Unmet Needs for Care and Support for the Elderly in : Gaps in Experiences and Expectations of the Aged in , South-West Nigeria DOI: 10.36108/NJSA/4102/12(0120) Akanni Ibukun Akinyemi 1 Ambrose Akinlo Department of Demography and Social Statistics Obafemi Awolowo University, Ile Ife, Nigeria

1Corresponding author: [email protected]

Abstract The study is focused on understanding the broad issues of care and support of the elderly with a view to explaining factors influencing the gaps in their expectations and experiences. This is an empirical attempt with a view to understanding and under- scoring the importance and limitation of the domains of support from core family members (spouses and children) within the available support networks for the elderly. The study utilized primary dataset including quantitative and qualitative data collected in Ijesa communities in South-west, Nigeria. The findings showed that children and spouses ranked highest among sources of support networks rated by the elderly for five patterns of support identified. Logistic regression results showed that individual variables including age, education, family of orientation, and living in same town with children to a large extent determine level of unmet need for support. The study concluded that personal attributes rather than other social variables are important determinants of high level of unmet need for elderly.

Keywords: unmet needs, care and support, elderly, Ilesa, Nigeria

Introduction Increasing trend in the population of the aged or elderly has been a big challenge for many developed countries. Their prevailing high life expectancy and low total fertility rates, hovering around the replacement level of 2.1, have given rise to a population structure with a large proportion of the aged relative to the working population. The steady increase of life expectancy in the developing countries coupled with gradual decline in fertility implies that the aging phenomenon deserves more well-structured attention. Currently, the elderly account for almost 5 per cent of over 200 million populations in the sub-Saharan Africa region; it is projected that the elderly will constitute about 10 percent of the over 600 million population in 2050 in the sub-region (UN, 2002; UN, 2012). Nigeria, with over 170 million population, is a youthful population with a progressive growth rate of 2.8% and a median age of 17.3 for males and 18.4 for females (NPC, 2008), and about 45 per cent of the country’s total population are under 15 years of age. This broad description of the country as a Unmet Needs for Elderly in Nigeria 29 youthful population, however, beclouds the population dynamics as it relates to the growing elderly population. By these statistics and figures, there is a tendency of a rising proportion of Nigerians who are expected to reach age 60 years and beyond (see table 1). This huge population is characterized with attendant social and economic challenges and consequences particularly on social and public infrastructures.

Table 1: Nigeria Survival Rate and Life Expectation at age 60 years+ Survival Rate Expectation of life 2000-2005 2025-2030 2045-2050 2000-2005 2025-2030 2045-2050 At Birth ------52.1 62.5 69.3 60 years 49.3 64.1 75.7 16.3 18.5 20.1 65 years 43.4 58.5 70.8 13.2 15.0 16.3 80 years 17.6 29.4 39.9 5.7 6.5 7.1 United Nations 2002: World Population Ageing 1950-2050

As documented in a current review of ageing situation in Nigeria (Togonu- Bickersteth and Akinyemi, 2014), care and support of the elderly in Nigeria is based on a generalist view within the public space . As noted by Akinyemi and Isiugo-Abanihe (2014), there is no formal social security benefit for the elderly in Nigeria except for only about two states (Osun and Ekiti) that provide some paltry sum of money of between five to ten thousand naira (less than USD70) as monthly benefit to selected vulnerable elderly population. However, informal arrangement through the family system, religious organizations, non-governmental organizations and community-based organizations dominate the bulk of network of support for the elderly (Akinyemi, 2006). With the growing proportion of the elderly and the lack of direct policy and programme intervention relating to social security and non- work related support to the elderly, it is important to understand the expectation of the elderly as well as their experience. A recently published Global Age Watch Index, with the objective of measuring older people’s wellbeing as well as the enabling attributes of older people and the enabling social environment for their wellbeing (Taipale, 2014), ranked Nigeria in the 85 th position (on a 91-nation list) with an overall ageing index of 24.0. Ghana is West Africa’s highest ranked country (69 th ) with an index of 39.2, while Mauritius’ ageing index of 58.0 makes it the highest ranked African country (33 rd ). Sweden is the highest ranked country with the overall ageing index of 89.9. Within the four scoring domains, Nigeria’s index was 14.2 in terms of income security, 26.4 in terms of health, 30.5 in terms of employment and education and 53.6 in terms of enabling environment. The statistics clearly show that even in Africa, Nigeria lags behind in terms of support for the elderly. The objective of this paper, therefore, is to examine the available support provided to the elderly by the immediate family including children and spouses with reference to Ilesa, south-western Nigeria and also to assess their level of

