i UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK EXTENDED FAMILY SUPPORT AND ELDERLY CARE IN BAMANG, ASHANTI REGION OF GHANA By Kwadwo Ofori-Dua (10018238) B.A (Honours) Sociology with Political Science, University of Ghana, Legon, Accra, Ghana, 1994 M. Phil. Sociology, University of Ghana, Legon Accra, Ghana, 2000 This thesis is submitted to the University of Ghana, Legon in partial fulfillment of the requirement for the award of PhD Social Work degree. June, 2014 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ii DECLARATION I hereby declare that this submission is my own work towards Doctor of Philosophy (PhD) Degree in Social Work and that, to the best of my knowledge, it contains no material previously published by another person nor material which has been accepted for the award of any other degree by the University, except where due acknowledgement has been made in the text. Kwadwo Ofori - Dua, 10018238 …………………............... ……………………….. Student Name & ID Signature Date Certificated by: Dr Kofi Ohene - Konadu ……………………………. ………………………… 1 st Supervisor‟s Name Signature Date Certificated by: Professor Steve Tonah ……………………………… …………………………. 2 nd Supervisor‟s Name Signature Date Certificated by: Dr Ebenezer Saka Manful ……………………………… .………………………. 3 rd Supervisor‟s Name Signature Date University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iii DEDICATION This work is dedicated to my late father Agya Kwaku Dua who did not live to see the fruits of his labour. It is also dedicated to all elderly persons in rural Ghana, “The Forgotten Group.” University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT To Jehovah God the Most High be the glory for the gift of life, strength, wisdom and knowledge. In the preparation of this document, many individuals made various contributions to make this piece a success and it is appropriate to acknowledged them properly. First, I wish to express my deepest appreciation to my supervisory team made up of Dr. Kofi Ohene-Konadu, Professor Steve Tonah and Dr. Ebenezer Saka Manful for their immense contributions which have greatly shaped the final outcome of this work. Sirs, I am really grateful. I am also extremely grateful to the Dean, Jannah Mather, Associate Dean, Hank Lise, the Faculty and staff of the College of Social Work, University of Utah, Salt Lake City, USA, for opening their doors to me during my literature search and write-up. I am particularly grateful to Dr. Caren Frost, Dr. Ruth Gerristen-McKane, and Delva Hommes, for the special roles they played in my stay at Salt Lake City, USA. To all the Ghanaian students at the U of U, Salt Lake City, Chris, Sammy, Joe, Priscilla and Gina I say thank you. I want to specially thank Mr. Isaac Karikari, of Indiana University, Indianapolis, for his comments and suggestions. To you Mr. Joy Ato Nyarko I really appreciate the role you played in the data collection. I want to specially express my gratitude my Mum, Ms Cecilia Ofori and my siblings Kofi, Kwaku, Adwoa, Yaa and Akosua and their families for their prayers, encouragement and support. Your names will forever be attached to my achievements. Last but not the least, I want to deeply appreciate my wife Esther and our children Afia, Adwoa and Akwasi for their support and understanding for the many days I was absent from home. I really love you all. Finally, to all my colleagues and staff of the Department of Sociology and Social Work, KNUST, your support is deeply appreciated. To my respondents, aide and all those people who contributed in diverse ways but space will not allow me to mention your names, I say thank you. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh v ABSTRACT Social change is causing great transformation in every area of society. The objective of this study was to examine how this transformation is affecting the traditional role of extended family to provide support and care to the elderly in rural Ghana. Bamang; a small rural community in Ashanti Region, was used as research site to collect data for the study. Methodologically, a qualitative research technique was employed, including; face to face interviews and observations as methods for data collection from 60 study participants consisting of 30 elderly persons, 25 caretakers and five opinion leaders. Sampling approach consisted of purposive and snowball techniques. The study revealed that the traditional family is undergoing some transformations; from the traditional extended family to modernized nuclear family. This transformation has unfortunately created a vacuum of social responsibility towards elderly relatives who are in need of support and care. Also, the study found that old age is associated with poverty because of bad economic situation in Bamang which constrained savings against future uncertainties. Further, it was recognized that the living conditions of most participating elderly in the study showed signs of poverty and multiple deprivation. Also acknowledging their low educational background, most of the elderly participants lacked information and access to resources that can be accessed to improve their conditions. The study suggests that there is a great need to decentralize implementation and management of programmes like LEAP to local communities and villages to remove bureaucracy. This will make the program more accessible to many elderly citizens in rural communities. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vi TABLE OF CONTENTS Title Page Declaration ……………………………………………………………………………………......ii Dedication ………………………………………………………………………………………..iii Acknowledgement ……………………………………………………………………………….iii Abstract ………………………………………………………………………………………….iv Table of contents ………………………………………………………………………………….v List of Tables …………………………………………………………………………………….vi List of Figures …………………………………………………………………………………...vii Chapter One: Introduction……………………………………………………..……………….1 1.1 Background to the Study………………………………………………………………………1 1.2 Statement of the Problem ……………………………………………………………...……...3 1.3 Objectives of the Study…………………………………………………………………….….6 1.4 Research Questions ……………………………………………………………………….…..8 1.6 Significance of Study …………………………………………………………………………9 1.7 Scope of the Study …………………………………………………………………………..11 1.8 Operationalization of Concepts ……………………………………………………………...11 1.9 Theoretical Framewok ……………………………………………………………………....14 1.10 The Research Location………………………………………….………..……………..….20 1.11 Limitations of the Study ……………………………………………………………......….21 1.12 Organization of the Study ………………………………...……………………………..…21 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vii Chapter Two : Literature Review ….………………………………………………………....23 2.0 Introduction ………………………………………………………………………………….23 2.1 The Concept of Aging and Elderly …………………………………………………..……...23 2.2 Aging Theories…………………... ………………………………………………………....27 2.3 Elderly Population in Global Context …………………………………………………….....31 2.3.1 Elderly Population in Africa …………………………………………………...……….....34 2.3.2 Elderly Population in Ghana …………………………………………………………...….36 2.3.3 Aging and Gender …………………………………………………………………...…....37 2.3.4 Determinants of Population Aging …………………………………………….……...….38 2.4 Social Support as a Concept ……………………………………………………………......41 2.4.1 The Impact of Social Support on the Recipient ………………………………...…………44 2.5 Elderly Care in Global Context - Institutional Structures …………………………………...46 2.5.1 Elderly Care in Ghana - ……………………… ………………………………...………...49 2.6 Changing Structures of Elderly Care in Modern World …………………………………….51 2.7 Conclusion …………………………………………………………………………….........59 Chapter Three: The Research Setting …...………………………………………....................62 3.0 Introduction..………………………………………………………………………………....62 3.1 Profile of Bamang …………………………………………………………………………...62 3.2 Economic Activities ………………………………………………………........................…67 3.3 Political Administration ……………………………………………………………..............71 3.9 Major Infrastructural Facilities in Bamang………………………………………………….77 3.5 The Village Life in Bamang ………………………………………………………….…….79 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh viii 3.6 Conclusion ………………………………………………………………………….…..…..89 Chapter Four: Research Methodology …………………………………………………..…....91 4.0 Introduction. …………………………………………………………………………..……..91 4.1 Methodological Approach ……………………………………………………………..……91 4.1.1 Research Design ……………………………………………………………….…………..91 4.2 Sampling and Sample Design ……………………………………………………...……......93 4.2.1 Target and target Populations…………………………………………………..………….93 4.2.2 Sampling Units.……………………………………………………………………….…..93 4.2.3 Sampling Techniques……………………………………………………………………...93 4.2.4 Sample size ………………………………………………………...………………….….95 4.3 Fieldwork and Data Collection ………………………………………………….…………..96 4.3.1 Recruitment and Training of Research Assistant…………………………….…………….96 4.3.2 Six Months of Fieldwork …………………………..……………………………………...97 4.4 Methods of Data Collection ………………………………………………………….……...99 4.4.1 Sources of Data………………………………………………………………...……….....99 4.4.2 Primary Data………………………………………………………………...……………..99 4.4.3 Secondary Data…………………………………………………………………………...102 4.5 Data Management ………………………………………………………………….….......103 4.6 Reflective Accounts as an "Insider Researcher" …………………………………………...104 4.7 Ethical Issues ……………………………………….………………….……………......…106 4.8 Conclusion ………………………………………………….………………….………......107 Chapter Five: Analysis and Discussion of elderly Persons in Bamang…...…………….….108 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ix 5.0 Introduction. ……………………………………………………………………...…..........108 5.1 Socio-demographic and Economic Characteristics of Respondents. …………………........109 5.2 Economic Activities of Elderly Persons in Bamang …………………….………….….......125 5.3 How Elderly Persons Live and Care for Themselves Bamang………….………...……….131 5.4 The Role of the Extended Family in the Lives of Elderly Persons in Bamang…………….151 Chapter Six: Family Systemand Elderly Care – Experiences of Elderly Persons in Bamang …………………………………………………………………………………….…………….162 6.0 Famaily System and Elderly Care in Pre-colonial in Bamang…………………………….162 6.1 Family Changes and Elderly Care in Post-colonial Bamang ……………………..………..165 6.2 Respondents' Interpretation of Family Changes and Elderly Care in Bamang …………….168 6.3 Implications of the Changing Extended Family System for Support and Care to Elderly Persons in Bamang…………………………………………………………..………………….173 6.4 Elderly Care in Bamang - The Way Forward……………………………...………………184 6.5 The Role of Elderly Persons in Present Day Bamang………………...…………………...190 6.6 Conclusion………………………..………………..……………………………………….191 CHAPTER SEVEN:Summary, Conclusions and Recommendations...................................193 7.0 Summary of the Study…………….………………………………………………...……..193 7.1 Conclusions of Study Findings ……………………………………………………….........196 7.2 Recommendations for Policy and Practice…………………………………………………204 7.3 Contribution to Literature and Knowledge………………………………………………...214 7.4 Suggestions for Future Research ..………………………………………………...............215 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh x Bibliography ………………………………………………………………………………......218 Appendix A: Interview Schedule (A) for Elderly Respondents …….……………………........246 Appendix B: Interview Schedule (B) for the Household Member ……………………….........252 Appendix C: Participant Informed Consent Form ………………………………………..........256 Appendix D: Pictures showing some sections of the road from Bonwire to Bamang ...……… 258 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xi LIST OF TABLES Title Page Table 1: Projected Population Ageing in sub-Saharan African Regions, Ghana and Nigeria from 2005 – 2050 ……………………………………………………..