Week 1 - Assignment: Create an Annotated Bibliography for Selected Topic

Vol.:(0123456789)

https://doi.org/10.1007/s12126-021-09436-8

1 3

“It is all About Giving Priority to Older Adults’ Needs:” Challenges of Formal Caregivers in Two Old Age Homes in Ethiopia

Meriem Dawud1 · Messay Gebremariam Kotecho2,3  · Margaret E. Adamek4

Accepted: 22 July 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract With a growing older population needing long-term care in Ethiopia, this study examined the challenges and needs of formal caregivers at two older adult homes. A qualitative, exploratory design was employed. Purposive sampling was used to iden- tify 14 formal caregivers and 6 key informants who engaged in in-depth interviews. Formal caregivers assisted older adults with personal care, medication administra- tion, and emotional support. As a result of high workloads, long work hours, an absence of training, and minimal compensation, caregivers faced many challenges including managing older adults’ difficult behavior, exposure to health hazards, and task burden. The all-encompassing demands of caring for older adults in resource- poor environments contributed to negative consequences that spilled over into car- egivers’ personal lives. The capacity of formal caregivers to meet the needs of long term care residents in developing nations can be enhanced through training in geri- atric care, adequate compensation, and best practice guidelines for long term care.

Keywords Older adults · Formal caregiver · Long-term care · Old age home

* Margaret E. Adamek [email protected]

Meriem Dawud [email protected]

Messay Gebremariam Kotecho [email protected]

1 Mizan Tepi University, Mizan Teferi, Ethiopia 2 School of Social Work, Addis Ababa University, Addis Ababa, Ethiopia 3 Department of Social Work and Community Development, University of Johannesburg,

Johannesburg, South Africa 4 Indiana University School of Social Work, Indiana, USA

Ageing International (2022) 47:847–865

/ Published online: 14 August 2021

1 3

Currently, the world’s population is aging at an alarming rate (Dovie, 2019). According to the United Nations (2019), in 2019 there were 703 million persons aged 65 and above globally. This number is projected to more than double to 1.5 billion by 2050. The older population is growing at a faster rate than the younger population and thus by 2050, 1 in 6 people in the world will be 65 or over (UN, 2019). With the rate of increase being higher in less economically developed nations (Shrestha, 2000), it is projected that by 2050 over 80% of older adults globally will live in developing regions (UN, 2017).

In Sub-Saharan Africa, the number of older adults is expected to increase from 32 million currently to 101.4 million by 2050 (UN, 2019). Others estimate a six-fold increase in older adults in Sub-Saharan Africa to 215 million by 2050 (Schatz & Seeley, 2015). Based on assertions that Africa is the world’s poorest continent and the pace of population aging is greater in Africa than in other world regions, Muza and Mangombe (2019) surmise that “Africa may get demographi- cally old before getting socioeconomically developed” (p. 4914). The current study was based in Ethiopia, the second most populous nation in Africa. Though exact data regarding the number of older adults in the country is lacking, the Cen- tral Statistical Agency (CSA, 2007) projected that older adults (60 and above) constituted 5% of the population of Ethiopia in 2010. If the current demographic trend continues, Ethiopia’s aged population is projected to more than double to 10.3% (19.4 million) by 2050 (CSA, 2007).

Globally, the most rapid increase in the aging population is occurring among those 80 and over—the age group with the greatest care needs—with northern Africa being among the world regions with the greatest increase in the 80 + age group (United Nations, 2019). Advanced aging is associated with fragility and reduced functionality that brings many responsibilities to both informal and for- mal caregivers. As an increasing number of older adults require caregiver assis- tance to meet their health, social, physical, and emotional needs, care provision for older adults has become a public issue (Batista et al., 2014; Kloppers, 2011; Özçakar et al., 2012).

Based on demographic projections, Sheresta (2000) points out that old-age dependency ratios will increase dramatically in most developing nations and these shifts “will likely have significant consequences on the demand for and pro- vision of social and support services—among them health care, housing, income security, and long-term care” (paras. 19). In addition to population aging, the lack of middle generation family members available to serve as caregivers as a result of the HIV/AIDS pandemic has contributed to the “growing care deficit” in parts of Africa (Schatz & Seeley, 2015, p. 1185). A study in Zimbabwe indi- cated that the lack of family support and abject poverty were primary reasons that older adults became residents of old age homes (Ncube, 2017). Adamek and Balaswamy (2016) likewise concluded that poverty and waning family supports were two major factors contributing to the growing need for congregate long-term care in sub-Saharan Africa. Thus, at a time when population aging is increasing and traditional family care is diminishing, the demand for support services for older adults in Africa is steadily climbing (Kpessa-Whyte, 2018).

848 Ageing International (2022) 47:847–865

1 3

In the absence of public social welfare programs and social protection to support older adults in developing countries, older adults who can no longer work and who lack family support have few options. Even older adults who have families willing to care for them are at-risk because families are often too impoverished to provide support (Chane & Adamek, 2015; Zelalem et al., 2020). Though Cattell (1993) called attention to waning family supports in Sub-Saharan Africa nearly 30  years ago, organized care and social services for older adults remain lacking. Older adults who have care needs that exceed the capabilities of their families or who lack family support will increase the demand for residential long-term care (Lima et al., 2016). Nevertheless, according to the World Health Organization (2017), “in many sub-Saharan African countries, organized long-term care services are essentially non-existent” (p. 26).

Despite population aging occurring much faster in developing nations, gerontol- ogy remains a neglected area of research in the African continent (Ahmad & Komai, 2015). A recent survey of gerontology scholars identified the top five critical issues facing older adults in Sub-Saharan Africa as: poverty, local of geriatric profession- als, food insecurity, disability and health issues, and the growing need for long-term care (Adamek et al., 2021). Yet, thus far, relatively little is known about the extent, quality, and nature of institutional long-term care for older adults in developing nations (Balaswamy & Adamek, 2017).

More likely to be referred to as “old age homes” in Africa, residential care facili- ties provide care for older persons who are ill, disabled, or suffering from dementia and are thus unable to care for themselves (Changala et al., 2016). Old age homes in developing nations are much less likely to be regulated or monitored by government oversight agencies. In addition, government-sponsored institutions tend to be under- resourced and overcrowded, and thus hampered in providing quality services.