30 The Nigerian Journal of Sociology and Anthropology Vol. 12 no. 1 unmet expectations and significant factors influencing high unmet needs among the elderly.

Review of Literature Culture, norms and values are naturally part of normal way of life in traditional Nigerian societies. Such were passed from one generation to another and were held in high esteem (Akinyemi, 2009). The issue of support for the elderly is one of such values. In any traditional African society and in most countries of the world the family is charged with the responsibility for the provision of support for the elderly (Chappell, 1985). Such support predominates and it is provided voluntarily without any remuneration (Kosberg, 1992; Brown, 1999). The emerging challenges of the elderly population caught most countries in the African region unawares and exposed their insensitivity to this crucial demographic issue. The expectation of the elderly is built in anticipation of adequate support from the family when “inactivity time comes.” The social and economic needs of the elderly were therefore expected to be catered for through the extended family system, which was a three-to-four generation bounded together by strong kinship ties. Several reasons supported the anticipation of the elderly and the expected roles of the family towards their support in older ages. History and generational trend has always been that elderly care is a responsibility of the family in which he had been part of. Informal sanctions were sometimes meted out to the “irresponsible family members” who failed in supporting the elderly (Kosberg, 1992). Traditional religious belief of ancestral worship largely supported that family members should cater for the elderly. For instance, in Yorubaland some traditionalists believed that the spirits of their ancestors are always around them, and that favour or reprisal from such spirits depends on how well the spirits are pleased. Also, the transfer of land ownership through inheritance in a predominant agrarian society contributed to the traditional expectation of old age support. Infertility and childlessness are also crucial issues in the expectations of the elderly. However, several living arrangement patterns including foster and surrogate parentage were aimed at cushioning the effect of childlessness. It is generally believed that having surviving children at old age is a blessing. The premise is that informal systems of age integration and support by the family will continue to play critical roles in the support of the elderly. There are customs and adage that supported this orientation. The elders provided care to the children who in turn provided care to them in their old age, hence the Yoruba adage, “ ti okete ba dagba tan, omu omo re ni o ma nmu ” (As rodent aged, it sucks the child’s breast). The more children one has the more chances of receiving better care when one is no longer able to support oneself. There was a system that ensured that the needs of individuals were catered for within the family. Nobody would starve when other members of the family had plenty. However social and economic changes currently occurring have put into doubt the continued viability of such traditional arrangements for the Unmet Needs for Elderly in Nigeria 31 elderly. Such changes like increased emphasis on small family units, migration to urban areas, more working wives, new life styles and changing values all have effects on the entire society, as well as the youth who are less disposed to supporting their elderly parents.

Methods The study was conducted in in South-western Nigeria. Osun State was created out of the old Oyo State in 1991 and the state has 30 local government areas (LGAs). The total population of the state was 3,423,535 in the 2006 population census. The state comprises various ethnicities including the Ijesa, Ife, Oyo, and Igbomina. This study however covered only the predominantly Ijesa communities which consist of six local government areas (LGAs), namely , Ilesa East, , Atakumosa East, Atakumosa West and LGAs, with a combined population size of over 700,000. Of the six LGAs in Ijesa, Ilesa East and West are urban (municipal) LGAs, and West are semi-urban while Oriade and Obokun comprise of predominantly rural settlements. Three out of the six LGAs were selected such that each strata - urban, rural, and semi-urban was represented in the study sample. These are Ilesa East, and Oriade LGAs. Enumeration Area maps (EAs) used in the 2006 national population census were obtained for the three LGAs and the EAs were randomly selected from each LGA. A complete listing of the households in each EA provided the sampling frame for the identification and selection of eligible respondents. The criterion for inclusion in the sample was the presence of an elderly person aged 60 years or more. The study sample included a total of 456 elderly men and 491 elderly women. Information was collected through the administration of questionnaires, using face-to-face interviews, on selected respondents. Qualitative data was collected through in-depth interviews and focus group discussions.

