An Exploration of the Knowledge of Informal Caregivers on Ageing Related Health Conditions at Matero and Chawama Old People’s Homes, Zambia

Caring for older adults requires a multidisciplinary approach and this includes a primary caregiver and a knowledge of the physiology and epidemiology of aging. The objective of this study was to explore the knowledge of caregivers on ageing-related health conditions at Matero and Chawama old peoples’ homes in Lusaka. A qualitative case study design with a sample size of 12 based on the criteria of theoretical saturation was used. The results showed caregivers’ views on ageing-related health conditions, common ageing-related health conditions seen at both nursing homes, clinic/hospital and nursing home management of these conditions. The challenges faced by caregivers were revealed and they included attitude of the elderly, inadequate equipment, lack of transport, financial challenges, work overload and participant’s characteristics like personal needs, their age and gender influencing caregivers’ work output. Caregivers knew most of the ageing-related health conditions and are knowledgeable on the nursing management of these conditions. There are various things affecting knowledge of caregivers on ageing health and management skills. Various challenges such as financial challenges, lack of transport, and inadequate equipment were also pointed out and are seen to greatly influence the work output of caregivers.


Background
Human aging is associated with a wide range of physiological changes that limit normal functions and renders a human being more susceptible to a number of diseases [1,2]. Changes associated with age have an impact on the function of every body system, even in the healthiest older people [3]. Normal age-related changes may be accompanied by chronic health problems such as diabetes or heart disease and the management of many such chronic conditions may increase the complexity of care. Caring for older adults requires a multidisciplinary approach and includes a primary caregiver who coordinates care with other team members, including physiotherapists, occupational therapists, pharmacists, nurses, and other health professionals [4]. Caregivers are essential partners in the delivery of complex health care services. Unlike professional caregivers such as physicians and nurses, informal caregivers provide care to individuals with a variety of conditions, most commonly advanced age [5]. Elderly patients with multiple comorbid conditions such, have intricate treatment protocols that require caregiver involvement, further complicating this already difficult care. Because better treatments have extended the life spans of most patients with chronic illnesses, caregiver involvement often is required for several years [6].
Caring for people aged 65 and older can be complicated and requires specialized knowledge of this demographic group. Knowledge of the physiology and epidemiology of aging helps manage conditions that have special significance in the elderly. This information is also vital for planning and implementing interventions that will help in further Conditions at Matero and Chawama Old People's Homes, Zambia management [7]. The amount or level of knowledge possessed by those who are rendering care has the potential to either positively or negatively affect the outcome of a health condition. However, little information is available about the knowledge and skills that informal caregivers need to have provide or how their knowledge and skills affect care [8].
Therefore, exploring the knowledge that caregivers have on health conditions that are mainly attributed to the process of aging is vital for the successful management of the aged.

Design and Setting
This study utilized a qualitative case study design conducted at Chawama and Matero homes for the aged. This type of design was selected because it facilitated exploration of a phenomenon within its context by using a variety of data sources.
Chawama and Matero homes for the aged are the main homes in Lusaka, Zambia caring for the aging population. Chawama Home for the aged is under the Cheshire Homes and is a Divine providence home for the aged, homeless and the orphans. It is located in Lusaka's Chawama area. It was first established in 1988 under the name St. Theresa and was officially opened in 1992. It accommodates an average of 20 aged people and 25 orphans.
Matero home for the aged on the other hand is an after care centre running under the government of the Republic of Zambia under the Department of Social Welfare. It is located in Lusaka's Matero area. Both these centres are situated close to health centres in the said areas.

Selection of Participants and Data Collection
The study utilised a sample size of twelve (12) caregivers using a theoretical saturation method, by use of a convenience sampling method. This included 6 caregivers from each centre. Of the six, two key informants were selected from each centre making a total of 4 key informants. The remaining 4 caregivers from each centre i.e. (4 from Chawama and 4 from Matero) were grouped in to two (2) focus group discussions.
Data collection was done with the assistance of an interview guide, an audio recorder and note taking to describe the study setting and non-verbal communication.
The data was later transcribed and reported verbatim.