A study in Malaysia comparing government and non-governmental institutions found that government-owned centers were money-centric and did not offer high quality services (Wagiman et al., 2016). The government-sponsored old age homes were described as simply a place to stay, eat, and sleep (Wagiman et  al., 2016). Habjanic (2009) found similar results in Slovenia where institutions run by the government were known for physical maltreatment, poor building standards, over- crowding, and lack of privacy. With few resources and little training, staff members were dissatisfied with the working conditions and experienced physical and emo- tional fatigue (Habjanic, 2009).

In Africa, most nations do not have organized geriatric training and education (Dotchin, et al., 2012). Likewise, in Ghana, where institutional care for older adults is a new phenomenon, qualified caregivers are nonexistent (Dovie, 2019). There is inadequate training, a lack of geriatricians and health care facilities, and limited financial support for long term care dedicated to older adults (Essuman et al., 2019). Two recent studies documented the lack of training facilities for geriatric care in Ghana (Karikari et al., 2020; Kpessa-Whyte, 2018). A qualitative inquiry conducted in an older adult home in Ethiopia revealed that formal caregivers did not receive training and lacked professional qualifications to address older adults’ physical and mental health needs (Teka & Adamek, 2014).

Given the slow emergence of long term care institutions in much of Sub-Saharan Africa, it is not surprising that research on long term care for older adults on the

849Ageing International (2022) 47:847–865

1 3

continent is minimal. Thirteen of 20 studies identified (Chabeli, 2003; Chipps & Jarvis, 2016; Conradie, 1999; Hansson & Kluven, 2016; Le Roux & Kemp, 2009; Puckree et al., 1997; Ramlall et al., 2014; Robb et al., 2017; Roos, 2004; Roos & Du Toit, 2014; Roos & Malan, 2012; Van Bijon & Roos, 2015; Van Bijon, et al., 2015 were conducted in South Africa. The others  took place in old age homes in Ghana (Malmedal & Anyan, 2020), Namibia (Kloppers, 2011), Zimbabwe (Hungwe, 2011; Ncube, 2017), Ethiopia (Teka & Adamek, 2014), and Zambia (Changala et al., 2016). Understandably, some aspect of resident well-being was the focus of nearly all of the studies—including older adults’ psychosocial well-being (Teka & Adamek, 2014), cognitive status (Ramlall et al., 2014), functional status (Puckree et al, 1997), quality of life (Van Bijon & Roos, 2015), and loneliness (Roos & Malan, 2012). Resource- poor environments and lack of trained staff in long term care settings contrib- ute to poor outcomes of older residents such as inadequate nutritional status (Robb et al., 2017) and even abuse (Malmedal & Anyan, 2020).

Though not specifically focused on formal caregivers, Roos and Du Toit (2014) con- sidered older residents’ views of their relationships with caregivers, noting that residents viewed caregivers as friendly, flexible, empathetic, and trustworthy. Kloppers (2011) found that caregivers in old age homes in Namibia lacked administrative support, food, medication, transportation, promotion, and incentives in their practice. A study of nine old age homes in Zambia found that caregivers faced many challenges including “inad- equate and erratic funding, low staffing levels, lack of training opportunities, absence of a national policy on ageing, lack of transport, lack of information communication tech- nology facilities, and high demand for admission” (Changala et al., 2016, p. 7). Unfortu- nately, the high stress placed on formal caregivers in residential care settings may lead to burnout (Özçakar et al., 2012) and even abuse of elder residents (Conradie, 1999).

Studies conducted in developing nations outside of Africa likewise point to criti- cal needs of paid caregivers caring for older adults in residential settings. A study in Singapore found that caregivers experience emotional and psychological stress asso- ciated with the caregiver-care recipient relationship, lack of cooperation, financial issues, physical abuse, and a sense of helplessness (Mehta & Leng, 2017). Similarly, in Malaysia, Goh et  al. (2013) found that both formal and informal caregivers face challenges of preparing nutritious food, cleaning/bathing, work obligation, moving of immobile residents, and managing and monitoring the medicine intake of elderly residents. The study in Malaysia further documented caregivers’ needs for ambulance services, geriatric training, flexible work hours, counseling, physical therapy center, senior citizens’ club, social day care and support group service (Goh et al., 2013). A study in Brazil revealed that formal caregivers need a procedures manual that specifies professional duties and responsibilities as well as training about how to care for older adults (Batista et al., 2014). Based on a study in New Zealand documenting the stress of non-health professionals working in a long term setting, Czuba (2015) concluded, “To meet the increasing demand for long-term care, it is important to enhance under- standing of and address the work stress that formal caregivers’ experience” (p. 9).

Due to the lack of empirical studies on formal caregivers of older adults in sub- Saharan Africa, this study explored the challenges and needs of formal caregivers at two large old age homes in Addis Ababa, Ethiopia. Three overarching questions guided the study:

850 Ageing International (2022) 47:847–865

1 3

(1) What are the challenges faced by formal caregivers of older adults in old age homes in Ethiopia?

(2) What are the needs of formal caregivers of older adults in old age homes in Ethiopia?

(3) What are the differences in the experiences of formal caregivers in a government- sponsored old age home compared to caregivers in a non-governmental long term care setting?

Methods

A qualitative, multiple case design was employed to investigate the experiences of formal caregivers and to examine the similarities and differences of the care provision context at two large long-term care institutions in the capital city of Addis Ababa: Kality Institutional Care Center for the Elderly (“Kality Center”) and the Mekedonia Home for the Elderly and Mentally Disabled (“Mekedonia Home”). While there is no exact data or historical account of the emergence of long term care in Ethiopia, the Kality Center was the first old age home in the nation. Established by the order of Emperor Haile Selassie in 1970, when first opened this institution separated older adults by marital status and by age. Later on, both government-owned and other pri- vate old age homes were established. Currently, there are about 10 old age homes or long-term care institutions throughout the country. Non-governmental institutions including long term care centers are registered, monitored, and regulated under the Societies and Charities Proclamation No. 621/2009.

A multiple case study was selected to analyze the challenges and needs of formal caregivers within and across the two types of old age homes. Preliminary observa- tions were conducted at five old age homes in Addis Ababa before the primary data collection. Three of the old-age homes were small non-profit organizations housing fewer than 10 older residents. Based on the observations, Kality Center was cho- sen because it has been housing older adults since 1970 and is a government-owned institution. The Mekedonia Home was selected because it is a well-known non-profit organization that hosts a huge number of older adults and employs many formal caregivers.