Variable Measurement Guided by literature, the study identified five main support domains as critical for old age support. These include financial care, routine daily care, personal visitation, improved social status, and medical care. Financial expectations relate to issues that directly bother on money. These include things that they needed money for. Daily care covered issues that they do daily, like feeding, clothing etc. Visitation is on personal visitation made to the elderly; this excludes phone calls and electronic mails. Improved status relates to social status like owning personal houses, chieftaincy titles, etc. While medical care covers all that relates to health care of the elderly. Also, extensive review of literatures in Africa and beyond identified ten sources of people or groups of people that provide the elderly with care and support. Respondents were asked on a Likert scale (1-5) to score expected level of care and the actual level of care received from children on items on each of the five patterns of support. Weights were assigned to each of the items for each of

32 The Nigerian Journal of Sociology and Anthropology Vol. 12 no. 1 the pattern of support (the weights attached to the categories were as thus; 1 for low, 2 for below average, 3 for average, 4 for high and 5 for very high). These were cumulated for all the items for each pattern of support identified. Those below the mid-values (median) were regarded as low, while points above the mid-values were regarded as high. So, we have low, middle and high values. Unmet need for care and support is a concept in gerontology studies which has been extensively used in many publications (Krause and Markides, 1990; Krause, 1995; Allen & Mor, 1997; Lévesque et al ., 2004; LaPlante et al. , 2004; and Akinyemi, 2009). The proportion of those with computed values of unmet need above the median scores was assigned as high unmet need. The dependent variable was measured as the proportion of respondents with high unmet needs for each of the five patterns of support. Studies have suggested gender dimension to levels of unmet needs for support in old age, so we included sex as one of the independent variables. Other covariates used were age group, education, religion, marital status, family type, residence, household headship, wealth index, children ever born (CEB), child/children living in the same town, child/children abroad (as a proxy for empowerment).

Findings Basic Socio-Demographics Table 2 gives the description of the background of the respondents. In all, 947 respondents were surveyed (456 males and 491 females). More than 50 percent across both sexes were aged 70 years and above with slightly more than one out of every five as an octogenarian for both sexes. About 70 per cent of males and almost 96 percent of females had no formal education or a maximum of primary school education. Also, the result shows that males were substantially more educated than females as almost 30 per cent of males, compared with only 3 per cent of females completed secondary school or had tertiary education. More than 3 out of every 5 respondents (about 60%) were in monogamous family type. About 68 per cent of males compared with 27 per cent of females were currently married, while 25 per cent of males were widowers compared to 58 per cent of females who were widows. About 42 per cent of men compared with 54 per cent of women were engaged in paid activities within the last 12 months preceding the survey. Trading and farming activities were the major occupations reported in the study area.

Unmet Needs for Elderly in Nigeria 33

Table 2: Basic Demographic and Socio-Economic Background of the Elderly by Gender Socio-economic variable Male Female Total (N=947) (N=456) (N=491) Residence Urban 57.0 64.4 60.8 Rural 43.0 35.6 39.2 Age 60-65 years 24.3 28.9 26.7 66-70 years 23.0 20.0 21.4 71-75 years 16.7 9.2 12.8 76-80 years 15.1 18.3 16.8 81 years and above 20.8 23.6 22.3 Education Primary or less 70.6 96.5 84.1 Secondary school completed 9.0 1.8 5.3 Tertiary school 20.4 1.7 10.7 Religion Christian denominations 90.3 95.9 93.2 Islam 7.0 2.9 4.9 Traditional and others 2.7 1.2 1.9 Marital Status Unmarried 6.8 15.9 11.5 Married 68.2 26.5 46.6 Widow/widowed 25.0 57.6 41.9 Family type Monogamous 68.0 59.9 63.8 Polygamous 32.0 40.1 36.2 Current Work status Work within the last 12 months 42.0 54.4 48.5 No work within the last 12 months 58.0 45.6 51.5 No of living children No child 6.6 7.1 6.9 1-2 children 23.3 12.4 17.6 3-4 children 18.0 32.9 25.8 5 or more 52.2 47.5 49.7