……...2 Table 2: Dynamics of Population Aging in the Modern World …………………………............32 Table 3: Sex Characteristics of Respondents...……………...……………………………….....110 Table 4: Age Characteristics of Respondents.……………...…………………………….…….112 Table 5: Educational Attainment of Respondents …..……………………………….………...115 Table 6: Relationship of Household Respondents to Elderly Participants ……...……………..120 Table 7: Marital Status of Respondents ……...………………………………………………...122 Table 8: Number of Children and Grand Children of Elderly Respondents ……...…….……...123 Table 9: Main Sources of Economic and Material Support for Elderly Participants………......139 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xii LIST OF FIGURES Title Page Figure 1: Relationship Between Social Support and Well-being …………………...…………..19 Figure 2: Map of Kwabre East District Showing Bamang the Study Area ………...………...... 63 Figure 3: Hierarchical Structure of Traditional Authority in Ashanti ……………………...…...72 Figure 4: Pictorial Representation of Computer Handling of Data …………………………....104 Figure 5: A Picture Showing Kente Weavers at Work…………………………………………141 Figure 6: A Picture Showing a Bottle that Contains a Remedy for Emotional Problems According to One Respondent……………………………………………………..159 Figure 7: Diagrammatic Representation of Elderly Experience with the Family System ..……172 Figure 8: The Researcher Walking Toward a Participant‟s House ……………...……………..174 Figure 9: A Rear View of One of the Family Houses in the Village .……………………...…..175 Figure 10: A compound of One of the Family Houses ……….………………………………..175 Figure 11: A Picture Showing the Researcher and the Aide Recruited from the Village in One of the Relatively New Houses………………………..………………………...176 Figure 12: A Picture Showing a Woman Selling Cassava on a Tray in the Village ………….177 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 1 Chapter 1 Introduction 1.1 Background to the Study Population aging is a global phenomenon that has heightened the care giving needs of elderly persons on a global scale (Shaibu & Wallhagen 2002). Mba (2010) indicated that in 2007, there were over 700 million adults over the age of 60 in the world. This number is projected to reach two billion by the year 2050. Even though the level and pace of population aging vary widely by geographic region, and usually within regions as well, virtually all nations have experienced growth in their numbers of elderly residents (Okumagba, 2011). The percentage of the world‟s population aged 65 and above increased from 5.2 per cent in 1952 to 6.9 per cent in 2000. In Europe, however, the proportion was 14.7 per cent in 2000 (Gavrilov & Heuveline, 2003; Kinsella & Phillips 2005). In Africa, the numbers of those aged 60 and above was 45.7 million in 2005. This number is expected to increase to 182.6 million in 2050 (Ogwumike & Aboderin 2005). In sub- Saharan Africa, as Table 1 shows, the Southern region will see the most rapid population aging by 2050, while the largest number of older people, 51.6 million, will live in West Africa. Within West Africa, population ageing will be most marked in Nigeria and Ghana. While Ghana will see the most rapid rise in the population share of older people, Nigeria will experience the greatest impact in terms of sheer numbers (Ogwumike & Aboderin, 2005). Half of all older people in West Africa presently do, and will continue to live in Nigeria, their number rising from 6.4 million in 2005 to 25.5 million by 2050 (Ogwumike & Aboderin 2005; UN, 2005). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 2 Table 1: Projected Population Aging in sub-Saharan African Regions, Ghana and Nigeria from 2005 to 2050 Regions Population 60+ (Percentage of total population) Population 60+ (millions) 2005 2025 2050 2005 2025 2050 West Africa 4.7 5.5 9.0 12.0 21.8 51.6 Southern Africa 6.6 10.6 12.8 3.4 5.2 5.95 Middle Africa 4.8 4.4 6.6 4.9 7.6 17.6 East Africa 4.5 4.9 7.8 12.7 20.8 47.8 Ghana 5.4 7.6 14.6 1.18 2.3 5.8 Nigeria 4.9 6.0 9.9 6.4 11.5 25.5 Source: UN (2005) cited in Ogwumike & Aboderin (2005). In spite of the growing elderly population in Africa, families take care of their elderly relatives (Shaibu & Wallhagen 2002). In Ghana, institutions like nursing homes for elderly persons are not well developed as such many older persons are cared for in their own homes. Yet urbanization and modern economies have placed great strains on the African extended family with adverse consequences on the care of older persons (Apt, 1992; 2012). Consequently, an accurate understanding of the social support available to elderly persons and the extent to which families provide this support adequately in rural Ghana is critical if social workers are to be effective in helping to resolve the needs of the increasingly aging population (Cantor 1980; Mba, 2007). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 3 This study seeks to find out how urbanization, migration and social change have affected the extended family system and its support to elderly persons in rural Ghana. The aim is to promote knowledge regarding the resources available to elderly persons and thus enable social workers and other professionals to be better equipped to provide appropriate and needed social services for the elderly in rural areas. 1.2 Statement of the Problem Since the 1960s, Ghana has witnessed a steady increase in the percentage of the elderly population (Madrid International Plan of Action and Ageing [MIPAA], 2007). In 1960, 3.2 per cent of the population in Ghana was 65 years and over. The percentage increased to 3.6 per cent in 1970, also 4.0 per cent in 1980 and 5.3 per cent in 2000 (MIPAA, 2007; Tonah, 2009). Though the percentage decreased to 4.7% in 2010 (Ghana Statistical Service 2012), the percentage of the elderly population in relation to the total population of Ghana has been argued to be growing rapidly than those in developed countries of Western Europe and North America (MIPAA, 2007). The implication of this development is that, the number of people who will fall within the 60 years and above bracket is likely to increase in the near future. It is thus imperative for Ghana to put institutions and structures in place and hold itself in readiness to contain any effects that the anticipated increase in the elderly population might bring. In view of this development, both the 1992 Constitution of Ghana and the National Population Policy, revised in 1994, recognised the need for laws and formal institutions to promote the well-being of the elderly in Ghana (MIPAA, 2007). In practice, however, caring for elderly persons in Ghana falls mostly on the immediate and/or the extended family. Elderly persons in Ghana are more likely to reside with and depend on family members, particularly University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 4 children, for support (Mba, 2004). In traditional (pre-colonial) Ghana, mutual aid societies, organised around kinship ties provided support and aid to family members, including the aged (Brown, 1999; Nukunya, 2003). Nukunya (2003) explained the importance of the extended family and its role in providing support for members of the family. He maintained that within an extended family, individuals had reciprocal obligations, duties and responsibilities towards other family members. Thus, it could be argued that elderly persons were supported and cared for within the extended family structure in traditional Ghanaian societies (Brown, 1999). This care giving was backed not simply by the emotional bonds of relationship emerging out of blood or marital relationships, but by the force of the pervasive influence of traditional values, norms and behaviour which were not simply practiced as a matter of routine but also deified and pursued with vigour (Nukunya, 2003). The literature as discussed above raises three very important problems related to the social conditions of elderly persons in modern Ghana. First, the percentage of the elderly population in relation to the total population of Ghana is likely to increase in the coming years (Ogwumike & Aboderin, 2005). Second, formal institutions and structures as well as sources of support for elderly persons are not fully developed in Ghana, especially in the rural areas. Third, the extended family system, particularly children, in Ghana has been the primary source of support for the elderly persons (Mba, 2004; Nukunya, 2003). However, migration, urbanization and social change are gradually transforming the family from the extended system to a more nuclear system (Amponsah, Akotia & Olowu, 2006; Apt, 2012; Takyi & Oheneba-Sakyi, 1994). This shift is gradually weakening the loyalty and obligations of family members towards their kin members (Nukunya, 2003). This means that the support that existed under the traditional extended family system for elderly persons may no University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 5 longer be available. Nukunya (1992) further explained that the changes that have occurred in the family have led to the compression of genealogical ties in effective and routine kinship behaviour. He asserted that, unlike in pre-colonial Ghana, people now virtually disregard their traditional reciprocal obligations and responsibilities to relatives outside their nuclear families except the closest and the most immediate. Thus, people tend to be more concerned with the needs of their immediate relations than kin groups (Avendal, 2012; Nukunya, 1992). The assertion by Apt (2012) and Nukunya, (1992; 2003) was corroborated by the Madrid International Plan of Action and Ageing (MIPAA). In a report on the implementation of the Madrid International Plan of Action and Ageing (MIPAA, 2007), it was revealed that urbanization, rural-urban migration and international migration of the working population in Ghana have created social and physical distances between the working population and their relatives thereby increasing the number of neglected and isolated older persons in Ghana. Other studies (Abdul-Korah, 2011; Yeboah, 1998) that have examined the family and social support have revealed that imported cultural models and social dislocation among other changes have caused the waning of many traditional mechanisms of social support. Other scholars have similarly noticed these trends and patterns in Ghanaian traditional and social life (Abdul-Korah, 2011; Amponsah, Akotia & Olowu, 2006). The main argument of this study is that, in a country like Ghana where institutional facilities like nursing homes for elderly persons in rural areas are non-existing, there has been a residue of benign neglect when it comes to the issue of who cares for the elderly or how the older people meet their basic needs (Kumar, Kalache, Hennessy & Acanfora, 2001). Even though on paper, both the 1992 Constitution and the National Population Policy, revised in 1994, advocate University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 6 for laws and institutions to cater for elderly persons, not much have been done beyond the paper work in practical terms. Given that elderly persons in rural communities in Ghana mostly work in the informal sector and therefore do not retire on formal pension benefits (Tonah, 2009), changes in the extended family and its support would have effect on the socio-economic and emotional lives of the rural elderly. This study thus seeks to find out if indeed there have been changes in the nature of the extended family in Bamang. If so, what are the factors that account for the changes? What are the implications of such changes, if any, on the care and support to the elderly? What is the extent of extended family involvement in the lives of elderly persons in Bamang amidst changes in the extended family system as portrayed by various studies in the literature? Finally, the study examines the living conditions of the elderly in Bamang, a rural community in Ghana to determine the extent of changes occurring. 