The Kality Center is the only fully government-financed institution providing long-term care to older adults and is located in the capital city of Ethiopia, Addis Ababa. The Addis Ababa City Administration Bureau of Labor and Social Affairs covers all the costs for running the center including employee salaries. At the time of data collection, the Center housed 124 older adults including 94 males and 30 women. Of them, 27 were bedridden and needed the close supervision of caregivers. Of the 38 staff members, 12 were formal caregivers–10 female and 2 male. Other staff members included the general manager, coordinator, counselor, nurses, guards, cooks, record officer, finance officer, laundry staff, and housecleaners.

The Mekedonia Home is a non-governmental, non-profit organization founded in 2010 starting with 20 residents in the private home of the Executive Man- ager. Mekedonia has grown to providing care to over 2,300 elderly and men- tally disabled residents at its current location on the outskirts of Addis Ababa.

851Ageing International (2022) 47:847–865

1 3

About one-quarter of the residents are age 60 and over (Our Impact, 2020). The home raises financial support from different sources, including contributions in cash and in-kind from the community and online donations. The Addis Ababa City Administration donated a plot of land as a site for constructing buildings to provide residential and health care. In addition to the Executive Manager, pro- ject coordinator, social worker, special needs expert, psychologist, medical staff (including two doctors and 6–12 nurses) and dozens of volunteers, the Mekedo- nia Home employees 80 to 90 formal caregivers, many of whom started out as volunteers.

The International Federation on Ageing (2014) defined formal care as paid care services by a health care institution or by an individual for a person in need. For- mal caregivers include paid carers, nurse aides, direct care staff, support workers, personal assistants, and health care assistants who provide the majority of paid care to those who need assistance with activities of daily living (Czuba, 2015).

Purposive sampling was used to identify study participants. Potential partici- pants were contacted with the help of a gatekeeper of each institution. Formal car- egivers who met the following inclusion criteria were identified: (a) paid employ- ees from Mekedonia and Kality, (b) minimum of six months of work experience, (c) willingness to participate in the study. Data were gathered from March to May 2018. The same inclusion criteria were applied in identifying key informants, along with a fourth criterion of being considered professional staff. Altogether 20 participants, including 14 formal caregivers (7 from Mekedonia and 7 from the Kality) and 6 key informants (2 from Kality and 4 from Mekedonia) participated in semi-structured interviews.

Data was gathered through in-depth interviews with formal caregivers and with key informants who were professional staff at the long term care facilities. The perspectives of both the professional staff and the hands-on caregivers were documented in an effort to triangulate the data (Flick, 2018). The interview guide included both closed-ended socio-demographic items to describe the profile of the study participants and several open-ended questions focused on the challenges and needs of formal caregivers in relation to their work environment and care duties with older residents. The interviews took place on site in the two long term care settings and lasted from 34 to 67 minutes. Interviews were audio-recorded with the permission of participants.

The narrative data was analyzed thematically using Braun and Clarke’s (2006) six steps of thematic analysis. Recorded audios of each interview were transcribed first into Amharic language and then translated into English. After becoming familiar with the data by repeatedly reading the transcripts, the first author developed the initial codes. Next, the initial codes were developed into potential themes. The themes were reviewed by the researchers to determine whether the elements within each theme were sound and related to each other. The themes and sub-themes were further refined to accurately reflect the data. Ethical oversight and approval for the study was provided by Addis Ababa Uni- versity. To preserve study participants’ confidentiality, pseudonyms are used in presenting the study results.

852 Ageing International (2022) 47:847–865

1 3

Results

Fourteen formal caregivers were the primary respondents in this study—7 from Kality and 7 from Mekedonia. Eight caregivers were female and 6 were male. Their ages ranged from 18 to 52 with an average age of 30.2  years. Half were married and half were not. None of the caregivers had a college degree. Their years of work experience as caregivers ranged from 3 to 23  years (x = 6.4) (see Table  1), with caregivers at Kality having longer work experience on average (x = 8.3 years) than caregivers at Mekedonia (x = 5.1  years). Caregivers in Mekedonia were younger (x = 22.6 years) on average than those at Kality (x = 37.8 years). At Mekedonia, most of caregivers first joined as youth volunteers and later become paid caregivers (see Table 1). The six key informants were a counselor, nurse, social worker, psycholo- gist, special needs expert, and HR manager. Key informants ranged in age from 24 to 48 (x = 30.3 years). Five were men and one was a woman. Their years of experi- ence in a long term care setting ranged from 2 to 22 years (x = 6.8) (see Table 2).

Types of Services Provided by Formal Caregivers

Caregivers reported that they assisted older adults with personal care, distribut- ing medication, and providing emotional support. We briefly describe the nature of the care provided to older adults below, followed by a description of the types of challenges caregivers faced and their needs as described by both the caregivers themselves and the key informants.

Table 1 Demographic Profile of Formal Caregivers (n = 14)

Pseudonym Sex Age Marital Status Religion Education Yrs of Experience

Work place

Simegn Female 40 Married Orthodox Grade 12 5 Kality Mastewal Female 52 Married Orthodox 10 + 3 10 Kality Belete Male 27 Married Orthodox 10 + 3 5 Kality Birtukan Female 37 Divorced Orthodox Grade 12 6 Kality Kelemua Female 23 Single Orthodox Grade 4 6 Mekedonia Mintesnot Male 20 Single Orthodox Grade 10 3 Mekedonia Bekalu Male 24 Married Orthodox 10 + 3 5 Mekedonia Hanan Female 28 Single Muslim 10 + 3 4 Mekedonia Asefa Male 43 Married Christian 9 23 Kality Chaltu Female 38 Single Protestant 10 5 Kality Aster Female 28 Married Orthodox 10 + 1 4 Kality Rahel Female 18 Single Orthodox 7 5 Mekedonia Bekalu Male 24 Married Orthodox 10 + 3 5 Mekedonia Tariku Male 21 Single Orthodox 10 4 Mekedonia

853Ageing International (2022) 47:847–865

1 3

Personal Care: All caregivers in both settings stated that assisted older residents with all ADLs such as bathing, feeding, dressing, cutting their hair and nails, assist- ing with mobility, changing their diapers and bandages. They also clean rooms, do laundry, cook, and offer bereavement support to families. For instance, Bekalu, who had been providing care for about five years in Mekedonia, reported that he assisted older adults in different types of personal care: “I cut their nails, wash their clothing, assist with bathing, change their bedding, and feed those who are unable to do so by acting like a child with his parent.”

Assisting Older adults with Medication: Formal caregivers in Kality assisted older adults who have tuberculosis, diabetes, and HIV with their daily medication. How- ever, in Mekedonia nurses are responsible for administering medication. Aster, who has provided care for older adults for four years in Kality explained that, “I usually give medicines before and after food depending on the physician’s prescription.”

