care of the elderly in Ghana: An emerging issue, Journal of Cross- Cultural Gerontology 8: 301–302 Apt, N A., & Peil, M. (1996). Coping with old age in a changing Africa. Ageing and Society, 16(5), 645-646. Apt, N. (1997). Aging in Ghana. Caring: National Association for Home Care Magazine, 16(4), 32-4. Aspers, P. (2009). Empirical phenomenology: A qualitative research approach (The Cologne Seminars). Indo-Pacific Journal of Phenomenology, 9(2), 1-12. Atchley, R. C. (1989). A continuity theory of normal aging. The gerontologist, 29(2), 183- 190. 67 University of Ghana http://ugspace.ug.edu.gh Atchley, R. C., & Barusch, A. S. (2004). The demography of aging. RC Atchley & A. S. Barusch (Éds.), Social forces and aging: An introduction to social gerontology. Belmont, CA: Wadsworth/Thomson Learning. Attias-Donfut, C., & Gallou, R. (2006). L'impact des cultures d'origine sur les pratiques d'entraide familiale. Informations sociales, (6), 86-97. Ayernor, P. K. (2012). Diseases of ageing in Ghana. Ghana medical journal, 46(2), 18-22. Azer, A., & Afifi, E. (1992). Social support systems for the aged in Egypt. United Nations University Press. Banga, E. H. (1993). The emerging image of the aged in Accra, capital of Ghana. BOLD, 3(4), 11-15. Bassah, N., Ubenoh, U. S., & Palle, J. N. (2018). An Exploratory Study of the Knowledge and Practices of Family Caregivers in the Care of the Elderly at Home in the Buea Health District, Cameroon. J Gerontol Geriatr Res, 7(473), 2. Bhattacherjee, A. (2012). Social science research: Principles, methods, and practices. Boerma, W., Kroneman, M., Hutchinson, A., & Saltman, R. B. (2012). Home care across Europe. N. Genet (Ed.). European Observatory on Health Systems and Policies. Boggatz, T., & Dassen, T. (2005). Ageing, care dependency, and care for older people in Egypt: a review of the literature. Journal of clinical nursing, 14, 56-63. Bourbonnais, A., & Ducharme, F. (2010). The meanings of screams in older people living with dementia in a nursing home. International Psychogeriatrics, 22(7), 1172-1184. Bronikowski, A. M., & Flatt, T. (2010). Aging and its demographic measurement. Nature Education Knowledge, 1(12), 1-6. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. Butler, R. N. (1969). Age-ism: Another form of bigotry. The gerontologist, 9(4_Part_1), 243-246. Coe, C. (2016). Not a nurse, not househelp: The new occupation of elder carer in Urban Ghana. Ghana Studies, 19(1), 46-72. Cohen-Manfield, J., Ejas, F. K., & Werner, P. (2000). Satisfaction surveys in long-term care. New York: Springer. Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches. Sage publications. Creswell, J. W., & Clark, V. L. P. (2017). Designing and conducting mixed methods research. Sage publications. 68 University of Ghana http://ugspace.ug.edu.gh Crouch, M., & McKenzie, H. (2006). The logic of small samples in interview-based qualitative research. Social science information, 45(4), 483-499. Darkwa, O. (1999). Toward a national policy for the elderly in Ghana. Ageing International, 25(1), 31-45. Devisch, R., Makoni, S., & Stroeken, K. (2002). African gerontology: critical models, future directions. In Ageing in Africa: Sociolinguistic and anthropological approaches (pp. 277-283). Ashgate Publishing. Dhemba, J., & Dhemba, B. (2015). Ageing and care of older persons in Southern Africa: Lesotho and Zimbabwe compared. Social Work & Society, 13(2). Dionigi, R. A. (2015). Stereotypes of aging: Their effects on the health of older adults. Journal of Geriatrics, 2015. Diop, A. M. (1989). The place of the elderly in African society. Impact of science on society, (153), 93-98. Dovie, D. A. (2019). The status of older adult care in contemporary Ghana: A profile of some emerging issues. Frontiers in Sociology, 4, 25. Echeta, U. F., & Ezeh, E. I. (2017). The Igbo care for the elderly in contemporary times: an old testament evaluation. International Journal