Analysis
Data was analyzed using thematic analysis, a method used in identifying, analyzing and reporting information in themes. The analysis was done according to the step-by-step six-stage process of thematic analysis. These are familiarization, generation of initial codes, searching for themes, reviewing themes, defining and naming themes and producing the final report [9]. Data transcribing was done as part of the familiarization stage.
Transcripts were carefully and thoroughly read and re-read after which initial coding and categorization of themes was done. Responses that were related through content and context were categorized as themes. This was continued until no new themes came up. Transcribed data was transferred to Nvivo version 10 for arrangement, coding and merging into themes. Codes were categorized according to similar contents and then developed into broader themes.

Results
Results revealed ageing related health conditions which encompassed caregivers' views on ageing-related health conditions and common ageing related health conditions seen by the caregivers at the nursing homes. They were of the view that some conditions are peculiar to aging and some are most commonly associated with the younger population. They were also knowledgeable on some of the conditions that specifically affect men and those that are most commonly associated with women. This was stated by one of the caregivers who said: I know that when people age, they come with certain conditions peculiar to aging like Alzheimer's or dementia, sexually transmitted diseases is more peculiar to the youth than the aged.
Additionally, most of the participants did not know the exact names for some of the conditions, but rather they described them based on the symptoms. Different age related health conditions were mentioned during the interviews and discussions although some of the conditions were not out rightly mentioned by their exact names. Terms used to describe them were collectively used to point to one particular condition such as waist pains and backache to mean low back pain and high blood pressure to mean hypertension. When asked about which ageing-related health conditions participants had seen to be more common than the others at both nursing homes, it was revealed that dementia, osteoporosis, hypertension and low back pain were more in occurrence as compared to the other condition: " …As a person grows old, there are complications… such as waist pain… the back bone as we grow, it also begins to bend... so the waist is the biggest problem followed by the legs.." Another participant narrated the following; "And then, I think the elderly…they are slowly losing their memory" Forgetfulness is a very common feature among the elderly and it is something expected; one participant mentioned this attribute during the interview and had this to say; "The other thing is forgetfulness. When they leave something, they forget were they left it..." "…mostly what is common for me is Osteoporosis and BP (Hypertension). Those are the ones I'm finding often… And also dementia, they forget a lot…"

Emerging Themes
Aside from the questions centred on the objectives, the interviews and the discussions also revealed some themes that were of relevance to the study being undertaken.

Society's Attitude and Perception Towards Ageing
Interviews with the key informants revealed that there is lack of care from society and even family towards the aging population. One of the key informants mentioned that the greatest challenge has been to learn that the family system has broken down and that society no longer has value for lineage.
"…The greatest challenge for me has been to learn that the family system has broken down. Society no longer has that value of lineage. People don't care about people when they age or when they have a health issue…" Another key informant also said that the elderly are being left and neglected by their families and society. She attributed this negligence of the aged by family and society to the fear of caring for elderly people when they are about to die.
"…what is happening also for the elderly…they are left by the family. Not only by the family, but people around also, they fear or they are afraid that someone will die, what shall we do...?"

Connotation of Aging to Witchcraft
The other point that was raised by both the participants from the FGDs and the key informants was the tendency of society to associate old age to witchcraft which was also one of the things precipitating into negligence.
"… People think when a person becomes old, then that person becomes a witch... I don't know why it is like that... So mostly, these people who we receive here, some are just dumped. Just right outside the gate…Others are left at the police station…" One of the key informants related this tendency to the cultural set up and she assumed that promoting the cultural values might help to get rid of this vice.
"…And also I think, this is a very big problem…the elderly they are suspected that they are witches...I think my assumption would be maybe improving the culture…"