1.3 Objectives of the Study The purpose of this study is to explore and describe the changes in the extended family system, if any, and its implications for family support and care to elderly persons in Bamang, a rural community in Ghana. Specifically, the study seeks: 1) To provide information on the socio-demographic and economic characteristics of elderly persons in Bamang. 2) To find out how the elderly live and care for themselves. 3) To explore the nature and extent of the extended family‟s involvement in the lives of elderly persons in the study area. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 7 4) To find out from elderly persons if they have experienced changes in the extended family system and its support and care for the elderly in Bamang. 5) To ascertain how elderly persons in Bamang interpret changes, if any, in the extended family system and its support and care to the elderly. 6) To provide relevant information that will serve as a guide to enhance social policy and social work practice with elderly persons. 1.4 Research Questions The central question addressed in this study is: how have the changes in the traditional extended family system affected family support and care to elderly persons in Bamang? To answer this question, the study is guided by the following specific questions. a. What are the socio-demographic and economic characteristics of elderly persons in Bamang? b. How do elderly persons in the study area live and care for themselves? c. To what extent is the extended family involved in the care of elderly persons in Bamang? d. What are the experiences of elderly persons with respect to the nature and changes, if any, in the extended family system in the community? e. How do the elderly in Bamang interpret the changes in the extended family support and care, if any? These questions serve as the searchlight of this research. Answers to these questions will provide an important source of information for social workers in Ghana and all those elsewhere who are interested in the welfare of elderly persons. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 8 1.5 Justification of the Study In modern times, scientific research has inevitably become the basic pre-requisite toward the studying and understanding of any social phenomenon. Indeed, when governments and corporate bodies seek to improve upon or enhance the performance of an aspect of their operation, they embark on social and scientific research upon which concrete decisions are made towards modification and improvement. It is on the basis of this assertion that this study is being undertaken. Elderly persons in low and middle income countries traditionally and mainly depend on families for care and support at old age. Very little or no support is available to the elderly through public programmes. Children live with them as three-generational families where the elderly hold higher rank and authority due to their wisdom and control of resources. The informal care givers include relatives, friends and neighbours (Jesmin, Amin, & Ingman, 2011). In Africa, many elderly persons expressed satisfaction with family care and they rarely lived alone (Unanka, 2003). However, this ideology of the family being the major care givers of elderly persons is slowly fading across the globe. In the last few decades, the nuclear family structure is becoming a worldwide phenomenon and support during old age is not automatically provided for (Apt, 2012; Jesmin, Amin, & Ingman, 2011). Many theories focus on westernization and modernization processes in societies that have transformed the family structure as well as family values (Cowgill, 1986). Although the filial piety still remains the official ideology employed by many Asian societies to instil a sense of responsibility, children find it constraining to support and care for the parents since the average family‟s resources and income are meagre in low income countries (Jesmin, Amin, & Ingman, 2011). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 9 Consequently, older persons without resources are more likely to be abandoned by children and relatives, and when faced with extreme poverty many family networks built in earlier phases of family lifecycles get broken or weaker (Chu & Chi, 2008; Jesmin, Amin, & Ingman, 2011). Although there is growing attention and interest among researchers in neglected care giving for elderly persons, most studies are conducted in western societies where there is more awareness of this issue. On the other hand, the nature and extent of neglected elderly care is relatively unexplored in rural areas of many developing societies. As a result of lack of empirical and quantifiable data on how elderly persons in rural Ghana are cared for, it has become difficult to promote awareness of the living conditions and the problems faced by elderly persons in rural area as an important issue to be tackled by national policy (Apt, 1992). By investigating and documenting the scale and magnitude of the living conditions of elderly persons in a rural community such as Bamang, this study will first, draw the attention of policy makers to this “forgotten group” and second, provide a basis for effective measures to ameliorate and combat the problems faced by elderly in rural Ghana and their care givers. 1.6 Significance of Study Professional social workers are concerned with reducing vulnerability and oppression, as well as promoting the well-being of people in society (National Association of Social Workers [NASW] 2008; Torgusen & Kosberg, 2006). As Dubois and Miley (2005) explained, in addition to helping to promote the competence and functioning of people in social situations, social workers are also engaged in assisting people to access social resources, to create responsive social situations and to increase the opportunities for the well-being of all persons. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 10 Consequently, an in depth understanding of disadvantaged groups in society, including elderly persons, is of primary concern to social workers (Greene, 2000; NASW, 2008; Tompkins & Rosen, 2007; Torgusen & Kosberg, 2006). Secondly, studies investigating why social support from relatives within the extended family is dwindling have identified a number of predisposing factors. Notable among these factors are migration, urbanization, emphasis on the nuclear family, and worsening economic conditions. These explanations and the relevant policy responses that flow from them are based largely on the experience of developed countries (Karikari & Bettmann, 2013). It is, therefore, not clear if the effects as being played out are the same in less developed countries. Studies on the social dynamics of sub-Saharan Africa suggest that the social context may differ in important ways from that of developed countries. A critical aspect of the social context is the kind of social support resources available to elderly persons and their access to these resources (Yeboah, 1998). This study will thus help increase social work knowledge and make social workers in Ghana better equipped to assist in promoting quality support services for elderly persons based on empirical evidence of what works, what is needed, what strengths and resources are already available to the elderly, and how these resources could be utilised. Again, Mba (2004) has argued that ageing and gerontology is one of the most under researched areas of social life in Ghana. This research will, therefore, contribute by reducing the knowledge deficiency in this area. In addition, social work students and academics can build on the knowledge this study has produced by testing some of the findings from the study in other areas of the country. Furthermore, the outcome of the study will also have national significance in terms of policy initiation, formulation and implementation since what were found in the study area might University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 11 be a microcosm of what pertains in the larger society. Besides, this research would be useful for governmental and non-governmental organizations working with elderly persons, and also a source of reference for anyone who might want to understand the effect of changes in the extended family system on the support and care of elderly persons in rural Ghana. 1.7 Scope of the Study The scope of any research delineates the parameters or confines of the study and provides the researcher(s) with variables to deal with. Typical with many concepts in social sciences, family support and elderly care are social constructs. The nature and extent of care in a given society are defined by the cultural norms and values of the society or group under consideration. The phenomenon of elderly care or support is wide and has many complex and intricate tentacles. The scope of this study covers support in terms of physical assistance in activities of daily living, socio-economic support (such as food, clothing, shelter, cosmetics etc), health care, emotional support and companionship provided to elderly persons (60 years and above) in Bamang by relatives or members within the extended family. 1.8 Operationalization of Concepts Elderly persons: Elderly persons, the aged or older people are all considered as older adults and all these concepts are used interchangeably in this study. The question about who is an elderly person does not amend itself to a single answer due to the standard differentials in the determination of whether someone is an elderly person or not (Flatt, 2012; Larkin, 2011). For instance while the US Census Bureau, Population Division, has set the age of an elderly person at 65 and above, Dubois and Miley (2005) dissented that this group rather constitutes persons of 60 years and above. Given Ghana‟s young age structure and shorter life expectancy, an elderly University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 12 person is defined in this study as all persons aged 60 years and over. This definition is in line with the mandatory retirement age for most persons working in the formal or government sector in Ghana (Aboderin, 2002; National Pensions Act, 2008). Extended Family: For the purpose of this study, the extended family is used to mean close relatives or a social arrangement in which an individual has extensive reciprocal duties, obligations and responsibilities to relatives outside his or her immediate nuclear family. It includes members of the nuclear family, in-laws, siblings, and members of a household (Nukunya, 2003). Nuclear Family: The nuclear family is used in this study to refer to a married couple and their dependent children (Nukunya, 2003). Urban Area: The use of multiple definitions reflects the reality that “rural” and “urban” are multidimensional concepts, and as such making clear-cut distinctions between the two invokes appreciable difficulty. In Ghana, any residential community with a population of 5000 inhabitants or more is considered an urban area (Ghana Statistical Service [GSS], 2012). This