Emotional Support: Formal caregivers in both settings also provide emotional care and support for older adults by being available to them, listening to their stories, sharing their feelings–both their sorrow and happiness–and giving affection and spe- cial regard as they do for their own parents. Bekala stipulated that, “In order to fulfill the needs of older adults, I will be around them for 24 hours during breakfast, lunch, and dinner and do whatever they need. I am like their child and they are like my parents.”

Challenges Faced by Formal Caregivers

Formal caregivers in this study who provide care to older adults in an institu- tional setting faced many challenges that were categorized into two overall types:

Table 2 Demographic Profile of Key Informants (n = 6)

Pseudonym Sex Age Marital Status

Religion Education Duration on Site

Position Work place

Kebede Male 48 Divorced Protestant MA 22 Counselor Kality Center Eyasu Male 26 Single Orthodox Degree 4 Psycholo-

gist Mekedonia

Kumsa Male 26 Single Orthodox Degree 3 Social Worker

Mekedonia

Samuel Male 24 Single Orthodox Degree 2 Special Needs Expert

Mekedonia

Selam Female 28 Married Orthodox Degree 4 Nurse Kality Center Yonas Male 30 Married Orthodox 10 + 3 6 HR

Manager Mekedonia

854 Ageing International (2022) 47:847–865

1 3

• challenges related to providing care to dependent older adults, and • negative consequences in caregivers’ personal lives.

The care-related challenges included managing older adult’s difficult behav- ior, exposure to health hazards, and caregiver burden. The challenges related to negative consequences experienced by caregivers in their personal lives included: restrictions on their social lives, family conflict, financial struggles, psychological problems, and lack of self-care.

Older Adult Care‑related Challenges

Older Adult’s Difficult Behavior. Formal caregivers reported that they faced behavioral problems from some older residents, particularly those with dementia. Some older adults resist taking medicine as prescribed preferring injections over pills, they may be easily irritated and disappointed with caregivers, drink tradi- tional alcoholic beverages such as Areki and Tela, and become aggressive and behave destructively–sometimes even beating the caregivers. For instance, Mas- tewal, a caregiver in Kality stated that,

Older adults can be like babies. They easily become angry, resist eating food, taking medicine, not taking off their clothes when asked that require us being patient. They also fight with others because of hallucinations, which is problematic for us to manage.

In relation to the behavioral problems faced by formal caregivers, Mintesnot shared:

Older adults hesitate to take their medicine on time. They cry, harm them- selves, and other older adults and also abuse us [caregivers]. Older adults with mental health problems are more difficult than their counterparts, because we can’t pinch or control them as one can do on babies as they are old. In some cases, when older adults with mental illness act aggressively we may use an injection.

Samuel, a key informant from Mekedonia, elaborated on the behavioral prob- lems faced by formal caregivers:

Older adults in Mekedonia are allowed to go outside the institution and return drunk and disturb caregivers as some of them have pension benefits and others will be given money on holidays and even worse others may sell their T-shirts to buy alcohol.

Exposure to Health Hazards. Caregivers reported facing a number of health- related challenges including physical health problems like abdominal pain, kid- ney disease, and vomiting. They are also susceptible to communicable illnesses such as colds, tuberculosis, and other diseases transmitted by blood contact with the long term care residents. Caregivers felt insecure about their own health

855Ageing International (2022) 47:847–865

1 3

because of the lack of health screenings of incoming residents. Mastewal, a car- egiver from Kality, reported that, “When older adults become sick on my shift I will spend the whole night in the hospital and I am exposed to asthma associ- ated with the bad smell in the hospital.” Kelemua, a caregiver from Mekedo- nia stated, “I am easily caught by colds and other communicable diseases as a result of close interaction with older adults during service provision.” Moreo- ver, Birtukans, a caregiver from Mekedonia, shared:

Because of their [older adults] inability to control their feces and urine, I am exposed to bad smell in their rooms that have high risk of airborne disease. I don’t commonly use masks, as you can see me today my voice is changed as I am sensitive to bad smell.

Caregiving Burden. Perhaps the biggest challenge faced by caregivers is the non-stop press of care duties. Formal caregivers experienced caregiving burden as there are many tasks such as changing diapers, feeding, bathing, assisting with mobility, washing clothes, and administering medicines. Female caregiv- ers in Kality are more burdened due to having care responsibilities both at work and at home. At Mekedonia caregivers live onsite and do not have other outside responsibilities. With regard to the physical and emotional burdens faced by car- egivers, Kumsa, a key informant from Mekedonia stated:

Since there are a number of older adults in Mekedonia, one caregiver will be assigned to care for at least four older adults per day, leading to both physical burden and emotional exhaustion. To that end, caregivers may not have enough time for themselves resulting in poor personal care.

In relation to the burdens faced by formal caregivers, Mintesnot, a caregiver in Mekedonia stated: “it [caring] is all about giving priority to elder’s needs at the expense of the caregiver’s safety and well-being. I don’t eat unless I make sure that older adults eat, take their medicine, and their needs are met.” Asefa, who provided care for 23 years in Kality, elaborated about caregiving burden: “I become very tired as caring for an older person is an awkward task; it costs a huge energy to satisfy them. Because of tiredness, I sometimes prefer to take rest and don’t eat.” Chaltu, a caregiver in Kality, described the burdens associated with providing care:

Starting from the time I enter the institution, I have no break time. I will be busy cleaning urine and feces from overnight, changing their blankets, bathing, giving their medicine, and feeding them.

Negative Consequences Experienced by Formal Caregivers

Financial Struggles. Almost all caregivers reported that they face significant financial struggles in meeting their personal needs such as for clothing, trans- portation, household expenses, rent, and health expenses as they do not have any health insurance especially the females and younger caregivers. Caregiv- ers, particularly from Kality, face significant financial challenges. In contrast,

856 Ageing International (2022) 47:847–865

1 3

caregivers at Mekedonia live at the facility where their basic needs are covered. As stipulated by Eyasu, a key informant from Mekedonia, “I think that caregiv- ers here have a better chance in terms of living standard as the institution covers all the basic living costs such as food, health, shelter, and clothing.” Neverthe- less, a young caregiver in Mekedonia depicted her financial problems as follows, “Because I am youth, I need money to buy jewelry, to go to beauty salon, or to buy clothes like my friends. But now even one standard shoe cost 300–400 birr which is unthinkable for me.” Similarly, Kebede, a key informant from Kality, stated that there are some reparations given to caregivers by institutions even if it is not enough: “Caregivers employed in Kality will be given uniforms and some money for milk; however, it is not enough. Furthermore, they make personal sac- rifice for phone calls since there is no budget allowance for mobile card.” Belete, another caregiver in Kality, stressed the financial challenges he faced: “I am liv- ing in a rented house and there I face economic problems as the standard of liv- ing in Addis Ababa is very expensive so I have difficulty allocating the salary to cover the household expenditures.”