of Development and Management Review, 12(1), 140-151. Ennuyer, B. (2002). Les CLIC: un nouvel enfermement des personnes vieillissantes?. Gérontologie et société, 25(1), 83-94. Fabian, D., & Flatt, T. (2011). The evolution of aging. Nature Education Knowledge, 3(3), 1-10. Finlay, L. (2009). Exploring lived experience: Principles and practice of phenomenological research. International Journal of Therapy and Rehabilitation, 16(9), 474-481. Finlay, L. (2013). Unfolding the phenomenological research process: Iterative stages of “seeing afresh”. Journal of Humanistic Psychology, 53(2), 172-201. Flatt, T. (2012). A new definition of aging?. Frontiers in genetics, 3, 148. Flatt, T., & Schmidt, P. S. (2009). Integrating evolutionary and molecular genetics of aging. Biochimica et Biophysica Acta (BBA)-General Subjects, 1790(10), 951-962. Gelbard, R., Inaba, K., Okoye, O. T., Morrell, M., Saadi, Z., Lam, L., ... & Demetriades, D. (2014). Falls in the elderly: a modern look at an old problem. The American Journal of Surgery, 208(2), 249-253. Ghana Statistical Service, (2014). Ghana Living Standards Survey (GLSS 6) 69 University of Ghana http://ugspace.ug.edu.gh Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified Husserlian approach. Duquesne University Press. Giorgi, A., & Giorgi, B. (2003). Phenomenology. Sage Publications, Inc. Green, J., & Thorogood, N. (2009). In-depth interviews. Qualitative methods for health research, 2, 93-122. Hermanns, M., & Mastel-Smith, B. (2012). Caregiving: A qualitative concept analysis. The Qualitative Report, 17(38), 1-18. Heslop A. 1999. Poverty and livelihoods in an ageing world. The Ageing & Development Report: Poverty, Independence and the World’s Older People. Earthscan Publications: London; 22–32. Holmes, E. R., & Holmes, L. D. (1995). Other cultures, elder years. Sage. Hussein, S., & Ismail, M. (2017). Ageing and elderly care in the Arab region: policy challenges and opportunities. Ageing international, 42(3), 274-289. Kavanaugh, M. S., Stamatopoulos, V., Cohen, D., & Zhang, L. (2016). Unacknowledged caregivers: A scoping review of research on caregiving youth in the United States. Adolescent Research Review, 1(1), 29-49. Kwankye, S. O. (2013). Growing old in Ghana: health and economic implications. Postgraduate Medical Journal of Ghana, 2(2), 88-97. Lagacé, M., Charmarkeh, H., & Grandena, F. (2012). Cultural perceptions of aging: the perspective of Somali Canadians in Ottawa. Journal of cross-cultural gerontology, 27(4), 409-424. Lepage, A. (n.d). The quality of life model as attribute of the sustainability concept. Lund University. Quality of life Research Unit (n.d), University of Toronto. Retrieved from http://www.utoronto.ca/qol/. Levinson, D. J. (1978). The seasons of a man's life. Random House Digital, Inc.. Mba, C. J. (2002). Determinants of living arrangements of Lesotho’s elderly female population. Journal of International Women's Studies, 3(2), 1-22. Mba, C. J. (2004). Population ageing and poverty in rural Ghana. Legon, Ghana: Regional Institute for Population Studies, University of Ghana. Mba, C. J. (2010). Population ageing in Ghana: research gaps and the way forward. Journal of aging research, 2010. Mbamaonyeukwu, C. J. (2001). The ageing of Africa's populations. BOLD-VALLETTA-, 11(4), 3-7. 70 University of Ghana http://ugspace.ug.edu.gh Menken, J., Cohen, B., Mann, A. S., Ezeh, A., Kaseke, E., & Kuate-Defo, B. (2006). Aging in Sub-Saharan Africa: recommendations for furthering research. Aging in Sub- Saharan Africa: recommendations for furthering research. Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Africa. Cohen B, Menken J The National Academies Press. Washington DC, 9-51. Ministry of Employment and Social Welfare, (2010). Ghana Ageing Policy (2010) Moustakas, C. (1994). Phenomenological research methods. Sage. Nally, D., & Taylor, S. (2015). The politics of self-help: The Rockefeller Foundation, philanthropy and the ‘long’Green Revolution. Political Geography, 49, 51-63. Ncube, N. (2017). Pathways to institutional care for elderly indigenous Africans: navigating contours of alternatives. African Journal of Social Work, 7(1), 44-51. Noelker, L. S., & Harel, Z. (Eds.). (2000). Linking quality of long-term care and quality of life. Springer Publishing Company. Nortey, S. T., Aryeetey, G. C., Aikins, M., Amendah, D., & Nonvignon, J. (2017). Economic burden of family caregiving for elderly population in southern Ghana: the case of a peri-urban district. International journal for equity in health, 16(1), 16. Nwoke, John. 12/07/2014.Oral interview transcribed by Echeta U.F. in Echeta, U. F., & Ezeh, E. I. (2017). The Igbo care for the elderly in contemporary times: an old testament evaluation. International Journal of Development and Management Review, 12(1), 140-151. Ogburn, W. F., & Tibbitts, C. (1933). The family and its functions. Recent social trends in the United States, 1, 661-708. Ogburn, W. F., & Nimkoff, M. F. (1955). Technology and the changing family. Boston: Houghton Mifflin. Okraku (1985) cited in Oppong, C. (2006). Familial roles and social transformations: Older men and women in sub-Saharan Africa. Research on Aging, 28(6), 654-668. Oppong, C. (2006). Familial roles and social transformations: Older men and women in sub- Saharan Africa. Research on Aging, 28(6), 654-668. Palmore, E. (1999). Ageism: Negative and positive. Springer Publishing Company. Palmore, E. (2001). The ageism survey: First findings. The gerontologist, 41(5), 572-575. Palmore, E. B. (2004). Research note: ageism in Canada and the United States. Journal of cross-cultural gerontology, 19(1), 41-46. Papalia, D. E., Olds, S. W., & Feldman, R. D. (2007). Human development. McGraw-Hill. 71 University of Ghana http://ugspace.ug.edu.gh Promislow, D. E. L., & Bronikowski, A. M. (2006). The evolutionary genetics of senescence. Evolutionary Genetics: Concepts and Case Studies, 464-481. Reinhard, S. C., Given, B., Petlick, N. H., & Bemis, A. (2008). Supporting family caregivers in providing care. In Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US). Roelen, K., Delap, E., Jones, C., & Chettri, H. K. (2017). Improving child wellbeing and care in Sub-Saharan Africa: The role of social protection. Children and Youth Services Review, 73, 309-318. Schatz, E., & Seeley, J. (2015). Gender, ageing and carework in East and Southern Africa: A review. Global public health, 10(10), 1185-1200. Shawney, M. (2003). The role of non-governmental organizations for the welfare of the elderly: The case of HelpAge India. Journal of aging and social policy, 15(2-3), 179- 191 Simic, A. (1990). Aging, world view, and intergenerational relations in America and Yugoslavia. The cultural context of aging: Worldwide perspectives, 108-898. Stone, R., Cafferata, G. L., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27(5), 616-626. Streib, G. F. (1987). Old age in sociocultural context: China and the United States. Journal of Aging Studies, 1(2), 95-112. Sung, K. T. (2004). Elder respect among young adults: A cross-cultural study of Americans and Koreans. Journal of Aging Studies, 18(2), 215-230. Tawiah, E. O. (2011). Population ageing in Ghana: a profile and emerging issues. African Population Studies, 25(2). Tran, M. (2012). UN Report Calls for Action to Fulfil Potential of Ageing Global Population. Am J Physiol Cell Physiol, 302, C1226-1242. United Nations Population Division, World Population Prospects: the 2002 Revision, Highlights (online database). ESA/P/WP.180, revised 26 February 2003, p. vi. Available at: http://esa.un.org/unpp/ (retrieved on 4/06/2019). Uwakwe, R., & Modebe, I. (2007). Disability and care-giving in old age in a Nigerian community. Nigerian journal of clinical practice, 10(1), 58-65. Van der Geest, S. (2002). Respect and reciprocity: Care of elderly people in rural Ghana. Journal of Cross-Cultural Gerontology, 17(1), 3-31. 