Strengthening of Policies
Another important point that emerged from the interviews with the key informants was the need for government to strengthen the laws and policies that govern the aging population in Zambia. One of the key informants said there is no law which ensures the protection of the elderly when they are abused even by their own relatives.
""…There are a lot of elderly people out there who are being abused. So there needs to be a strengthening of policies and laws… there is no law, if you are abusing your grandmother today, I can report you to the police but you can defend yourself because you are the one who is related to your grandmother... There just needs to be a law that elderly people need to be taken care of…" Another key informant was of the view that the government is not playing their part in taking care of the aging population. She further added that government needs to take care of its people.
"Among the challenges I would also say that the government is also not taking care of its people. The government has a part to play but they don't…"

Factors Influencing Caregivers' Knowledge
Caregivers expressed a number of things that influence their knowledge on different age related health conditions.

(i) Work Experience
Work experience was one of the major things influencing the level of knowledge that the caregivers have on different ageing-related health conditions. During the discussions and interviews with the participants, it was revealed that most of the information they have on health conditions affecting the elderly and the management of these conditions is based on experience and the number of years they have worked at the nursing homes.
"…following the number of years we have been working here, from experience just like this, I can say the information is a lot…the time that I have worked here, and the diseases that I have seen here, they are a lot" However, other caregivers were of the view working for a long period of time as a caregiver had a tendency to make caregivers lose interest in the job further affecting their performance towards work. One of them had this to say; "…when a person does the same job over and over again, sometimes they end up getting tired...or lose interest in the job…so once the interest is gone, it means, even the performance will be poor… "

(ii) Level of Education
Most of the key informants mentioned that the level of education for caregivers was also another important aspect influencing caregivers' knowledge. They said that the level of education gave an understanding of ageing-related health conditions and the patience needed towards the elderly in caring for their conditions. "Level of education of the caregivers does influence because if you don't have knowledge, you will never understand them (the health conditions). And you will never know how to react at certain situations...And also you know having that patience and how to understand the elderly…"

(iii) Lack of Training in Caregiving Services
Another important thing that was thought to influence caregivers' knowledge was the lack of training in caregiving services. One of the key informants mentioned that there is a lack of education and training in caregiving services leading to a lack of understanding and lack of respect for work ethics. She further mentioned that lack of respect and understanding for work ethics is one of the leading causes of abuse towards the elderly.
"There is a lack of education and training. Also lack of understanding the conditions...And also lack of respecting ethics… That's why you find that there is a lot of abuse because people don't know what the ethics are..."

(iv) Lack of Background Information
The discussions and interviews also pointed out that lack of background information about the elderly clients being cared for had an influence on the knowledge that caregivers had. One of the key informants said that if an elderly person is brought to them, it is easier to understand the conditions if the caregivers know about that elderly person's past.
One of the participants said that it is sometimes hard for them to tell what is exactly wrong with the elderly because there are some who come to the homes when they are already sick. He further explained that when the elderly are taken to the hospital, it is difficult to explain exactly what is wrong with them to the medical personnel at the hospital.
"…sometimes we are found with those elderly people who were maybe just picked by the police… they come here when they are already sick. It is hard for us to tell exactly what is wrong with that person...when we take them to the hospital…the medical staff at the hospital ask us … how did the problem start ?so it becomes difficult to answer..."

Root cause of Knowledge of Informal Caregivers on Ageing-related Health Conditions
The root cause analysis diagram below illustrates how the findings of the study are linked to knowledge of caregivers on ageing-related health conditions

