Elder abuse refers to the mistreatment of older people by those in a position of trust, power or responsibility for their care. This is a global problem that is likely to intensify in view of the increasing number of older people and the changing socio-economic and environmental conditions worldwide (Randel et al. 1999). Throughout the experience of HAI, access to health care has always been of major Concern to elderly. Help Age International has strongly emphasized: “Access to Health services are not a benevolent act but are a basic human right for any human being regardless of age”.
Earlier evidence adduced that the attitude and behavior of some health workers towards older people was negative. Elderly respondents taking part in focus group discussions reported that public health providers utter discouraging remarks, for example: “Wewe si mgonjwa, shida yako ni uzee”, translated into English as: “You are not sick, your problem is old age” (Ochola et al. 2000: 55). Viable intervention strategies, we opine, must have basis on multi-sectorial approaches with primary focus on attitudes and the community.
Research Purpose The purpose of this study is to analyses views of older people and health workers on indicators, context, causes and interventions in elder abuse in primary health care in Kenya. This study is aimed at helping one understand the dynamics of abuse of older persons’ rights within the primary health care system in Kenya. The report is thus largely a collection of ‘voices’ on elder abuse. The issues raised by these voices require further investigation to enrich the empirical evidence on elder abuse.
The objective of the study was to gather empirical evidence of elder abuse within the healthcare system so as to use the information in formulating appropriate strategies for intervention. It is part of a broader strategy to intervene in the major rights issues of concern to older persons. The study was intended to answer questions such as: a. Does abuse occur in the hospitals? b. Is abuse or some form it unique to older persons c. How does this abuse affect the older persons? d. What causes this abuse (policy, structure, and economics, social-such as attitude? )
e. Who perpetrates the abuse? f. Can anything be done to intervene and if so, what is it that can be done?. Role and importance of the Elderly in the Community Despite the changing socio-economic structures of the African societies, the socioeconomic roles of the elderly remain very important within the family and the Community. It is worth noting however that their roles are often unrewarded and grossly undervalued today. A female discussant in Misyani noted that “In the olden days, the old people used to stay with their younger children and were, therefore, well taken care of.
But nowadays, the young have to migrate away from home in order to search for survival and they leave the old at home. “In all the nine focus group discussions carried out, participants emphasized the importance of older people’s contribution to communities and singled out the following roles: a. Caring for the Vulnerable Older persons often care for the children while the younger adults are out of the Homestead in economic pursuits. Health workers also reported that older persons often accompany children to hospital and with children who have been admitted.
The role of older persons in caring for the vulnerable has become ever so important in the face of the ravages of HIV/AIDS. Participants in ALL focus groups discussions lamented that older persons face the multi-faceted tragedy of losing economic support of their children who are infected, economically having to support their children who are infected (and their children’s families), nursing their children when infection turns to full-blown AIDS, losing their children and having to care and support their orphaned grandchildren.
In the course of the survey, we encountered an eighty-five year old woman at Misyani Health Clinic who was taking care of four grandchildren orphaned by HIV/AIDS has to share her food ration (which is barely adequate for one adult) with four of her grandchildren. b. Advising and Resolving Conflict within Family and Community Older persons (within the family and the community) are often called upon to advise and to resolve conflict. Their roles as conflict resolvers are vitally important in the face of a rapidly changing society. With the advent of multi-party olitics, tribal conflicts have taken a political dimension apart from the traditional dimensions of cattle rustling, land conflicts and conquests.
c. Caretakers Older persons often watch over homesteads while the rest of the family members are away. d. Entrepreneurs Older persons often contribute to economic development through their involvement in farming, business, handicraft, trade and formal employment (e. g. teaching). The performance of domestic chores by women such as cooking, washing, gardening and looking after livestock often goes on until very late into old age. . HealthCare Providers With the paying system introduced in government hospitals in the country, many citizens cannot afford formal healthcare. The first form of healthcare that the majority of the sick seek in the villages is from traditional healers. These roles of traditional healers, midwives and serving as African traditional religion’s specialists are usually carried out by older persons: It is evident from the focus group discussions that female discussants pointed out roles in the domestic sphere while male discussants identified roles in the public sphere.