72 University of Ghana http://ugspace.ug.edu.gh Vaarama, M., Pieper, R., & Sixsmith, A. (Eds.) (2008). Care-related quality of life in old age: concepts, models and empirical findings. New York, NY: Springer Science + Business Media, LLC. Waite, L. J., & Hughes, M. E. (1999). At risk on the cusp of old age: Living arrangements and functional status among black, white and Hispanic adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 54(3), S136- S144. Wolf, D. A., Freedman, V. A., & Soldo, B. J. (1997). The division of family labor: Care for elderly parents. Journals of Gerontology Series B, 52, 102-109. www.hel.fi//institutionalcarefortheelderly visited on 4/04/2019 www.who.int//ageingandhealth-worldhealthorganization visited on 01/06/2019 Youde, J. (2013). The Rockefeller and Gates Foundations in global health governance. Global Society, 27(2), 139-158. Zhang, W., & Creswell, J. (2013). The use of "mixing" procedure of mixed methods in health services research. Medical Care, 51, e51-7. 73 University of Ghana http://ugspace.ug.edu.gh APPENDIX: INTERVIEW GUIDE INTERVIEW GUIDE DEMOGRAPHIC CHARACTERISTICS OF THE ELDERLY AT HELP AGE 1. NAME 2. AGE 3. SEX 4. ETHNICITY 5. MARITAL STATUS 6. NUMBER OF CHILDREN 7. OCCUPATION OF CHILDREN 8. LOCATION OF CHILDREN 9. MARITAL STATUS OF CHILDREN 10. HOW LONG HAVE YOU BEEN A MEMBER OF HELPAGE OBJECTIVE ONE (the elderly would be asked these questions) Investigate the normative attitudes, values and expectations on what constitute quality care for the elderly 1. What does Help Age do for you? 2. How did you become a member? 3. What does help age do for you? 4. Are you satisfied with what Help Age does for you? 5. Who assists you with house chores in the house? 6. Tell me about the care you receive? (What exactly does your caregiver do for you?) 7. What other things do you expect him/her to do for you that are not being done? (How different is the care you receive from the care you ideally desire?) 8. How satisfied are you with the care you receive? 9. Tell me what you think should go into providing acceptable care for the elderly. Is that what you receive? 10. What do you not like about the current caregiving received? 11. In your view do you think the care an elderly person receives affects their lives OBJECTIVE TWO (Elderly) To explore perceptions about emerging alternative long-term caregiving arrangements. 74 University of Ghana http://ugspace.ug.edu.gh 1. What do you think about institutional/nursing homes caregiving for the aged? a. Confinement (imprisonment) b. Privacy issues (strange carers) c. Home/ Abandonment d. Social benefit (new friends; shared experience) e. Cost f. Quality of care (professionalism) 3. What should be the provisions of an ideal caregiving arrangement? (your preferred care arrangement) (Family/home care, day care or institution/nursing home) SOURCES OF SUPPORT (caregivers and the elderly in the aged home will be asked) A. FORMAL SUPPORT 1. Do you receive support from the government? (Benefit from LEAP)? B. INFORMAL SUPPORT 1. Who do you receive support from? 2. What type of support do you receive 75 University of Ghana http://ugspace.ug.edu.gh INTERVIEW GUIDE DEMOGRAPHIC CHARACTERISTICS OF THE ELDERLY AT MERCY HOME 11. NAME 12. AGE 13. SEX 14. ETHNICITY 15. MARITAL STATUS 16. NUMBER OF CHILDREN 17. OCCUPATION OF CHILDREN 18. LOCATION OF CHILDREN 19. MARITAL STATUS OF CHILDREN 20. DURATION OF STAY IN AGED HOME**** OBJECTIVE ONE (the elderly would be asked these questions) Investigate the normative attitudes, values and expectations on what constitute quality care for the elderly 12. Tell me about the care you receive? (What exactly does your caregiver do for you?) 13. What other things do you expect him/her to do for you that are not being done? (How different is the care you receive from the care you ideally desire?) 