Restrictions on their Social Life. In addition to their caregiving tasks, almost all caregivers shared significant social time with older adults in the context of providing care including taking part in major events such as holiday and birthday celebrations. As a result, caregivers lack time to spend with their own friends and family. In line with this, Tariku, a caregiver in Mekedonia, revealed that, “we [me and my friends] have spent a lot of bad and good times and have unforgettable memories. However, after I started to work here, we have separated and I always miss them.” Similarly, Aster, a caregiver from Kality, elaborated:

While Sunday serves as break time for government employees they will spend it with their friends and peers. However, it does not work for us. If it is my turn, I do not have any excuse to be off from work that I will not respect appointments that forced me to lose my close friends.

Hanan, a caregiver from Mekedonia, described the social challenges she faced:

As we work all the days here, I don’t have time to attend to major social events like weddings, mourning, and birthdays which negatively affect my social interaction and involvements and end up with separation from peers and relatives.

Paradoxically, one key informant from Kality had the perspective that provid- ing care for older adults does not negatively impact caregiver’s social life. Kebede stated,

I don’t think caregiving has a negative impact on caregivers’ social life as they work in shifts. They will have adequate time to spend for their personal and social life.

Family Conflict. Some caregivers reported that after they began providing care, conflicts increased in their families due to the huge time commitment of their work.

857Ageing International (2022) 47:847–865

1 3

For example, Aster, explained that, “There is no one who will take my son from school and sometimes I and my husband argue when I go to work on Sunday. He says what type of work do you have on Sunday?” Mastewal, who had been provid- ing care for older adults in Kality for about ten years, explained that, “When I go home I become totally tired, and moreover household chores will wait for me. Then, I become angry at my daughter why she didn’t perform household tasks, even if I know she is reading.”

Psychological Problems. As a result of the social, health, and economic conse- quences of being a full-time formal caregiver in an old age home, study respondents experienced various emotional difficulties such as loneliness, distress, fear, depres- sion, guilt, and uncertainty about fulfilling the older adults’ needs. For example, Rahel shared,

I feel like I treat them improperly, do not meet their needs, or I disappointed them unintentionally when they keep silent or shout for no reason. The food may not be delicious for them, they may be afraid to eat from my hand, or they may not eat adequately. Because of this fear, I prefer not to feed them from my hand as I think that they may not eat as they want because of fear- ing me.

Lack of Self‑Care. Participants asserted that their work demands as older adult car- egivers have made their personal lives unpredictable as they prioritize care receivers’ needs and provide them with holistic care, but fail to take care of themselves. For instance, as described by Birtukan from Kality, “I become tired of the caregiving tasks, so I don’t eat food even if I become hungry rather, I prefer to sleep because I become eager for break and I don’t care where I sleep.”

Needs of Formal Caregivers

In order to provide quality care and minimize caregiving burden, formal car- egivers prefer that incoming residents have prior health examinations. Given the all-consuming nature of the work they perform, they also need better salary and incentives. Birtukan, who has been providing care for older adults in Kality for about six years stated that, “Compared to the cumbersomeness of caregiving, I don’t even think the salary as salary because it is nothing. So, we need a bal- anced payment that would help our caregiving experience better than this.” Chaltu, a caregiver from Kality, also emphasized the need for improved salary:

In order to cope with this changing world, there needs to be an improvement in our salary that would help caregivers to update themselves and that fur- ther will help us to be more committed to our task.

Caregivers also need assistive facilities such as laundry facilities, baking machines, more wheelchairs, information, and transportation. As Rahel stated, “We still use our hands to wash clothes, but we need washing machines and

858 Ageing International (2022) 47:847–865

1 3

cleaning equipment to clean rooms that will not only reduce our burdens but also save time.”

According to Asefa, a caregiver from Kality, there is no convenient transporta- tion for formal caregivers which in turn negatively affects their care provision:

We have no break at weekends as it [caregiving] is a day-to-day activity; however, there is no convenient public service on all days. The absence and lack of transport have a negative influence on the quality of care we provide that the time of taking medicine may be delayed or skipped. So, we need a public (transport) service on weekends for caregivers working in institu- tions.

Moreover, formal caregivers need accessible restrooms to lighten their car- egiving burdens. As explained by Asefa, a caregiver from Kality, bathrooms were not accessible for dependent older adults:

Older adults are weak and unable to use toilets and bathrooms on their own as the facilities and buildings are classic and narrow and don’t consider the needs of dependent older adults. So, they always need our supervision. The rooms should be redesigned so that older adults with disabilities and mental illness are able to use them independently. That will also help us to reduce our caregiving burden.

Caregivers expressed a need for a conducive work atmosphere including reduced work hours, training and psychosocial education, and respite services. Belete, a caregiver in Kality, valued the importance of training, sharing that “Older adults have varying needs and behaviors. So, we need trainings about how to manage their behavior and to respond accordingly as issues we face are complex and dynamic.” In line with the need for training, Kumsa, a key informant from Mekedonia, stated that:

Caregivers are not aware of their tasks and responsibilities, how to inter- act and communicate with older people, the behavior of older adults and in general how to care for older adults. They only deliver services out of a passion to help older adults. However, it will be better if they are given training in order to professionalize care.

Likewise, Selam, a nurse from Kality, elaborated on the need for training for formal caregivers:

Caregivers have closer interaction with older adults than anybody else, so the government before hiring and distributing caregivers to institutions should give those trainings and other life skill trainings about the nature of caregiving. It will further help novel caregivers to be free from the confu- sion they experience at the beginning of their stay with older adults.

859Ageing International (2022) 47:847–865

1 3

Discussion

This study explored the challenges and needs of formal caregivers in two old age homes in Ethiopia–one governmental and one non-governmental. In addition to providing personal care to older adults such as feeding, bathing, dressing, mobility, medication, and hygiene, the formal caregivers in this study provided ongoing emo- tional support to older adults, sharing both their joys and sorrows. Formal caregivers in old age homes in Ethiopia essentially provide all of the supports that family mem- bers provide to older adults in need of care in their own homes. The type of services provided to older adults was similar in the two types of old age homes.