However, certain roles are played by both male and female older persons. Such roles include watching over homesteads while the rest of the family members are away, contributing to economic development through involvement in farming, business, handcraft, trade, provision of healthcare services and serving as religious specialists. Issues of Elder Abuse Identified In the Research a. Abandonment The survey concluded that abandonment was the most impacting issue in elder abuse in both healthcare context and in other social contexts.
The African family structure has changed and as such, fewer younger people are willing to care for the older family members. This has led to an alarming number of older persons being abandoned in hospital without any family member responsible. This has serious healthcare implications for older persons given that they (or their families) are expected to pay for healthcare before it is provided. b. Attitudes of Healthcare workers being a reflection of the attitude of society With the changing structure of society, the older persons have lost their traditional roles and respect.
The extreme economic conditions have made economic considerations ever more important. Older persons are thus increasingly marginalized within communities as they are viewed as a waste of scarce c. Economy With cost sharing introduced in the hospitals, the abuse of older persons’ rights within the healthcare system has taken a new economic dimension. With the introduction of SAP, the smaller satellite health facilities were abandoned giving regional hospitals greater catchment populations to serve.
The healthcare system of the country is often stretched beyond capacity with the staff working under very difficult conditions. In Kenyatta, the admission to the wards in the year 2000 was at 135% of capacity. d. Hospital policies and Structures In Misyani an older woman and an older man stated that they had observed physical abuse ‘of hitting patients’ at a district hospital. e. Training of healthcare workers The current training of health workers is not sufficient to prepare them enough to provide the kind of care expected by older persons.
This is evidenced in the comments of health f. Remuneration and morale of Healthcare workers In Nakuru hospital, the staff observed that what they were being paid was not sufficient to sustain them and their families. They thus felt generally unmotivated in their work. They observed that with the low morale as a result of ‘low’ pay, they found it difficult to go the extra mile to cater for the ‘additional’ needs of older patients. A female discussant in Nakuru with trauma to the arm had not had any form of medication in 24 hours.
It had taken 6 hours to get an x-ray done on her injured arm. This was because the paramedic responsible was not at his post for that long even though he was officially “on duty”. The staff confessed that they take every opportunity available to augment income by taking on assignments outside the hospital. g. Gender perspective The abuse of older persons within the healthcare system was observed to be taking on a gender dimension. The Social worker at Nanyuki observed that the 60% to 70% of the abandoned older patients were male.
This was generally attributed to their having Abandoned their families during their youth. The perception is that they squandered their youth and because of that negative attitude they get even less favorable treatment than Consequences of Elder Abuse The following table summarizes the consequences reported by respondents. Deterioration in health and incidence of ill health (diabetes, hypertension, arthritis, loss of teeth, eye problems etc. ) Generates and intensifies conflicts. Economic strain. Community raises funds to deal with effects of abuse, e. g. hospital bills.
Of course a few persons exploit such efforts for selfish interests. Increases demand for space: some patients share beds and others sleep on the floor. Emotional stress, leading to depression, loss of appetite and earlier deaths. Feelings of loneliness Strained relationships between family members (e. g. between daughter sin-law and the rest of the family, stepchildren). Increases the use of traditional/herbal medicine. Increases demand for fee waiver: hospitals unable to waive fee for all. Needy cases. Loss of self-esteem; embarrassment Abandonment and neglect by family.
Weakens social cohesion and networks. Places extra demands on Staff: time, skills and care. Physical hurt injury and death Family instability. Police interventions and court cases Poverty cycle is intensified. Facilities for their rehabilitation which are expensive and limited. Destitution and begging (street aged) Disaffection by children towards parents, especially the perpetrator of abuse Response to remove the abuse or/and its consequences: some individuals and organizations are moved to intervene, e. g. Church-based groups.
Burden of care is increased on hospitals. Withholding vital information; some develop dislike for hospitals and negative feelings towards health workers and hospitals Financial burden because of costs incurred in seeking redress Inter-community tension and revenge, e. g. in the case of cattle rustling. Loss of girls and young women through Abduction. Difficulties in tracing families of abandoned older persons. Increases physical weariness and frailty Loss of property Embarrassment Relational problems with older patients Decline in nutritional tatus (malnutrition) Loss of respect and honor in society Curses Demand for specialized services for the elderly, e. g. wards, mobility aids.