definition is adopted for this study. Rural Area: Given the definition of urban area, as indicated above, it stands to reason that any community in Ghana with a population below the threshold of 5000 inhabitants by implication, constitute a rural area (GSS, 2012). The study maintains this definition of a rural area. Social support: Social support is a multidimensional construct that has been defined in many ways, as such there is little agreement about the definition of this concept (Cornman, Goldman, Glei, Weinstein & Chang, 2003; Sarason, Sarason & Pierce, 1990). Social support in University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 13 this study is used to mean any physical, financial, material and emotional assistance received from close relatives, that is, members of the nuclear family, in-laws, siblings, and members of a household. Social support, extended family support, and informal social support are used interchangeably in this study. Household: A household, according to Nukunya (1992) is a person or a group of persons who live together in the same compound, share the same housekeeping arrangements and are catered for as a unit. It may be a domestic group or family. The study adopts this definition. Well-being: Well- being is used in this study to mean the degree to which a person meets the basic necessities of life; food, clothing, shelter, healthcare and companionship among others. Traditional Ghanaian Society: Traditional Ghanaian society as used in this study refers to the society that existed before and throughout the colonial period to the time of independence. Modern Ghanaian Society: Given the definition of traditional Ghanaian society as indicated above, modern Ghanaian society is used in this study to mean the society after post colonial period. Elderly Care: As already indicated, elderly care is a social construct therefore its nature and extent is influenced by cultural norms and values of a particularly society. For the purpose of this study, elderly care is used to mean physical assistance, social support, financial and material assistance, companionship and emotional assistance provided by family members to their elderly relatives. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 14 Caretakers: Caretakers as used in this study refers to persons who provide day-to-day support and care in terms of activities of daily living, financial or material assistance, social and emotional support or companionship to elderly persons within their households. Caregivers: On other hand caregivers is used in this study to mean relatives outside the household (e.g. in-laws, siblings, children, grandchildren, etc) who provide financial and material support to elderly persons in Bamang. 1.9 Theoretical Framework The relationship between social support and well-being must address the question of how precisely social support works to influence the living conditions of recipients. Over the last few years various theories have emerged to explain the relationship between social support and physical well-being (Hutchison, 2003). This study employed the modernization and buffering theories to explain the impact of availability or lack of family support on the living conditions of elderly persons. i. Modernization Theory Modernization theory emerged in the 1950s and 1960s. However, the ideas embedded in modernization theory precede these time periods. The notion of social evolution and constructs seeking to explain the development of societies can be found in the works of early scholars such as Emile Durkheim and William James (Giddens, 1991b; Green, 2008; Lerner, 1958; Przeworski & Limongi, 1997; Webster, 1990). Modernization theory is a set of theoretical postulations offering explanations about how societies evolve overtime. It specifically focuses on the patterns of change and transition as societies make the shift from traditional to modern forms. Modernization theory seeks to show a University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 15 distinction between traditional and modern societies (Green, 2008; Lerner, 1958; Przeworski & Limongi, 1997; Wang, 2009). Some of the features or characteristics of modern societies border on the advancement of science and technology and the consequential increase in industrialization and automation. Modernization theory does not only concern itself with scientific and technological advancements but also with social and political processes. As societies evolve, so do their forms of organization and government. Further, social roles change as well, and the position and status of the family may thereby be affected (Fangjun, 2009; Green, 2008; Lerner, 1958; Przeworski & Limongi, 1997). Modernization involves the transformation of many social and political institutions (Wucherpfennig & Deutsch, 2009). Academic training and education, as well as forms of communication and transportation become increasingly complex. Urbanization and bureaucratization increase as well. The trends of urbanization are often reflected in the time- space distantiation of modernizing societies, and in recent times, the reliance on interactive media and technology. In traditional societies, what is common is more direct interaction (Giddens, 1991a, 1991b). The basic premise of the modernization theory is that as societies modernize, elderly persons who are unable to work outside of the home or have less to offer economically are seen as a burden. This model thus suggests that, as people age, they will be abandoned and lose much of their familial support when they become non-productive (Harwood, 2007; Hooyman & Kiyak, 2011). These conditions may be applied to both the developed and the developing world. Explaining the effect of modernization on older persons, Cowgill and Holmes (1972) suggested that the primary cause of elderly persons losing power and influence in society were the parallel forces of industrialization and modernization. In preindustrial societies, strong social norms enjoined the younger generation to care for the older generation. As societies University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh file:///F:/Aizaek/Documents/Mr.%20Dua%20-%20Disso/Harwood 16 industrialized, the nuclear family replaced the extended family creating individualistic society where caring for an older relative was seen as a voluntary obligation that may be ignored without fear of social censure (Harwood, 2007; Hooyman & Kiyak, 2011). One of the criticisms of modernization theory has been the assumption that the process of change is unilinear. Modernization theory is deemed by some to be inadequate in explaining the uneven distribution of wealth and resources among people in societies. Criticisms of modernization theory have also included the projection and use of the West as the standardized format of how modernization takes place. Thus, it has sometimes been viewed as an instance of Western hegemony. Essentially, it fails to capture and represent the unique experiences of different countries (Przeworski & Limongi, 1997; Schiller, 1976). Also it is argued that the dichotomy of “traditional” and “modern” forms is overly simplified. It does not account for or properly represent some of the real details and entailments of development. Chan (2005) noted the uniqueness of the Asian experience of population aging, and how that experience somehow contradicts the postulations of modernization theory. Further, Chan (2005) highlighted the distinct role culture plays in the aging processes and experiences of Asian societies. Similarly, Hossen (2007) stressed the need for consideration to be given to contextual factors, and how situations vary from place to place. Notwithstanding the criticisms of modernization theory, it contributes profoundly to an understanding of societies and many social processes. The theory is relevant in explaining the nature and extent of family support and care to the elderly in both traditional and modern Bamang. It thus provides an ideal framework for understanding the changes in the extended family system and its implications for support and care to the elderly in Bamang. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh file:///F:/Aizaek/Documents/Mr.%20Dua%20-%20Disso/Harwood 17 ii. The Buffering Model The buffering hypothesis also emerged in 1976. It was developed by John Cassel and Sidney Cobb (Cohen & Pressman, 2004). According to this theory, social support is directly linked to people‟s well-being. The model conceptualised social support as an external source of emotional, informational and instrumental aid (Auslander & Litwin, 1987). Cohen and McKay (1984) posited that psychosocial stress will have adverse effects on the health and well-being of those with little or no social support, while these effects will be lessened or eliminated for those with stronger support systems (Cohen & Wills, 1985; Thoits, 1986). From the buffering perspective therefore, support is seen as a factor that intervenes between a stressful event and our action. Recognising our support helps us to diminish or prevent a stress response. We recognise a potential stress, but our perception that we have resources available redefines the potential for harm or reduce reaction by influencing our cognitive, emotional and physiological processes (Cohen & Wills, 1985; Hutchison, 2003). This theory is thus linked to both mental and physical health outcomes. Social support is considered fundamental in helping people cope with stressful life events. The buffering theory also indicates that social support guards people against the generally deleterious and sometimes life-threatening effects of stressors. Hence, it maintains that social support is beneficial in ensuring wholesome life experiences (Johnson, Wood, Gooding, Taylor & Tarrier, 2010; Mezuk, Diez Roux & Seeman, 2010). There is continued interest in the role of interpersonal relationships as a protective factor in the prevention and control of stressful life events. Studies conducted in this regard cover diverse populations including children and adults, and also across different fields and disciplines such as social work, psychology and medicine (Al-Kandari, 2011; Cohen & McKay, 1984; Cohen & Pressman, 2004; Johnson, Wood, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 18 Gooding, Taylor & Tarrier, 2010; Seeman, Lusignolo, Albert & Berkman, 2001). Some of these studies and materials about social support have specifically focused on geriatrics and gerontology (Al-Kandari, 2011; Seeman et al., 2001). A major strength of the buffering theory is that it provides a good ground on which the relationship between social support and emotional and/or health conditions of elderly persons could be examined. Some scholars have indicated that studies about the perceived beneficial effects of social support are inconclusive (McDade, Hawkley, & Cacioppo, 2006; Seeman, Lusignolo, Albert & Berkman, 2001). Reasons for this inconclusiveness include the lack of a consistent or universal conceptual framework for such studies. For instance not all researchers agree on the meaning of social support. Further, the measuring instruments may also not be the same (Cohen & McKay, 1984). Other scholars have also argued that for social support to serve as a buffer to a person, adequate social networks, proper social embeddedness and right social climate are vital. Social network is the structure of an interactive process which describes the people with whom an individual maintains interpersonal relations (Antonucci, 2001). Social