Patterns of Support Five patterns of support are of interest in this study. Table 3 presents the distribution of the elderly by those who ranked their expectations and experiences on a Likert scale. These were scored over the ten main sources from which support were expected. As shown in table 3, the distribution of the respondents across the levels of expectation and experience showed that for financial support, 61 per cent of the males had high level of expectation while 58 per cent had a high-level of experience. Among females, 39 per cent had high level of expectation and 38 per cent had high level of experience of financial support.

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The distribution of respondents across daily care showed that 54 per cent expected high support while 36 per cent had high experience of support among males. The distribution among females is somehow puzzling as more than those expecting high daily care support enjoyed high experience of support (expected-25%, experienced-32%) children take care of their mothers more than they do to their fathers. About 56 per cent of males expected high level of support in terms of personal visit, but only 40 per cent reported they experienced same. For females, high expectation for personal visit was 44 per cent while 35 percent reported they enjoyed high experience of personal visit.

Table 3: Proportion of Respondents by High Levels of Support Expected and Experienced across Gender Male Female Expectation Experience Expectation Experience Finance 61.2 (279) 57.9 (264) 39.3 (193) 38.3 (188) Daily Care 54.2 (247) 35.8 (163) 24.9 (122) 31.8 (156) Personal Visit 55.9 (255) 39.7 (181) 44.2 (217) 35.2 (173) Improved Status 59.0 (269) 36.6 (167) 39.5 (194) 28.7 (141) Sick/Medical care 64.5 (294) 57.2 (261) 32.8 (161) 33.8 (166)

From the FGDs, views expressed by the elderly discussants and the adults who participated in the in-depth interviews suggested that men in these communities had more expectations than women. The views expressed showed that men expected support for various things from personal needs to improved status. Women on the other hand are more likely to require limited support in buying clothing items for ceremonies, feeding, and general upkeep. A 66-year-old uneducated male discussant from Oriade expressed his needs as follows: First is to get my children complete a good house for me, then, my chieftaincy title coronation, a new car and money to spend.

Another 67 year old uneducated male discussant in Osu community articulated his expectation for old age support as follows: I will need a new house owned by myself, a new car, new clothes, a new wife, and some of these new things like phones etc.

Some of the male discussants in Ilesa mentioned that they will need support to give their parents befitting burial ceremony. Of a particular reference was the case of an educated retired male discussant of 71 years old in Ilesa. He expressed his views as follows: It is important that my children support me with money so that I can give a befitting burial ceremony to my late parents. Also, I wish to be buried in my own house which I should occupy before Unmet Needs for Elderly in Nigeria 35

I passed on. I had laboured so much on my children so that they can be relied upon when it matters.

Among female discussants, these views which were also corroborated. Most of the women discussants that expressed their expectation have limited requests, particularly from their children. A 61-year-old widow from Osu expressed herself thus: My expectation is that my children will be sending foodstuffs to me regularly and enough money to eat. Every other thing outside this will be additional.

This view received the applause of the people and many of the discussants echoed a popular Yoruba adage: “ti ounje ba ti kuro ninu ise, abuse buse ”, which literarily translates, “food is the most important issue for a poor person.” Beside this, clothing items and money for petty trading were widely reported among women. In-depth interview conducted with the working adults also confirmed that elderly fathers expected more from their children than mothers. In the views of some of the participants, the frequency of requests from mothers may be higher than that of the fathers but the extent of expectation from fathers are usually greater than that of mothers. One of in-depth interview participant, a 42-year- old banker in Ilesa reported that: My mother will like to request for the same things over and over again from me. In most cases, it is money to buy clothes, shoes, bags etc. She asks for this almost every festive periods, such as Easter, Christmas or celebration times. My father’s request is most of the times once in a year but they are heavy demands. For instance, money to roof a house, money for a building project, money promised his society in church or town, car, money for a big ceremony like burial etc.