This section summarizes the interventions currently available and those that are recommended. Interventions Available Though some forms of interventions currently exist in the community and within the hospitals, discussants opined that these interventions were not sufficient to protect older persons from rights abuse within the healthcare context.
Interventions within the Community
While older persons prefer to spend their lives within their communities and families, a worrying trend today is the ease with which the community is willing. Interventions within Health Institutions Very few interventions exist within hospital structures that specifically address the needs and rights of older persons. Whilst policies exist to protect the rights of the everybody in general, they are sorely lacking in serving the elderly because of the (negative) attitudes with which older persons are viewed.
Compounding the inadequacy of the existing policy is their insensitivity to the unique needs of older persons as a vulnerable group. So while a policy might be quite efficient in serving the rights of a young male, it would be grossly wanting in protecting the rights of an older person. But the existence of these policies have somewhat improved the situation among older Interventions Recommended by Discussants Due to limitations apparent above, discussants offered the following recommendations: • More homes should be established in Kenya to cater for the ever increasing number of the elderly. Interventions in the abuse of older persons need to take into account the social Structure in Kenya. Home-based care should be promoted so that only the very Desperate and abandoned older persons are institutionalized. Concerted efforts should be made to ensure that the elderly in homes have regular contact with children such as orphans and the youth to enhance a good relationship between the old and the young as was the case in the indigenous cultural setting. When asked ow the health needs of the elderly are addressed, discussants observed that: Given the crucial role that indigenous healers play in addressing the health needs of the elderly, this study recommends that the healing activities of these healers should be regulated and co-ordinated by a formal or government body. There should be increased collaboration in the work of doctors and that of traditional healers. The government should however ensure that it protects its citizens like the elderly from abuse by unscrupulous healers.
Discussants also made the following suggestions: • There is need for the elderly to have separate wards so that their health needs are Addressed separately from those of other patients (Kenyatta National Hospital health workers, 24-8-2001; Nakuru health workers, 27-8-2001). This approach will ensure that the rights of the elderly to privacy are respected. The elderly will have more room to discuss issues that affect them in their youthful days, thereby rejuvenating their spirits rather than making them feel outdated amongst youthful patients as is the case today. There is need for health workers in Kenya to have special training in the areas of Handling the elderly (geriatrics) instead of the current training where there is only limited coverage of this subject in the general training (Kenyatta National Hospital health workers, 24-8-2001; Nakuru health workers, 27-8-2001). Such training would equip health workers with skills to enable them to handle the elderly in a more humane manner than is the case today where some health workers abuse rights of the elderly through verbal, physical and psychological abuse.
Recommended Interventions The following is a summary of the recommendations adduced from the study: a. It is recommended that there is need for the government to initiate the establishment of healthcare policies and structures that ensure the protection of the rights of ALL citizens while being especially sensitive to the rights of the older persons and other vulnerable sections of the community. b. Hospital administration should come up with policies and systems to monitor the Work of health workers to ensure that patients are handled well.
Again, these hospitals should borrow a leaf from Kenyatta National Hospital and provide special diet for the elderly that is full of protein food such as eggs and milk instead of giving them same as those for general patients. Such a strategy would help in improving the nutritional needs of the elderly. c. It is suggested that the government of Kenya should review the cost-sharing Programmer in public hospitals. Paid healthcare as recommended by the structural Adjustment programmer (SAPs) is beyond the majority of Kenyans.
It is way Beyond the mainly income less older persons of this country. d. It is further recommended that non-governmental organizations (NGOs) step up to the need to sustainably improve the lives of the elderly in Kenya rather than leaving the task to the government and charitable foundations. Other interventions that need to be strengthened are legal redress system and community arbitration system. The provincial administration, ministry of health, social services and the judiciary are other channels through which elder abuse can be tackled.
e. There is need for older people’s organizations to input into the training curricula of the health care workers to ensure that the rights and special needs of older people are addressed at every level of the healthcare delivery system. f. It is strongly recommended that further research be undertaken so as to enable Better understanding of the problem and effective planning for its intervention. The survey would include an analysis of the magnitude and various dimensions of Elder abuse, an assessment of the effectiveness of existing interventions and the Status of implementation of global and national policy/action instruments in Kenya.