embeddedness on the other hand is the depth and strength of relational ties between a person and each member of his or her social networks (Barrera, 1986). Some degree of connectedness must exist in order to derive support from the environment. Social climate refers to a conducive environment that promotes help giving (Moos & Lenke 1992). Without a structure of people (network) with the quality of connectedness (embeddedness) to generate an atmosphere of helpfulness (social climate), social support cannot occur. The above discussions suggest that social support is not automatically available to all elderly persons at all times but rather depends on the adequacy of the person‟s social network, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 19 the degree of his or her connectedness to the social network, and the right kind of environment. This idea is illustrated in the diagram below. Figure 1: Relationship between social support and well-being Source: Author‟s design. The buffering theory is a relevant framework for understanding the relationship between social support and the living conditions of recipients. The theory is, therefore, used in this study to examine the differences in terms of living conditions (social, economic, physical and emotional) of elderly persons with social support and those without social support. For a person to receive social support, the individual: Must have adequate social network, Be properly embedded in the social network, and Have the right kind of social climate The fulfilment of these three conditions leads to provision and /or receipt of social support in any of the following forms: Emotional Instrumental Informational Appraisal Availability of social support in their right proportion leads to: Good health and psychological well-being, Economic well-being, and Proper social functioning. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 20 1.10 Description of the Research Location This research was conducted in Bamang a village in the Kwabre East District of the Ashanti region in Ghana. It is located in the south-eastern part of the district. The 2010 population census puts the total population of the village at 2,628 (Ghana Statistical Service, 2010). The choice of Bamang was motivated by my observation of the living conditions of some elderly person in the village. As typical with many villages in Ghana, Bamang lacks many social amenities like all year motorable road networks, potable water, health facilities, adequate educational facilities (libraries and computer laboratories), and employment opportunities. Most of the economically active people are subsistence farmers. Most young men supplement farming activities with kente weaving. A large number of the economically active group hardly makes enough from either their farming or weaving activities to adequately care for their family needs. As such, the standard of living for most people there is very low. Symptoms of poverty are quite visible. In view of these developments, majority of junior high school graduates in the village migrate to Kumasi and other urban areas in search of either further educational facilities (senior high schools) or employment opportunities leaving the elderly to fend for themselves in the villages. Given these conditions, many elderly persons depend on either economic and/or farming activities or support from either children and/or close relatives for a living. It is not uncommon to find many elderly persons still engaged in farming or other forms of economic activities with some difficulties. From casual observation, it is difficult to tell whether elderly persons in the village engaged in these activities out of necessity or for other purposes. It is only through scientific study that one can ascertain the role of the extended family in the lives of the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 21 elderly in the village. Bamang thus provides a good setting for looking at the extended family support and care to the elderly in a rural community. In addition to my association with the Kwabre East Community for over twenty years gave me some advantages in the area of data collection. First, I speak and understand the local dialect very well and therefore understood any information given during the data collection. Secondly, as a native of the community, I am well versed in the culture and practices of the people and therefore had some knowledge about how to conduct myself in the course of the data collection. 1.11 Limitation of Study Despite the potential contribution that this study would make to social work in Ghana, the research faces one major limitation. A major limitation of this research is the scope. This study is based on a sample of purposively selected participants. Even though the use of interviews enabled in-depth discussions with selected participants, the ability to generalise from the findings of this research to other parts of Ghana may be limited. This is because Bamang in the Kwabre East District of the Ashanti region is made up of quite distinct socio-economic and cultural conditions than what happens in other parts of the country. 1.12 Organization of the Study The study has been organized into seven chapters. The introductory chapter contains the background to the study, statement of the research problem, research questions, objectives of the study, justification and the significance of the study. Also included in this chapter are the scope of the study, operationalization of concepts used in the study, theoretical framework, description University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 22 of the research location, limitations of the study and organization of the study. Chapter two reviews the existing literature on the phenomenon under consideration. The third chapter provides a comprehensive profile of the research setting and background of the study area. An outline of the methodology employed to collect the data and the field work constitute the fourth chapter. The result of field data collected is presented, analysed and discussed in chapter five. The experiences of the respondents in respect to changes in the extended family system are discussed in chapter six. The last chapter (seven) summarises the findings of the study and makes recommendations based on the findings. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 23 Chapter 2 Literature Review 2.0 Introduction This chapter provides a comprehensive review of literature relevant to the study. The first section provides definitions of aging. Concomitantly, the concepts of aging, elderly and theories of aging are presented. This discussion is followed by an overview of the demographic characteristics of aging in the global context and an exploration of the various factors that may be contributing to the gradual increase in the proportion of the elderly population in most countries worldwide. A discussion of the elderly in Ghana and the various characteristics associated with their lives is also presented. Closely following this discussion, is a review of the concept of social support and the role it plays in the lives of older adults. The discussion is narrowed down to institutional structures of elderly care in the past and the changes that have occurred in elderly care. The review concludes with the role of the elderly in modern society. 2.1 The Concept of Aging and Elderly Aging is often described as a process involving continuous changes in the tissues or organs of the body which leads to a reduction in bodily functions and eventual death (Balcombe & Sinclair, 2001). Some of the features associated with aging include loss of skin elasticity, decline in muscular strength, loss of hair and a decline in immune competence. Old age thus consists of ages nearing or surpassing the average life span of human beings leading to the end of the human life cycle. Euphemisms and terms for old people include seniors (American usage), senior citizens (British and American usage), older adults in the social sciences, and the elderly. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh http://en.wikipedia.org/wiki/Average_life_span http://en.wikipedia.org/wiki/Human_being http://en.wikipedia.org/wiki/Biological_life_cycle http://en.wikipedia.org/wiki/Euphemism http://en.wikipedia.org/wiki/Social_science 24 The ageing process is, of course, a biological reality which has its own dynamic, largely beyond human control (Harwood, 2007). However, it is also subject to the constructions by which each society makes sense of old age. In other words, there is an element of social construction, both local and global, in the way individuals and nations define who is an elderly person, that is, the shared meaning of the concept of elderly is created through interactions among people in society. This concept is exemplified by the saying that you are only as old as you feel (Harwood, 2007). Although there are commonly used definitions of old age, social definitions of the elderly vary from one society to another (Wong, 2004) such that there is no general agreement on the age at which a person becomes old. In general, the conventional age for retirement reflects the social recognition of old age (Gergen & Gergen, 2000; Wong, 2004). Most developed countries have accepted the chronological age of 65 years as a definition of “elderly” or older persons, but like many westernized concepts, this does not adapt well to the situation in Africa. While this definition is somewhat arbitrary, it is many times associated with the age at which one can begin to receive pension benefits in the developed countries (Makoni, 2008; WHO, 2012; U.S. Social Security Administration, n.d). Considering that a majority of old persons in sub- Saharan Africa live in rural areas and work outside the formal sector, and thus expect no formal retirement or retirement benefits, this imported reasoning seems quite illogical (Makoni, 2008; WHO, 2012; U.S. Social Security Administration, n.d). Further, when this definition is applied to regions where average life expectancy is much lower and the size of older populations is much smaller, the utility of this definition becomes even more limited (WHO, 2012; U.S. Social Security Administration, n.d). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html 25 In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age (Devi & Bagga, 2006; Makoni, 2008). Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution to society is no longer possible (Devi & Bagga, 2006; Gorman, 1999). Study results published in 1980 provide a basis for a definition of old age in developing countries (Glascock & Feinman, 1980). An international anthropological study was conducted in the late 1970s and included multiple areas in Africa. From this research, definitions of aging fell into three main categories: chronology; change in social role (i.e., change in work patterns, adult status and menopause); and change in capabilities (i.e., invalid status, senility and change in physical characteristics). Results from this cultural analysis of old age suggested that change in social roles is the predominant means of defining old age. When the preferred definition was chronological, it was most often accompanied by an additional definition (W.H.O., 2012). At the moment, there is no United Nations (U.N.) standard numerical criterion, but the U.N. agreed cut-off is 60 years and above. In view of the lack of accepted and acceptable definition, the age at which a person becomes eligible for statutory and occupational retirement pensions has, in many instances, become the default definition (Thane, 1989). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html 26 While a single definition, such as chronological age or social, cultural and functional markers, is commonly used by, amongst others, demographers, sociologists, anthropologists, economists and researchers, it seems more appropriate in Africa to use a combination of chronological, functional and social definitions. However, the challenge of how to incorporate a suitable multidimensional definition into the "pensionable age" concept remains (W.H.O., 2012). i. Patterns of Aging The older population can be broken down into three reasonably distinct groups (Mackenzie, 2012): i. entering old age, ii. transitional phase, and iii. the frail elderly. The first stage is entered upon retirement; thus, it is a socially constructed definition. At this point, individuals normally enjoy good health, and social work interventions should be aimed at reducing risk of illness and promoting healthy lifestyle choices (Mackenzie, 2012). As aging continues, functions decline and co-morbidities develop. These changes are often seen between the ages of 70 and 85 years. Such co-morbidities need to be identified and actively managed, while continuing to focus on reducing the risk of further deterioration but not to lose sight of the background ageing process which may continue at an accelerated rate (Mackenzie, 2012). A time may eventually be reached when a person becomes frail to the point that independent living becomes impossible, often due to illness such as stroke or dementia (Wahlin, MacDonald, de Frias, Nilsson & Dixon, 2006). Frailty is a commonly used term, yet it remains a poorly defined concept. Buchner and Wagner (1992) cited in Markle-Reid and Browne (2003) defined frail elders as those who are University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 27 unable to fulfill social roles and perform activities of daily living. Rockwood, Fox, Robertson, and Beattie (1994) also defined the group as those for whom social and physical deficits outweigh the assets, so that they can no longer maintain independence in the community. Raphael et al. (1995) cited in Markle-Reid and Browne (2003) also maintained that frailty occurs when there is diminished ability to carry out the important practical and social activities of daily living. Generally therefore, frailty can be considered as a collection of biomedical factors which influence an individual's physiological state in a way that it reduces his or her capacity to withstand environmental stresses (Lally & Crane, 2007). It brings with it an increased likelihood of disability, dependence, vulnerability and death. These characteristics suggest that dependence on others is a sufficient condition for frailty (Markle-Reid & Browne, 2003). 2.2 Aging Theories. Theories of aging attempt to explain human development and aging in terms of changes in cognitive functions, behaviour, roles, relationships, coping ability and social change. Since the 1960s a number of aging theories have been propounded by different authors. Prominent among these theories are: i. disengagement theory, ii. activity theory, iii. continuity theory, iv. Erikson‟s psychodynamic theory of human development, and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 28 v. Gerotranscendence theory. These theories have developed further nuances and offshoot theories over time and debate still rages (Markle- Reid & Browne, 2003; Schultz, 2006). Aging theories are important because they describe what aging implies and therefore guide social workers in the care and treatment of older people (Alley, Putney, Rice & Bengtson, 2010; Bengtson & Schaie, 1999; Kunlin, 2010). The sociological perspectives on aging were chosen for this study because they represent theories with different views. Sociological explanations of aging have come from the three major perspectives in sociology, namely, the functionalist, conflict and interactionist perspectives (Open Stax College, 2012). a. The Functionalist Perspective Various social theories within the functionalist perspective were developed to explain how older people might deal with later-life experiences (Crosnoe & Elder, 2002). The earliest functionalist perspective is disengagement theory, which suggests that withdrawing from society and social relationships is a natural part of growing old (Schaefer, 2009). Because we experience physical and mental decline as we approach death, it is natural to withdraw from other persons and society. Social withdrawal is experienced differently by men and women. Because men focus on work and women focus on marriage and family, when men withdraw they become unhappy and directionless until they adopt a role to replace their accustomed role that is compatible with the disengaged state (Cummings & Henry, 1961). The disengagement theory has been criticised that it does not allow for the wide variation in the way people experience aging since it assumes that seniors universally naturally withdraw from society as they age. (Hothschild, 1975; Markles-Reid & Browne, 2003). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 29 Another attempt to understand aging from the functionalist perspective is rooted in the activity theory. According to this theory, activity levels and social involvement is a key to happiness (Havinghurst 1961; Havinghurst, Neugarten, & Tobin 1968). That is, for normal healthy aging to occur; activities must be maintained at the same level as in middle age. The core tenets of the activity theory are activity, equilibrium, adaptation to loss and life satisfaction. Critics of this theory point out that access to social opportunities and activity are not equally available to all. Moreover, not everyone finds fulfilment in the presence of others or participation in activities. This theory has also been criticised that activity levels are seen to inexorably decline over time even in those deemed to be aging well (Schulz, 2006). b. Conflict Perspective The guiding principle of conflict theory is that social groups compete with other groups for power and scarce resources. Applied to society‟s aging population, the principle means that the elderly struggle with other groups to retain a certain share of resources. At some point, this competition may become conflictual (Open Stax College, 2012; Schaefer, 2009). The modernization theory (Cowgill & Holmes, 1972), one of the conflict perspectives suggested that as societies modernize, the nuclear family replaces the extended family. Societies become increasingly individualistic, and norms regarding the care of older people change. Caring for an elderly relative is seen as a voluntary obligation that may be ignored without fear of social censure. This suggests that as people age they will be abandoned and lose much of their familial support when they become non-productive (Open Stax College, 2012, Schaefer, 2009). The exchange theory (Dowd, 1975), a rational choice approach, suggested that relationships are based on mutual exchanges and as the elderly become less able to exchange University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh file:///F:/Working%20Document%20-%20Thesis/Open file:///F:/Working%20Document%20-%20Thesis/Open 30 resources, they will see their social circles diminish. The only means to avoid being discarded is to engage in resource management, like maintaining a large inheritance or participating in social exchange systems via child care. The theory has been criticized for affording too much emphasis to material exchange and devaluing nonmaterial assets such as love and friendship (Cook & Rice, 2003; Cropanzano & Mitchell, 2005; Open Stax College, 2012). c. Symbolic Interactionist Perspective Generally, theories within the symbolic interactionist perspective focus on how society is created through the day-to-day interaction of individuals, as well as the way people perceive themselves and others based on cultural symbols (Reynolds & Herman-Kinney, 2003; Schaefer, 2009). Swedish sociologist Lars Tornstam developed a symbolic interactionist theory called gerotranscendence: the idea that as they age, people transcend the limited views of life they held in earlier times. Tornstam believes that throughout the aging process, the elderly become less self-centered and feel more peaceful and connected to the natural world. Wisdom comes to the elderly (Tornstam 2005). Tornstam does not claim that everyone will achieve wisdom in aging. Some elderly people might still grow bitter and isolated, feel ignored and left out, or become grumpy and judgmental. The three major sociological perspectives examined above inform the theories of aging. Theories in the functionalist perspective focus on the role of elders in terms of the functioning of society as a whole. Theories in the conflict perspective concentrate on how elders, as a group, are at odds with other groups in society (Aitken & Rudolph, 2010; Schaefer, 2009). And theories in University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh file:///F:/Working%20Document%20-%20Thesis/Open 31 the symbolic interactionist perspective focus on how elders‟ identities are created through their interactions (Reynolds & Herman-Kinney, 2003; Schaefer, 2009). 2.3 Elderly Population in Global Context Countries all over the world have been experiencing an increase in the percentage of older people in their populations (Okumagba, 2011). Even though the level and pace of population aging vary widely by geographic region, and usually within regions as well, virtually all nations have experienced growth in their numbers of elderly residents. The percentage of the world‟s population aged 65 and over only increased from 5.2 per cent in 1950 to 6.9 per cent in 2000. In Europe, however, the proportion was 14.7 per cent in 2000 (Gavrilov & Heuveline 2003). In 2004, it was estimated that the number of people aged 65 or older in the world was 461 million, which was a 10.3 million increase from the figure of 2003 (Kinsella & Phillips, 2005). By the year 2030, it is estimated that more than 60 countries will have about two million people each, aged 65 or older (Kinsella & Phillips, 2005). Future population aging will depend on future demographic trends, but most demographers agree that the fertility and mortality changes that would be required to reverse population aging in the coming decades are very unlikely to be achieved. According to current population forecasts, population aging in the first half of the 21 st century will exceed that of the second half of the 20 th century. For the world as a whole, the elderly will grow from 6.9 per cent of the population in 2000 to a projected 19.3 per cent in 2050 (Table 2.1). All regions are expected to see an increase, although it should be less in some regions, such as Africa where the projected increase is from 3.3 per cent in 2000 to 6.9 per cent in 2050. But in Latin America and the Caribbean, the increase will be from 5.4 per cent in 2000 to 16.9 per cent in 2050. The University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 32 increase should be even more spectacular in China: from 6.9 per cent in 2000 to 22.7 per cent in 2050 (Gavrilov & Heuveline 2003; Kinsella, Kevin & Velkoff, 2001) Table 2. Dynamics of Population Aging in the Modern World: Observed and Forecasted Percentages of the Elderly (65+ years) in Selected Areas, Regions, and Countries of the World: 1950, 2000 and 2050. Major Region and Country 1950 2000 2050 World 