14. How satisfied are you with the care you receive? 15. Tell me what you think should go into providing acceptable care for the elderly. Is that what you receive? 16. What do you not like about the current caregiving received? 17. In your view do you think the care an elderly person receives affects their lives 76 University of Ghana http://ugspace.ug.edu.gh OBJECTIVE TWO (Elderly) To explore perceptions about emerging alternative long-term caregiving arrangements. 2. What do you think about institutional/nursing homes caregiving for the aged? g. Confinement (imprisonment) h. Privacy issues (strange carers) i. Home/ Abandonment j. Social benefit (new friends; shared experience) k. Cost l. Quality of care (professionalism) 3. What should be the provisions of an ideal caregiving arrangement? (your preferred care arrangement) (Family/home care, day care or institution/nursing home) SOURCES OF SUPPORT (caregivers and the elderly in the aged home will be asked) C. FORMAL SUPPORT 2. Do you receive support from the government? (Benefit from LEAP)? D. INFORMAL SUPPORT 3. Who do you receive support from? 4. What type of support do you receive DEMOGRAPHIC CHARACTERISTICS OF CAREGIVERS 1. NAME 2. AGE 3. SEX 4. MARITAL STATUS 5. OCCUPATION 6. HIGHEST LEVEL OF EDUCATION 7. NUMBER OF DEPENDENTS 8. RELATION TO CARE RECIPIENT 77 University of Ghana http://ugspace.ug.edu.gh (Questions for family caregivers) 1. How was the nature of the relationship between you and the elderly you care (before and after the caring) 2. What are the (major) things you do for her/him? (PFSH) 3. What do you think should be done as a caregiver? (financial, physical, social, health etc) 4. How do you attend to other dependents (spouse/children etc)? 5. How do you balance the care with other duties? 6. What challenges do you face in providing care (relationship/logistics, and health etc) 7. How do these affect the caregiving relationship? 8. What could be done to make caregiving better? SOURCES OF SUPPORT (caregivers and the elderly in the aged home will be asked) E. FORMAL SUPPORT 3. Do you benefit from LEAP? 4. How helpful is the money? 5. Do you receive help from an NGO? 6. How helpful is it? F. INFORMAL SUPPORT 5. Who do you receive support from? 6. What type of support do you receive 7. Recipient of support 8. Benefit of support 78 University of Ghana http://ugspace.ug.edu.gh DEMOGRAPHIC CHARACTERISTICS OF CAREGIVERS 9. NAME 10. AGE 11. SEX 12. MARITAL STATUS 13. OCCUPATION 14. HIGHEST LEVEL OF EDUCATION 15. NUMBER OF CARE DEPENDENTS Carers in the Institution 1. How were you recruited (probe process, qualification experience) 2. What forms of training are available to you (who trains, and for how long? Are you given on the job training)? 3. Are there supervisors of the caregivers? (Probe how they supervise the carer periodically. Discuss regulation to ensure compliance and professionalism) 4. How satisfied are you with remuneration and services available? 5. How adequate is the logistics/facilities and infrastructure (ultramodern/outmoded/ accessible, user friendly). Do they help in the development of users/elderly? 6. What challenges do you encounter in your work? 7. How do you think it should be addressed? 79 University of Ghana http://ugspace.ug.edu.gh Questions for institutional leadership 1. How do you recruit your caregivers (probe process, qualification experience) 2. What forms of training are available to them (who trains, and for how long? Do you hold on the job training)? 3. Are there supervisors of the caregivers? (Probe how they work daily. Discuss regulation to ensure compliance and professionalism) 4. How does the organization get its funding? How adequate is the funding? 5. How adequate is the logistics and infrastructure (ultramodern/outmoded/ accessible, user friendly). Do they help in the development of users/elderly? 6. How do you ensure quality standards (Probe evaluation etc.) 80