As a result of high workloads, long work hours, an absence of training, and mini- mal compensation, the formal caregivers in this study faced many challenges includ- ing managing older adults’ difficult behavior, exposure to health hazards, and car- egiver burden. The all-encompassing demands of providing care to older adults in resource-poor environments contributed to negative consequences that spilled over into the caregivers’ personal lives–-resulting in financial struggles, restrictions on their social life, family conflict, psychological problems, and lack of self-care. These consequences mirror those experienced by family members of hospitalized older adults in India (Popli & Panday, 2018).

Both the caregivers and the key informants in this study identified various needs of caregivers including the need for better salary, respite care, health screening of incoming residents, transportation, and flexible work schedules to improve their well-being and thus the quality of care provision. In terms of the qualifications of formal caregivers, this study found that caregivers from both the governmental and non-government long term care settings did not have any geriatric qualification or training. Some caregivers did not complete even primary education. In Mekedonia, there are no standard criteria to hire caregivers. However, in Kality caregivers must attend at least grade ten in the current curriculum or grade twelve with the past aca- demic curriculum.

The study found that the Mekedonia Home was more comfortable, there were amicable interactions among staff, and the rules were flexible. Whereas, caregivers in the Kality Center worked long hours, lacked transportation, and are governed by rigid institutional rules which are top-down as they come from the Bureau of Labor and Social Affairs. Even though the Mekedonia Home is a non-governmental organ- ization, formal caregivers faced higher workloads because there were large numbers of bedridden older adults compared to Kality. In addition, residents’ rooms were overcrowded and lacked privacy.

Similar studies in South Africa and Brazil found that formal caregivers of older adults working in long-term care settings as paraprofessionals do not have adequate training. They are easily hired, without screening for physical and emotional prereq- uisites for their caregiving duties (Lima et al., 2016; Mehta & Leng, 2017; Ngubeni, 2011). Formal caregivers in developing nations likewise face poor self-care (Mehta & Leng, 2017), deteriorated physical and emotional well-being (Goh et al., 2013), and difficulties with eating and sleeping (Czuba, 2015). Those caregivers—typically females–who have additional responsibilities for their own families combined with

860 Ageing International (2022) 47:847–865

1 3

caring for older adults become overloaded with care duties, contributing to physical and emotional exhaustion (Mehta & Leng, 2017).

This study was limited by its small, non-representative sample making generaliz- ability difficult. The study focused on caregivers working in an institutional setting and so may not be applicable to formal caregivers in other settings. Moreover, since this study was cross-sectional, the findings represent only the current perspectives of participants and cannot demonstrate causality between the factors contributing to caregivers’ challenges and caregiver or older adult outcomes. Future studies should examine the beneficial aspects of the work of formal caregivers. Quantitative stud- ies are also needed to assess the need for congregate long term care in Sub Saharan Africa and to document the training needs of formal caregivers.

Consistent with studies in other developing nations, the formal caregivers in Ethi- opia need training and psychosocial education about caregiving as well as best prac- tice guidelines, assistive devices, accessible transportation, better salary, and respite services. The caregivers in this study demonstrated their commitment to caring for older adults, but lacked basic supports needed to be effective in their work without getting burned out. At this stage, most countries in Africa do not offer geriatrics training or education in their health care curricula (Dotchin et al., 2012; Essuman et al., 2019). Commenting on the status of geriatric expertise in Sub-Saharan Africa, Clarfield and Rosenthal (2017) call for “the relevant medical and social disci- plines….to invest more of their efforts in motivating and training young people to become interested in gerontology and geriatrics” (p. 1137). Policy makers and social work educators and practitioners in developing nations must advocate on behalf of formal caregivers to promote their well-being and capacity to deliver quality care.

In Ethiopia there are only a few studies on informal caregivers of older adults with this being the first that focused specifically on formal caregivers. Further stud- ies are needed on formal caregivers’ managing of older adults’ mental and physi- cal disabilities as well as comparative studies of formal and informal caregivers’ experiences. Based on their study of the needs of older adults at an old age home in Oromiya, Ethiopia, Teka and Adamek (2014) suggested adopting Conradie’s (1999) recommendations for improving institutional care for older adults in South Africa including “developing and offering training to caregivers, an ombudsman office, public awareness campaigns, an institutional bill of rights for residents of old age homes, and community involvement in institutional care" (p. 402).

From another point of view, Gutierrez- Robledo (2002) asserted that the lack of infrastructure in developing nations presents an opportunity to develop more home- based long term care models rather than institution-based facilities that are com- mon in more developed nations. Supporting families engaged in older adult care can ensure that aging Africans have the opportunity to age in place. For those lacking family support, community-based options including day care, respite, and outreach programs can be developed using a community development approach (Drower, 2002).

Based on a demographic analysis of population aging in Ethiopia, Moges and colleagues (2014) acknowledged that the growth in the older adult population will be a “serious challenge to the traditional extended family support network unless supported by innovative measures and new initiatives such as community circles and

861Ageing International (2022) 47:847–865

1 3

long term care services” (p. 14). These and other aging-relevant research efforts can help to build the type of uniquely African gerontology research agenda that has been missing—an agenda that accounts for the place of older adults in the development of African nations while also documenting older adults’ needs and advocating for their rights (Aboderin, 2017; Apt, 2012).

Conclusion

As population aging advances and family care for older adults diminishes in devel- oping nations, the demand for long-term care will undoubtedly increase. Currently, Ethiopia has only about ten long-term care facilities with less than 1,000 beds in a nation with over 5 million older adults. To meet the growing demand for older adult care in developing nations, the long term care workforce must be increased and receive training in best practices in older adult care. Based on its review of the sta- tus of long-term care in Sub Saharan Africa, the World Health Organization (2017) concluded that, “governments have an essential role to play as stewards of long-term care systems” (p. 24). In alignment with the recommendations of the African Union Common African Position on Long-term Care Systems for Africa, WHO (2017) advocates for:

1. Building understanding and commitment for long-term care systems, 2. Establishing national coordination mechanisms, 3. Developing indicators and mapping long term care, and 4. Fostering cross-national learning and exchange.

To build the capacity of the long-term care workforce in developing nations including both formal and informal caregivers, the needs of older adults must be prioritized, though not at the expense of caregivers. Respecting older adults entails supporting those who care for them.