5.2% 6.9% 19.3% Africa 3.2% 3.3% 6.9% Latin America & the Caribbean 3.7% 5.4% 16.9% China 4.5% 6.9% 22.7% India 3.3% 5.0% 14.8% Japan 4.9% 17.2% 36.4% Europe 8.2% 14.7% 29.2% Italy 8.3% 18.1% 35.9% Germany 9.7% 16.4% 31.0% Sweden 10.3% 17.4% 30.4% U.S.A. 8.3% 12.3% 21.1% Source: United Nations (2001) cited in Gavrilov & Heuveline (2003; pp. 32-37). . The number of older persons has more than tripled since 1950; it will almost triple again by 2050. In 1950, there were 205 million persons aged 60 and above throughout the world. At that time, only three countries had more than 10 million people aged 60 or over: China [41 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 33 million], India [20 million], and the United States [20 million]. By 2009, the number of persons aged 60 or over had increased three and a half times to 737 million and there were 12 countries with more than 10 million people aged 60 and above, including China [160 million], India [89 million], the United States [56 million], Japan [38 million], the Russian Federation [25 million] and Germany [21 million]. By 2050, the population aged 60 or over is projected to increase again nearly threefold to reach two billion. By 2050, 32 countries are expected to have more than 10 million people aged 60 or over, including five countries with more than 50 million older people: China [440 million], India [316 million], the United States [111 million], Indonesia [72 million] and Brazil [64 million] (UN DESA, 2009). The older population is growing faster than the total population in practically all regions of the world and the difference in growth rates is increasing. Between 1950 and 1955, the average annual growth rate of the number of persons aged 60 years or over [1.7 per cent] was similar to the rate of growth for the total population [1.8 per cent] (UN DESA, 2009). From 2005 to 2010, the growth rate of the older population, at 2.6 per cent annually, is more than twice that of the total population [1.2 per cent]. Over the mid-term future, the difference between those two growth rates is expected to increase as the baby boom generation reaches age 60 in several parts of the world. By 2025-2030, projections indicate that the population aged 60 or over will be growing about four times as rapidly as the total population, at an annual growth rate of 2.8 per cent compared to 0.7 per cent for the total population. Although the growth rate of the population aged 60 or over is expected to decline to 1.8 per cent in 2045-2050, this rate will still be more than five times the growth rate of the total population at that time [0.3 per cent] (UN DESA, 2009). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 34 Another significant dimension of the aging population is that older persons will increasingly be concentrated in the less developed regions of the globe. Although the proportion of older persons is higher in the more developed regions, their number is increasingly larger in the less developed regions. From 1950 to 2009, the number of persons aged 60 years or over increased globally by an average of nine million persons per year. Sixty-eight per cent of that increase occurred in the less developed regions and 32 per cent in the more developed regions. As a result, the proportion of all persons aged 60 years or over living in the less developed regions rose from 54 per cent in 1950 to 64 per cent in 2009 (UN DESA, 2009). Over the next four decades, the concentration of older persons in the less developed regions will intensify. The number of people aged 60 years or over living in the less developed regions is expected to increase more than threefold, passing from 473 million in 2009 to 1.6 billion in 2050. In contrast, the number of older persons in the more developed regions is projected to increase by about 60 per cent, passing from 264 million in 2009 to 416 million in 2050. Consequently, by 2050, nearly 80 per cent of the world‟s older population is expected to live in developing countries (UN DESA, 2009). 2.3.1 Elderly Population in Africa Africa‟s population will rapidly age in the coming decades, mainly as a result of falling death and birth rates. The numbers of those aged 60 and above will rise four-fold from 45.7 million in 2005 to 182.6 million in 2050; while their proportion of the total population will double from 5 per cent to 10 per cent in the same period (Ogwumike & Aboderin, 2005; UN, 2005). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 35 The changing population demographic profiles of the 1990s are beginning to manifest in Africa. Even though Africa is yet to experience the full impact of the demographic transition (a period of declining birth and death rates), its elderly population is increasing rapidly (Darkwa & Mazibuko, 2002; Nabalamba & Chikoko, 2011). Africa‟s population is not expected to “explode” until after 2025, but the continent is projected to experience one of the largest increases in the absolute number of persons aged 60 and over (Darkwa & Mazibuko 2002). The ageing of populations in African nations such as Nigeria and Ghana is unfolding in a context of entrenched economic strain (UNDP, 2002, 2003, cited in Ogwumike and Aboderin, 2005) and there is a growing concern about the threat of poverty facing people in old age without access to any formal income security protection (Ogwumike & Aboderin, 2005). Against this context, some researchers and international bodies have cautioned about the effect of these developments on the material, physical and emotional well-being of elderly persons (HAI, 2004; Randel, German & Edwing, 1999). Indeed the fears expressed by researchers and international bodies has already manifested with the increasing number of destitutes and beggars among older people in most sub- Saharan African countries particularly Nigeria and Ghana (Apt, 1993, 1997; Ayisanbola, 2004; Aboderin, 2004; Ahenkora, 1999; Baiyewu, Bella, Adeyemi, Bamgboye & Jegede, 1997; Van der Geest, 1997, 2002). The growing concern over the welfare of the ageing populations in African and other developing nations culminated in the ratification of the 2002 United Nations Madrid International Plan of Action on Ageing [MIPAA] (UN, 2002). This platform facilitated the development of African Union Policy framework and Plan of Action on Ageing (AU/HAI, 2003) and National ageing policy frameworks in several African countries, including Ghana and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 36 Nigeria (Ghana National Committee on Ageing, 2002; Nigeria Federal Ministry of Health, 2003). The clarion call of all these plans was to impress on governments to develop strategies to ensure the welfare and economic security of their older citizens, now and in the future (Nabalamba & Chikoko, 2011; Ogwumike & Aboderin, 2005). 2.3.2 Elderly Population in Ghana Like most developing countries in sub-Saharan Africa, the proportion of elderly persons in Ghana has been increasing at a rate that is faster than that observed in most developed countries (NPC, 2007). In 2010, elderly persons (60 years and over) constituted about 7.2 per cent of Ghana‟s population, which is one of the highest among the countries in sub-Saharan Africa (Mba, 2010). With continued campaigns to reduce fertility and mortality, it is expected that the percentage of elderly population will rise in the coming decades. It is estimated that the number of persons aged 60 years and over in Ghana will increase from 1.5 million in 2010 to 2.8 million by 2030 (Mba, 2010). These figures show that the aging population in Ghana is increasingly becoming an important social phenomenon. What is not known is the preparedness of the country for the significant changes in its age structure in response to this demographic transition (Darkwa, 2000; Ocansey, Awusabo-Asare, Kumi-Kyereme & Boadi-Kusi, 2013). Research into aging in Ghana, between 1984 and 2000, revealed that a majority of the aged population reside in rural areas and include more females than males (Mba, 2010). For instance in 1984, 74.7 per cent of the older population in Ghana lived in rural areas, while 25.3 per cent lived in urban areas. By the year 2000, however, the percentage of the elderly living in rural areas had reduced to 61.2 per cent (Mba, 2010). Despite this reduction, the percentage of the aged in Ghana living in rural areas still remains high. This higher percentage of older persons University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 37 living in rural areas may be due to the fact that most people in the cities return to the villages of their birth once they reach old age (Mba, 2010; NPC, 2007). Available evidence reveals that four out of every five elderly persons living in the rural areas of Ghana are engaged in agriculture. Agricultural activities may have implications on the living conditions of the older persons since at old age most do not possess the resources (physical and financial) to engage in large scale agriculture. Apart from living in rural areas and engaging in agriculture as the main source of income, lack of formal education is also a major area of concern for elderly persons in rural Ghana (Mba, 2010; NPC, 2007). In 1984 for instance, 74.8 per cent of the elderly population in Ghana did not have any formal education. Adults with less education are said to have less social contact with friends and the potential support that these friends may provide for the elderly (Today‟s Research on Aging, 2009). Other studies have also revealed that about 11 per cent of elderly persons in Ghana live alone and women are more likely than men to be living alone. What makes this situation (isolation) more difficult and crucial for elderly persons in Ghana is the fact that there exist no formal social security and welfare schemes, making the elderly who live alone more susceptible to economic, social and health difficulties (Mba, 2007; Today‟s Research on Aging, 2009). It is important that government prepares to deal with the various challenges that come with an aging population and address the needs of the elderly population (Grundy, 2006). 2.3.3 Aging and Gender As can be seen from the earlier discussion, aging also has an important gender dimension. Universally, women tend to live longer than men (Nyanguru, 2008; Tonah, 2009). As in other parts of the world, women are over-represented among the aging African population, a University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 38 phenomenon characterized as the feminization of the aged (Darkwa & Mazibuko 2002). In every age group for each time period, there are more women than men. This gender disparity is mainly due to consistently higher male death rates at every age. It is estimated that by 2020, the total population of the sub-Saharan region will be just over 1 billion, with 19 million women 65 years and above as against 13.5 million men within the same group. By 2025 elderly women (65 years and above) will increase to 21.8 million whereas their men counterparts will be 15.3 million (Darkwa & Mazibuko, 2002; Mba, 2004). 