Discussion
The study results showed objective-based or predetermined themes and also pointed out other major themes that had emerged from FGDs and interviews with the key informants.
The objective based findings adequately showed the common ageing-related health conditions at the nursing homes including the caregivers' views on these conditions and their management. The findings also brought out what influences knowledge of caregivers regarding ageing-related health conditions and the challenges faced by caregivers.
Participants knew a number of health conditions affecting the elderly at the nursing homes. They are also knowledgeable on the conditions that specifically affect men and those that are most commonly associated with women. This was pointed out by one the participants who said that when men reach 70 to 80 years, they develop the problem of tubes blocking ( Obstructive nephropathy) and women usually complain of painful legs (osteoarthritis) and waist pains ( low back pain). Similarly, according to a report by WHO on gender, health and ageing, the basic diseases which affect older men and women are the same. However, rates, trends, and specific types of these diseases differ between women and men. Perhaps more importantly, the gender picture of a given society has a great bearing on the health of the aged. It is further explained that osteoarthritis is common in older women than in older men [10] Amongst the many mentioned conditions, they were a few of them that were pointed out by the participants to be common and more in occurrence as compared to others. These included dementia, low back pain, hypertension, and osteoporosis. In line with these findings, a study done by Bain [11] also revealed similar findings.
Study finding is that several factors influence knowledge of caregivers on ageing-related health conditions, one of them was level of education. Although the participants knew most of the conditions affecting the elderly at the nursing homes, one of the things affecting their ability to identify the ageing health conditions by name and thus influencing their knowledge was level of education. Most of the participants from the FGDs unlike the key informants, did not exactly know the conditions by their names. This is because of the secondary level of education for most of the participants from the FGDs. Although some of the participants from the FGDs felt that the level of education had little to do with the understanding and management of ageing-related health conditions, a higher level of education showed a better ability of being able to identify the conditions as seen from the interviews with the key informants. Furthermore, the key informants stated that a higher level of education gave a better understanding of the conditions and the elderly themselves. Similarly, literature indicates that having a lower level of education provides a weaker platform for understanding frail adults and increases the informal caregiver's burden [8]. However, in some study [12] it has been stated that although the caregiving literature is vast, much of it is based on cross-sectional analyses of relatively small opportunity samples and that confounding effects such as the caregiver's level of education and health status have often not been controlled for in most study designs or statistical analyses [12]. This study was a qualitative study and is therefore different from this scenario.
The other thing influencing knowledge of caregivers on ageing-related health conditions is the lack of training in caregiving services. In the management of ageing-related health conditions, Authors have stated that many caregivers focus on leg strength and balance training in the elderly [13]. However, therapy designed to improve mobility in elderly patients such as caregivers focusing on leg strength and balance has not been fully attainable because most of the caregivers from both Chawama and Matero homes for the aged are not trained in any form of medical care or physiotherapy except for one caregiver from Chawama home for the aged who has been trained in community health work and HIV/AIDS management. Due to the lack of training in medical care and management skills of ageing-related health conditions, the caregivers do not have adequate knowledge and skills needed to help ensure the optimum wellbeing of the aged. In a similar study done by Murat et al., [14] on the knowledge and attitude of caregivers of Parkinson Disease (PD) patients, it was shown that 65% of these caregivers are not experienced or trained in providing care to PD patients or to the elderly with a chronic disease [14]. In another similar study done by Yadav et al, [15] it was revealed that there is a lack of knowledge about Alzheimer's disease among Hispanic older adults and caregivers precipitating into a lack of knowledge and skills on how to handle this condition [15]. Another researcher reports also that little information is available about the knowledge and skills that informal caregivers need to provide care or how their knowledge and skills affect care [16]. Another study found that most caregivers in old people's homes in Zambia lacked even basic training in elderly care and related aspects.
Furthermore, a retrospective study by Changala et al [12] identified approach considerations of comprehensive health care that had shown the potential to improve the quality, efficiency, or health-related outcomes of care for older persons.

Conclusion
It was found several opportunities to improve the knowledge of caregivers in order to consequently improve the quality of health and physiotherapy care provided to the elderly population. Many of the strategies we suggest for improving service delivery of the elderly care are in keeping with the emphasis on enhancing person-centred care. Through understanding the knowledge base and management of elderly patients, we hope that quality of life and other outcomes will be improved for elderly patients.