Declarations

Conflicts of Interest There was no conflict of interest.

Informed Consent All research participants provided informed consent to be interviewed. Participants were informed that they did not have to answer any questions they chose not to answer. They were aware that they could stop the interview at any time. All participants agreed to have their interviews audio- recorded.

Research Involving Human Participants Research participants were adults age 18 or over who were employees at one of two age old homes in Addis Ababa The study objectives and data collection methods were explained to all participants. Participants agreed to be interviewed in a private office at their work place.

862 Ageing International (2022) 47:847–865

1 3

References

Aboderin, I. (2017). Coming into its own? Developments and challenges for research on aging in Africa. Journals of Gerontology, Series B, 72(4), 643–645.

Ahmad, A., & Komai, S. (2015). Geriatrics and gerontology: Neglected areas of research in most devel- oping countries. Journal of the American Geriatrics Society, 63(6), 1283–1284.

Apt, N. A. (2012). Aging in Africa: Past experiences and strategic directions. Ageing International, 37(1), 93–103. https:// doi. org/ 10. 1007/ s12126- 011- 9138-8

Adamek, M., & Balaswamy, S. (2016, November). Long-term care for elders in developing countries in Asia and Africa: A systematic review. The 69th Annual Meeting of the Gerontological Society of America, New Orleans, LA.

Adamek, M., Kotecho, M., Chane, S., & Getachew, G. (2021). Challenges and assets of older adults in Sub-Saharan Africa: Perspectives of gerontology scholars. Journal of Aging & Social Policy. https:// doi. org/ 10. 1080/ 08959 420. 2021. 19276 14

Balaswamy, S. & Adamek, M. (2017, July). Institutional LTC for elders in Asia and Africa: Ownership, resident characteristics, and staffing. The 21st World Congress of the International Association of Geriatrics and Gerontology, San Francisco, CA. 

Batista, M. P. P., Barros, J. O., Almeid, M. H. M., Mângia, E. F., & Lancman, S. (2014). Formal caregiv- ers of older adults: Reflection about their practice. Rev Saude Publica, 48 (5), 732–738. https:// doi. org/ 10. 1590/ S0034- 8910. 20140 48005 270

Braun, V., & Clarke, V. (2006).Using thematic analysis in psychology. Qualitative Research in Psychol- ogy, 3(2), 77–101.https:// doi. org/ 10. 1191/ 14780 88706 qp063 oa

Cattell, M. G. (1993). Caring for the elderly in Sub-Saharan Africa. Ageing International, 20, 13–19. Central Statistical Agency of Ethiopia. (2007). The 2007 Population and housing census of Ethiopia-

statistical report. Addis Ababa, Ethiopia. Chabeli, M. M. (2003). Health care needs of older people living permanently in a residential home setting

in Gauteng. Curationis, 26(4), 14–21. Chane, S., & Adamek, M. (2015). Factors contributing to elder abuse in Ethiopia. Journal of Adult Pro-

tection, 17 (2), 1-12. https:// doi. org/ 10. 1108/ JAP- 07- 2014- 0026 Changala, M., Mbozi, E. H., & Kasonde-Ng’andu, S. (2016). Challenges faced by care givers in old peo-

ple’s homes in Zambia. National Journal of Advanced Research, 2(1), 1–8. Chipps, J., & Jarvis, M. (2016). Social capital and mental well-being of older people residing in a resi-

dential care facility in Durban. South Africa. Aging & Mental Health, 20(12), 1264–1270. Clarfield, A. M. & Rosenthal, A. (2017). Aging in Sub-Saharan Africa: Sub-par? Journal of the Ameri-

can Geriatrics Society, 65 (6), 1136–1138. https:// doi. org/ 10. 1111/ jgs. 14751 Conradie, G. (1999). Dealing with institutional abuse in a multicultural South African society. Journal of

Elder Abuse and Neglect, 10 (1/2), 153–163. Czuba, K. (2015). Understanding formal caregivers and work stress: An interpretive descriptive study.

Auckland University of Technology. http:// hdl. handle. net/ 10292/ 9831 Dotchin, C. L., Akinyemi, R. O., Gray, W. K., & Walker, R. W. (2012). Geriatric medicine: Services and

training in Africa. Age and Ageing, 42(1), 124–128. https:// doi. org/ 10. 3389/ fsoc. 2019. 00025 Dovie, D. A. (2019). The status of older adult care in contemporary Ghana: A profile of some emerging

issues. Frontiers in Sociology, 4, 25. https:// doi. org/ 10. 3389/ fsoc. 2019. 00025 Drower, S. J. (2002). A South African perspective. Journal of Social Work in Long-Term Care, 2, 9–14. Essuman, A., Gold, K. J., Vitale, C., Toma, G., Cigolle, C., Gyakobo, M., & Zazove, P. A. (2019). Estab-

lishing the first geriatric medicine fellowship program in Ghana. Journal of the American Geriatrics Society, 67(8), 1718–1723. https:// doi. org/ 10. 1111/ jgs. 16014

Flick, U. (2018). Triangulation in data collection. In U. Flick (Ed.). The SAGE handbook of qualitative data collection. (pp. 527–544). Sage.

Goh, Z., Lai, M., Lau, S., & Ahmad, N. (2013). The formal and informal long-term caregiving for the elderly: The Malaysian experience. Asian Social Science, 9 (4). https:// doi. org/ 10. 5539/ ass. v9n4p 174

Gutierrez-Robledo, L. M. (2002). Looking at the future of geriatric care in developing countries. Jour- nals of Gerontology, 57, 162–167.

Habjanic, A. (2009). Quality of institutional elderly care in Slovenia. Acta University Oulu.  University Press, Finland. http:// herku les. oulu. fi/ issn0 35532 21/

Hansson, I., & Kuven, B. M. (2016). Moments of joy and delight: The meaning of traditional food in dementia care. Journal of Clinical Nursing, 25, 866–874.

863Ageing International (2022) 47:847–865

1 3

Hungwe, C. (2011). The meaning of insitutionalisation to older Africans: A case study of a Zimbabwean old people’s home. Electronic Journal of Applied Psychology, 7(1), 37–42.