Unmet need for Support Table 4 presents the estimates of unmet for each of the domain of support of interest. The highest proportion of unmet need for both sexes is improved status in terms of personal fulfillment for social status. More than 95 percent of the respondents had high unmet need for improved status. Among elderly men, unmet need for financial support had the lowest proportion while unmet need for daily care ranked least among women.

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Table 4: Summary Statistics for Indices of Proportion of Unmet Needs for Support Unmet need for: Median Mean Standard Dev. High unmet needs % Male (456) Female (491) Finance 2 2.67 3.0 52.8 54.8 Daily Care 1 2.20 3.0 61.6 49.1 Personal visit 1 2.17 2.9 59.4 54.2 Improved 0 0.22 0.9 99.3 95.9 Status Medical/health 1 2.50 3.3 58.5 56.6

Some of the qualitative evidence suggested a relish of their disappointment and anger from some of the poor elderly people. A 78-year female discussant from Oriade expressed her disappointment from children and family as follows: I lack food, clothing and money, I begged from neighbors for food on a daily basis because my children and family will not bring anything for me to eat” [Poor old widow with poor clothing.

Children and spouses ranked high among other sources of support networks rated by the elderly. In order to be able to examine the correlates of unmet need for the five patterns of support from the two main sources identified, five binary logistic regression models were simulated to cover each of the five patterns for expectation from children and spouses. Comparing the distribution of high unmet need from children and spouse, it was evident that unmet need for finances, visitation and improved status were more pronounced among children than spouse as presented in Table 5.

Table 5: Distribution of Respondents by High unmet need from Children and Spouse Unmet need Children Spouse Both Male Female Both Male Female (n=947) (n=456) (n=491) (n=947) (n=456) (n=491) Finance 24.8 30.7 19.4 17.6 20.4 15.1 Daily care 14.9 18.4 11.8 16.9 17.5 16.3 Visitation 21.8 30.0 14.3 14.9 14.0 15.9 Improved status 33.4 34.8 31.9 14.6 23.4 6.5 Medical 12.1 14.9 9.6 13.1 16.0 10.4

Binary Logistic regression predicting high unmet-needs for support of the elderly As shown in Table 6, the main determinants of unmet need from children include age, education, household headship, status of residential apartment, wealth index, type of family of orientation and presence of a child within the Unmet Needs for Elderly in Nigeria 37 same town. The odd ratio of these significant variables showed that those that are 66 years old and above are less likely (0.6), compared with those below this age group, to report high unmet need for financial support from children. Those with high levels of education are more than twice (2.4) more likely than those with low education to report high unmet need of financial support from children. The elderly who, or whose spouses, are heads of households are thrice more likely than those headed by a child or family member to report high unmet need for financial support from their children. Those residing in personal houses, those of rich wealth index and those whose family of orientation are monogamous are less likely than the reference category to have high unmet need for financial status from children. Those with at least a child living within the same town are twice more likely than those without a child in the same town to report high unmet need for financial support from their children. Examining the correlates of respondents to high unmet need for financial support from their spouses, seven categorical predictor variables were seen to be of statistical significance (p<=0.05). These variables include marital status, family type, household headship, status of housing accommodation, and wealth index. The odds showed that those who are widowed were less likely to have high unmet need for financial support compared with those unmarried. Those in polygamous families were twice more likely than those in monogamous families to report high unmet need for finance. Those in rented apartments were less likely, compared with other categories, to have high unmet need for financial support from spouse. Those who are of rich wealth index were less likely to have high unmet need for financial support from spouse compared with other categories. There was no difference in levels of unmet need for financial support from spouse between those of poor wealth index and those of average wealth index. Three categorical variables were consistently significant in predicting high unmet need from children and spouse. Those who are household heads were thrice more likely and those headed by spouse more than twice likely, compared with that headed by a child to have high unmet financial need from the two sources. This pattern is similar in both models. Those residing in personal houses were less likely to report high unmet need from children but twice more likely to report high unmet financial need from spouse. In model 2 for children, age of the respondent, household headship (self), wealth status (average), family of orientation type, and presence of a child in the same town with the elderly were significant for high unmet need for daily care. Those in the 66 years and above were less likely (0.6) to report high unmet need than those 65 years or less. The possible explanation here is that those in the age group 65 years or less are likely to be economically active and therefore be able to support themselves. Those who are heads of households were three times more likely than those in children-headed households to have high unmet for daily care from children. This is possible in the sense that those living with the children are likely to have almost all their needs supported by the children.

