Who takes care of the elderly? Findings from rural South Africa
South Africa is aging rapidly, sparking increasing interest both in what care is needed for older adults and on how it's provided.
Care needs are often measured in relation to the capacity to perform core activities of daily living. These include getting dressed, taking a bath, going to the toilet, eating, walking across a room (mobility) and getting into or out of a sleeping place (transferring). The assumption is that these activities are critical to a person's ability to participate (and indeed simply survive) in society. But this raises key questions including how these needs are distributed, are they met, and are they met equally?
In South Africa neither the state nor the private sector consistently provide institutions for people living in poor communities. Care facilities are usually confined to urban areas, and are often considered a last resort. Personal care is therefore assumed to be provided by family and household members, with one person taking on most tasks.
Conventionally, women are expected to be the main providers of care to the elderly, an extension of the caregiving they might provide to infants and children, spouses and others. Specific assumptions include: that a kinswoman will be willing and able to provide personal care and assist in everyday household activities; that households have the economic capacity to provide this care; and that those who provide care do not in turn need care and their health is relatively stable. The reality is far more complex.
In recent work with colleagues, we analyzed data on the activities of daily living from the baseline round of a longitudinal study on aging among people aged 40 and older in a rural community in northeastern South Africa.
To get a sense of the extent of impairment and support, we first measured if people needed assistance with activities of everyday living, and if so how much. This included whether they used an aid to walk or used floors or furniture to help them move around. It also included whether anyone else assisted them. Secondly, we looked at whether there was a gap between the care they needed and the care they got.
What we found
Our work showed some things we had expected. For example, impairment in activities of daily living, and thus care needs, were unsurprisingly higher in older ages. Most care that was given was informal, almost always from relatives and almost never by government or NGOs. People who got help from other relatives were more likely to have their needs only partially met than those helped by their spouse.
But we also learned some unexpected things. Most worryingly, about a third of those who needed assistance with daily living didn't get help from anyone else. Unmet need was most often present in younger people—that is, care was most likely to be provided in older people, those with a greater number of disabilities. While we cannot prove it, this may be because younger people are not expected to need help.
In addition, women—of all ages—had greater unmet needs than men. Because of differences in life expectancy, older women were more likely widowed and so fewer lived with someone able to provide assistance with activities of daily living. But women aged 40-60 who needed assistance were more likely than women over 60 to have unmet care needs. Reasons for this may include that middle-aged women are providing care to others and therefore are not seen as needing support, or that they rely for care on others who are older, themselves need support and are unable to help much.
Elsewhere in South Africa other research shows evidence of challenges when it comes to reciprocal care and support between couples who age together. Such couples may be unable to access outside care because of their poor health and mobility. This lack of access can be made worse by a lack of transport, geographic isolation, limited finances and a limited social network. Our study did not find household wealth, household size or diagnosed chronic diseases predicted unmet need.
Overall, our study highlights some important and unexpected gaps in caregiving for older people in rural South Africa. In a place where formal care is largely absent, traditional ideas about big families supporting their older relatives may be asking too much. And while everywhere is different, other poor rural communities are likely to also have gaps in family-based care that need help. We hope studies like this will help start conversations between government and communities about how to come together to meet care needs in rural settings like ours.