International Federation on Ageing. (2014). Connecting the dots: Formal and informal care Senior Offi- cials Meeting (SOM) Background Paper Retrieved from: www. ifa- fiv. org

Karikari, G., Huber, L., Lohrmann, D. K., & Ozdogan, Z. (2020). Medical students’ perspectives and con- sideration of geriatrics for future practice. An exploratory study of a public medical school in Ghana. Gerontology & Geriatrics Education, 1–14. https:// doi. org/ 10. 1080/ 02701 960. 2020. 17249 97

Kloppers, M. J. (2011). An educational, practice- orientated programme for caregivers of the elderly in old age homes in Windhoek and Rehoboth. (PhD thesis). Windhoek: University of Namibia. https:// wwwis is. unam. na/ theses/ klopp ers20 11. pdf

Kpessa-Whyte, M. (2018). Aging and demographic transition in Ghana: State of older persons and emerging issues. The Gerontologist, 58(3), 403–408. https:// doi. org/ 10. 1093/ geront/ gnx205

Le Roux, M. C., & Kemp, R. (2009). Effect of a companion dog on depression and anxiety levels of elderly residents in a long-term care facility. Psychogeriatrics, 9, 23–26.

Lima, J. R., Leite Medeiros, A. F, Medeiros, T. A., & Nobregna, M. M. (2016). Profile of caregivers of institutionalized older adults. International Archives of Medicine section: Primary Care, 9(131), 1–8. https:// doi. org/ 10. 3823/ 2002

Malmedal, W., & Anyan, C. (2020). Elder abuse in Ghana: A qualitative exploratory study. Journal of Adult Protection. https:// doi. org/ 10. 1108/ JAP- 04- 2020- 0011.

Mehta, K. K. & Leng, T. L. (2017). Experiences of formal and informal caregivers of older per- sons in Singapore. Journal of Cross Cultural Gerontology, 32, 373–385. https:// doi. org/ 10. 1007/ s10823- 017- 9329-1

Moges, A., Tamiya, N. & Yamamoto, H. (2014). Emerging population aging challenges in Africa: A case of Ethiopia. Journal of International Health, 29 (1), 11-15.

Muza, C., & Mangombe, K. (2019). Population development in Africa with special regards to ageing. African Population Studies, 33 (2), 4913–4926.

Ncube, N. (2017). Pathways to institutional care for elderly indigenous Africans: Navigating contours of alternatives. African Journal of Social Work, 17(1), 44–51.

Ngubeni, P. (2011). An investigative study of the caregivers experiences in caring for the elderly, Master Thesis, University of Zululand, South Africa.

Our Impact. (2020, April 21). Mekedonia Home for the Elderly and Mentally Disabled. Retrieved April 21, 2020 from https:// Meked oniah omes. org/ our- impact

Özçakar, N., Kartal, M., Dirik, G., & Güldal, D. (2012). Burnout and relevant factors in nursing staff: What affects the staff working in an elderly nursing home? Turkish Journal of Geriatrics, 15(3), 266–272.

Popli, U. K, & Panday, R. (2018). Caregivers burden of hospitalized elderly. Journal of Gerontology and Geriatrics Research, 7, 483. https:// doi. org/ 10. 4172/ 2167- 7182. 10004 83

Puckree, T., Chetty, T. P., Ramlakan, S., Simelane, T. V. S., & Lin, J. (1997). An evaluation of the func- tional status of the residents of a geriatric residential facility in South Africa. Disability and Reha- bilitation, 19(12), 552–555.

Ramlall, S., Chipps, J., Bhigjee, A., & Pillay, B. J. (2014). Sensitivity and specificity of neuropsycho- logical tests for dementia and mild cognitive impairment in a sample of residential elderly in South Africa. South African Journal of Psychiatry, 20(4), 153–159.

Robb, L., Walsh, C. M., Nel, M., Nel, A., Odendaal, H., & van Aardt, R. (2017). Malnutrition in the elderly residing in long-term care facilities: A cross sectional survey using the Mini Nutritional Assessment (MNA®) screening tool. Southern African Journal of Clinical Nutrition, 30(2), 34–40.

Roos, V. (2004). Intergenerational interaction between insitutionalised older persons and biologically unrelated university students. Journal of Intergenerational Relationships, 2, 79–94.

Roos, V., & Du Toit, F. (2014). Perceptions of effective relationships in an institutional care setting for older people. South African Journal of Industrial Psychology, 40(1), 1–9. https:// doi. org/ 10. 4102/ sajip. v40i1. 1139

Roos, V., & Malan, L. (2012). The role of context and the interpersonal experience of loneliness among older people in a residential care facility. Global Health Action, 5, 18861.

Schatz, E., & Seeley, J. (2015). Gender, ageing, and carework in East and Southern Africa: A review. Global Public Health, 10(10), 1185–1200.

Shrestha, L. B. (2000). Population aging in developing countries. Health Affairs, 19 (3). https:// doi. org/ 10. 1377/ hltha ff. 19.3. 204

864 Ageing International (2022) 47:847–865

1 3

Teka, A., & Adamek, M. (2014). "We prefer greeting rather than eating:" Life in an elder care center in Ethiopia.  Journal of Cross-Cultural Gerontology, 29  (4), 389-404. https:// doi. org/ 10. 1007/ s10823- 014- 9244-7

United Nations, Department of Economic and Social Affairs, Population Division. (2017). World population ageing 2017: Highlights (ST/ESA/SER.A/397). https:// www. un. org/ en/ devel opment/ desa/ popul ation/ publi catio ns/ pdf/ ageing/ WPA20 17_ Highl ights. pdf

United Nations, Department of Economic and Social Affairs, Population Division. (2019). World population aging 2019: Highlights (ST/ESA/SER.A/430).

Van Biljon, L., & Roos, V. (2015). The nature of quality of life in residential care facilities: The case of White older South Africans. Journal of Psychology in Africa, 25(3), 201–207.

Van Biljon, L., Roos, V., & Botha, K. (2015). A conceptual model of quality of life for older people in residential care facilities in South Africa. Applied Research Quality Life, 10, 435–457.

Wagiman, A., Mohidin, H. H., & Ismail, S. A. (2016). Elderly care centre. IOP Conference Earth Envi- ronmrnt Science 30 012008. https:// doi. org/ 10. 1088/ 1755- 1315/ 30/1/ 012008

World Health Organization. (2017). Towards long-term care systems in sub-Saharan Africa. WHO. Zelalem, A., Kotecho, M., & Adamek, M. (2020). "The ugly face of old age:" Elders’ unmet expecta-

tions for care and support in rural Ethiopia. International Journal of Aging & Human Development, 0091415020911900

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

865Ageing International (2022) 47:847–865

Ageing International is a copyright of Springer, 2022. All Rights Reserved.