2.3.4 Determinants of Population Aging The numerical growth of elderly persons (population aged 60 years and over) is an eloquent testimony not only of reductions in fertility but also of reductions in infant and maternal mortality, improved nutrition, reduction in infectious and parasitic diseases, as well as improvement in health care, education and income (Mba, 2004; Mba, 2010). The global total fertility rate declined from 5.0 live births per woman between 1950 and 1955 to 2.7 live births per woman by the 2000 to 2005 time frame. It is further expected to decrease to 2.2 live births per woman by 2045-2050 (United Nations, 2001). Also life expectancy has increased from 46.5 years in 1950-1955 to 66.0 years in 2000-2005, and is expected to rise to 76 years by 2045-2050 (Mba, 2004). In sub-Saharan Africa, the corresponding fertility values are 6.7 live births per woman in the early 1950s to 5.5 live births per woman in the early 2000s and 2.4 live births per woman by 2045-2050. Similarly, life expectancy rose from 36.7 years in the 1950s to 48.4 years by 2000-2005, and is projected to peak at 68.4 during 2045-2050 (Mba, 2004). To understand the demographic factors that cause population aging, demographers often refer to stable populations (Preston, Heuveline & Guillot 2001). This population model assumes University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 39 that age-specific fertility and mortality rates remain constant over time, and these rates result in a population with an age distribution that stabilizes and eventually becomes time invariant as well. Conversely, this theoretical model suggests that any change in age structure, and population aging in particular, can only be caused by changes in fertility and mortality rates (Gavrilov & Heuveline 2003). The influence of changes in fertility rates on population aging is perhaps less intuitive than that of mortality rates. Everything else constant, however, a fertility decline reduces the size of the most recent birth cohorts relative to the previous birth cohorts, hence reducing the size of the youngest age groups relative to that of the older ones. The effects of changes in mortality rates on population aging appear more intuitive (Emery, 2013; Gavrilov & Heuveline, 2003). If increases in the human life span are correctly linked to population aging, reductions in mortality rates contribute to population aging. Population aging is thus related to the demographic transition, that is, the processes that lead a society from a demographic regime characterized by high rates of fertility and mortality to another one with lower fertility and mortality rates (Gavrilov & Heuveline, 2003). The rate of population aging may also be modulated migration. Immigration usually slows down population aging because immigrants tend to be younger and have more children. On the other hand, emigration of working-age adults accelerates population aging, as it is observed now in some Caribbean nations (Gavrilov & Heuveline, 2003). Population aging in these countries is also accelerated by the immigration of elderly retirees from other countries, and the return migration of former emigrants who are above the average population age (Gavrilov & Heuveline, 2003). Some demographers expect that migration will have a more prominent role in population aging in the future, particularly in low-fertility countries with a University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 40 stable or declining population size. The effects of migration on population aging are usually stronger in smaller populations, because of the higher relative weight (proportion) of migrants in such populations (Gavrilov & Heuveline, 2003). Caldwell‟s (1982) wealth flow theory, which depicts a relationship between economic and reproductive behaviour, also offers a useful theoretical framework for understanding the relationship between population aging and decreasing fertility in Africa. According to the theory, if children generally transfer income to their parents, then there is an incentive for adults to bear many children. If, on the other hand, parents seek to nullify the effects on their children of public sector pension programmes by increasing their familial transfers to their children, then children become more costly, and there is an incentive to reduce fertility (Willis, 1987, 1988). Thus, a fundamental issue in demographic transitioning is the direction and magnitude of intergenerational wealth flows or the net balance of the flows [one from parents to children and the other from children to parents] (Caldwell, 1982; Caldwell, 2005). A precondition for increases in the proportion of the elderly is the institutionalization of wealth flows away from elders to younger people. This net flow of wealth and the decline in fertility affects the number of children available to support older parents. Thus, the elderly can no longer anticipate consistent economic returns and economic support from the younger and economically active generations (Caldwell, 1982; Caldwell, 2005). Another factor likely to affect population aging in Africa is the incidence and prevalence of the acquired immunodeficiency syndrome (AIDS/HIV) pandemic. Africa has been severely affected by the AIDS pandemic with men, women, and children suffering equally (Darkwa & Mazibuko, 2002; King, 2008). While Africa‟s sub-Saharan region contains only 12 per cent of the global adult population, the vast majority of people living with AIDS or HIV infection are University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 41 located in Africa. Of the estimated 33.4 million adults and children living with HIV or AIDS at the end of 1998, 22.5 million were in sub-Saharan Africa (UNAIDS, 2000). In 1998, of the two and half million deaths from AIDS-related illnesses worldwide, two million were in sub-Saharan Africa (UNAIDS, 2000). The HIV/ AIDS problem is expected to affect life expectancy in almost all African countries due to increases in mortality in the young and adult ages. With many people dying at a younger age, the elderly are left without family caregivers (Darkwa & Mazibuko, 2002). In summary, Sub-Saharan Africa's elderly population is rapidly increasing and will probably continue to do so over the next 60 years, resulting from previous and current high fertility, declining mortality, and increasing life expectancy. Furthermore, the "older" elderly age groups will increase more rapidly than the "younger" elderly age groups, and there will be more elderly women than men in each age group. Even though the variation in the elderly population may not be substantial, it has implications for contemporary welfare policies and programs for the elderly. 2.4 Social Support as a Concept In recent years, social support has received considerable attention in social gerontology as well as other related disciplines, such as psychology, social policy, social work and social medicine because social support has been seen as an important determinant of psychological well-being among older persons in Western and Chinese societies (Phillips, Siu, Yeh & Cheng, 2008). It appears to influence their quality of life and service demands, and older adults who are embedded in supportive social networks have been found to enjoy better physical and mental health than older persons who do not maintain meaningful ties with others (Bajekal, Blane, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 42 Grewal, Karisen & Nazroo, 2004; Smith, Sim, Scharf & Phillipson 2004). Studies on mortality and morbidity provide especially compelling findings in this respect (Krause, 2001). There is little agreement about the definition of social support. The concept is either not defined or ill-defined in the literature and there is often definitional confusion between social network and social support both in conceptual models and measurement instruments (Gaugler, Kane & Langlois, 2000; Schroevers, et al. 2003). Social network is defined in the literature as a vehicle through which social support is provided (Antonucci, 2001). On the other hand, social support is usually defined as the existence of people who let us know that they care about, value, and love us (Atchley, 2000; Sarason, Sarason, Levine & Basham, 1983), or resources provided by others (Cohen & Syme, 1985). Cantor (1989) maintained that social support is a pattern of continuous or intermittent ties or interchanges of mutual assistance that play a significant role in maintaining the psychological, social and physical integrity of the individual over time. Social support can, thus, be said to be a “coping resource” or a social “fund” from which people may draw when handling stressors. Other academic definitions add that the recipient of social support should have a perception of someone caring for them and a resultant sense of well-being (Hupcey, 1998; Rash 2007). Hupcey, (1998) enumerated the factors required for social support as follows: i. the act of providing a resource, ii. the recipient having a sense of being cared for or a sense of well-being, iii. the act having an implied positive outcome, iv. the existence of a relationship between the provider and the recipient, v. support not given from or to an organization, the community, or a professional, and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 43 vi. support that does not have a negative intent or is given grudgingly (Hupcey, 1998; Rash, 2007). The above definitions suggest that social support is a multidimensional construct which has been differently described. Notwithstanding the fact that the meaning and nature of social support are still being debated, Langford, Bowsher, Maloney and Lillus (1997) suggested that all acts of social support can be categorised into instrumental, emotional, informational, and appraisal support. Instrumental support involves the provision of tangible aid and services that directly assist a person in need. It is normally provided by close friends, colleagues and neighbours (Barrientos & Sherlock, 2002; Weber, 1998). Emotional support is associated with sharing life experiences. It involves the provision of empathy, love, trust and caring which foster feelings of comfort. Informational support entails providing knowledge, advice, suggestions, and information that a person can use to address problems (Gottlieb, 1983; Marriot & Gooding, 2007). The final category is appraisal support, which involves the provision of information that is useful for self-evaluation purposes: constructive feedback, affirmation and social comparison (House, 1981) Social support is usually divided into either formal or informal. Formal social support is that support provided by paid professionals and public or private services set up specifically to provide support such as physical aid and counselling to the vulnerable or needy. Informal support, on the other hand, is that provided by relatives, friends and neighbours (Kinsella & Phillips, 2005). Irrespective of these differences however, “…the underlying goal of any support system is to strengthen the recipient‟s sense of mastery over self and environment…and plays a University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 44 significant role in maintaining the physical, psychological and social integrity of the recipient over time” (Cantor, 1980:133). 2.4.1 The Impact of Social Support on the Recipient There exists a semblance of agreement that social support has positive effects on a wide scope of outcomes, including physical health, mental well-being, and social functioning. A large body of research has demonstrated a positive association between aspects of social support and well-being in later life, and there is strong empirical evidence to confirm the role it [social support] may play in health and illness (Antonucci, 2001; Reinhardt, Boerner, & Horowitz, 2006; Uchino, 2004). According to Thoits (1995), social support positively influences health and mental health. From a classic study by Berkman and Syme (1979), the authors noted that people who