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Those in average wealth index category were less likely than the poor to report high unmet need for daily care from children. Those in monogamous families and those with a child within the same town were less likely than the reference category to report high unmet need for daily care. In model 2, the significant variables were marital status, family of orientation, children ever born and presence of a child within the same town. The odds for the significant variables showed that those married and widowed were less likely, compared with those unmarried, to report high unmet need for daily care. Also, those born into monogamous family and those with three or more children were more likely than the reference categories to report high unmet need for daily care. Those with a child living within the same town had lower odds of reporting high unmet need for daily care. Although the odds vary and showed inverse odd relationship, there was a consistency in the level of significance of unmet need for daily care from children and spouse by family of orientation type and presence of a child living in the same town. The odds of high unmet need for personal visitations from children were presented in model 3. Eight categorical variables were significant in predicting this. The odds showed that men are twice more likely than women to report high unmet need for personal visitation from children. Those who are widowed are three times more likely than those unmarried to report high unmet need for personal visitation. Those who are married were also almost twice more likely than the reference category to report this but the distribution was not statistically significant. Pensioners were eight times more likely than those self-employed to report high unmet need for personal visitation. Those who are household heads were twice more likely than those headed by a child to report high unmet needs for visitation. Those born into monogamous families were twice more likely than those born to polygamous families to report this. Those with three children or more were less likely than those with two or less, and those with a child living in the same town were less likely than the reference categories to report high unmet need for personal visit from children. Model 4 presents the distribution of the odds to high unmet need for improved status. The significant odds for predicting high unmet need for improved status from children showed that eleven variables were significant. These include; age, education, marital status, family type, residence, household headship, wealth index, type of family of orientation, children ever born, presence of a child living within the same town, and a child abroad. The odds of the significant variables showed that those aged 66 years and over were twice more likely than those younger, and those with high education were more than twice more likely than the reference categories to report high unmet need for improved status. Those married and those widowed were thrice more likely, compared with the unmarried, to have high unmet need for improved status. Those in polygamous family and those household headed by the elderly were twice more likely than the reference categories to report this. Those in urban areas, those of average or rich wealth index, those born into monogamous families, Unmet Needs for Elderly in Nigeria 39 and those with a child abroad had very low likelihood compared with the reference category to report high unmet need for improved status from children. It is of interest that those with six or more children and those with a child living in the same town are twice more likely than the reference categories to report high unmet need for improved status. Model 5 which examined the predictor variables for high unmet need for medical care from spouse showed that only five variables were significant. These variables include; education, marital status, type of family, household headship and presence of a child within the same town. The odds of these significant variables showed that those of high education, those in polygamous families, and those in self-headed households were twice or more likely, compared with the reference categories, to report high unmet need for medical care support. Those who are widowed or with a child living within the same town were less likely compared with the reference category to report high unmet need for medical care from spouse. Comparing the two models for predicting unmet need from children and spouse, only two of the variables showed a consistent pattern in both significance and odds. Those with high education were twice more likely than those with low education to report high unmet need for medical support from both children and spouse. Also, those in polygamous families were twice more likely to report high level of unmet need for this form of support from the children and spouse.