C u l t u r a l P e r s p e c t i v e T h e S t a t u s o f O l d e r P e r s o n s i n A f r i c a : C h a l l e n g e s F a c i n g P h y s i o t h e r a p i s t s AM O SUN SL, BSc; PhD Department of Physiotherapy, University of the Western Cape, Belfville A B S T R A C T : In many A frican countries, there has been an increase in the number o f older persons because o f the gains in life expectan­ cy made in the 20th century. The increase has led to concerns about how to provide necessary care fo r older persons as many on-going changes in the society threaten to erode the traditional support net- _____________________________________ work. The paper identifies some o f the many challenges facing physiotherapists in improving the status o f older persons in Africa, and gives suggestions on overcoming the challenges. KEYWORDS: OLDER PERSONS, AFRICA, PHYSIOTHERAPISTS INTRODUCTION The number of older persons in the gene­ ral population is increasing rapidly in many African countries due to the drama­ tic gains made in life expectancy during the 2 0 ^ century. In the near future, the number of older persons is likely to become staggering, although they will still be a low proportion of the entire population (Amosun & Alawale, 1994; Amosun et al, 1995; Apt, 1997). As the number of older persons escalates, the question o f how to care for them becomes more critical. A major concern is the possibility of an increase in the prevalence of physical disabilities. What can be done to ensure healthy aging and a good quality of life in old age? Issues about older persons differ from one country to another and from one culture to another. While this paper does not attempt to paint a single and complete picture of older persons in all of Africa, it is attempting to highlight some of the common issues influencing the status of CORRESPONDENCE: Prof SL Amosun Department of Physiotherapy University of the Western Cape Private Bag X I 7, Bellville 7535 Tel: 021-9592542 Fax: 021-9030476 E-mail: samosun@chs.uwc.ac.za older persons. The purpose o f this paper, therefore, is to document and create public awareness on the status of older persons in Africa, as well as estimate the challenges facing physiotherapists and other health care providers. A GLIMPSE AT OLDER PERSONS IN THE COM­ MUNITY In both traditional and contem porary African society, old age is regarded as a blessing, and older persons are highly respected (Apt, 1997). In addition, the extended family and the community still constitute their primary source of care and social security. Older persons live with their children, and are often looked after by daughters in-law. Older women in the community are seen as signifying dignity to a home or any gathering. Their roles include physically caring for and looking after grandchildren, giving the children proper cultural upbringing, and ensuring that correct procedures are fol­ lowed at communal activities such as weddings, funerals and during and after childbirth. Older men in a community could be compared to a “board of directors” who have to approve all decisions of public concern (Bruun et al, 1994). They have this position because of their advanced age and the assumption that older per­ sons are closer to the ancestors. The respect for older persons is linked to the belief in the power of the ancestors. To be on good terms with ones ancestors is considered to be very important, as this guarantees a blessed life and prevents any mishap. Older persons also serve as deposi­ taries of traditions, customs and popular wisdom that are currently under threat in a fast changing African society. It is well known that Africans still place a high value on traditional medical care, a tradi­ tion jealously guarded by older persons within a community. Such traditional medical care often involves the use of medicinal plants. Overall, older persons in the African community are expected to live sedentary lifestyles, enjoying the fruits of their past labour (Amosun, 1995). However, living “too long” is considered to be a nuisance, and such “unlucky” ones are suspected to be witches or wizards. OLDER PERSONS IN A CHANGING SOCIETY The current generation of older persons in Africa are survivors of generations who received poor education, who were often under-nourished in earlier life and suffered m ultiple infectious diseases (Amosun & Alawale, 1994). Living in a society where substantial changes are taking place could therefore pose a threat to their welfare. These changes seem to be irreversible and, by and large, do not favour traditional forms of caring for older persons in the community. Some of the major changes include population shift towards urban areas, 6 SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:samosun@chs.uwc.ac.za participation of women in the work force, and the trends towards nuclear fam ily from the extended family (Amosun 1995). Young men and women are leaving the rural areas for the cities in search of better means of livelihood, leaving older persons to care for them­ selves under prevailing economic hard­ ships. Daughters in law who have the traditional role of looking after older persons in the family have joined the w ork force for econom ic reasons. Unfortunately, many older persons are still heavily dependent on family mem­ bers, both in health and disease, for sus­ tenance (Am osun & Alawale 1994). They have little opportunity to share the benefits of the processes of moderniza­ tion, urbanization and industrialization. Older persons who traditionally were “omnipotent patriarchs” , now experi­ ence severe setbacks in many of their social roles because of modernization. They do not have the skills to compete for jobs, even if the jobs were to be made available to them, in a society that now depends on technology. These changes are directly or indirectly eroding the traditional support networks in car­ ing for older persons. Left alone to cater for themselves, older persons do not have easy access to health services (Amosun & Reddy, 1997). The barriers to access of services are primarily social and economic. This situation makes them vulnerable to develop health problems that could have been prevented. Additional changes in the society affecting older persons are brought about by the impact of hostilities (Apt, 1997) and HIV/AIDS (Gatsi et al, 1994; Burton, 1992). The advent of wars and HIV/AIDS further strains the socio-eco- nomic infrastructure in many African countries, and the elderly are often not in a position to cope with the implica­ tions which include stress and its out­ comes. However, though the debate around ageing-related issues often follow a negative view, this should not be the case. Survival into the “elderly age” by larger segments of the African popula­ tion should be seen as an achievement. This sense of achievement should there­ fore instil a positive attitude in facing the challenges posed by the increase in the number of older persons. CHALLENGES The changes taking place in the African society pose challenges to both older persons and health care providers, including physiotherapists. The World C onfederation for Physical Therapy issued a position statement on “Physical Therapy for the care of elderly persons” , which was ratified at a general meeting in Washington D.C in June 1995. The position statement highlighted the dearth of reliable information on older persons in many A frican countries (WCPT, 1999). Health care planners and policy makers are increasingly faced with the challenges of how to care for older per­ sons in their communities because of grossly inadequate information systems. There are no reliable data on the health needs of older persons, with little infor­ mation on their perceived or identified needs as well as their physical and func­ tional disabilities. Physiotherapists in Africa urgently require assistance to plan appropriately before crises arise. Two areas of immediate assistance are - a) There is the need to develop research abilities among physiotherapists with interest in the care of older persons. b) So far, the most comprehensive study on the health status of older persons in an African country is a comparative m ultidim ensional survey o f 4,400 elderly South Africans between 1990 and 1991 (Ferreira et al, 1992). The main objective of the survey was to provide baseline data needed for iden­ tifying the health problems of older persons. The success of the survey was partly attributed to the scholarly exchanges between the researchers in South Africa and colleagues from another “advanced” country. Similar surveys, with necessary technical assistance, are recommended for other African countries in order to provide inform ation to policy makers and planners. An audit of physiotherapy services utilised by older persons will contribute to the development of a reliable data bank on the health needs of older persons (Amosun & Alawale, 1994; Amosun et al, 1995; Jaswal et al, 1997). A second challenge is to ensure that the care of older persons continues at community level (Amosun & Alawale, 1994; Amosun & Reddy, 1997). Present economic difficulties may not create a favourable clim ate for the extended family structure to continue to give necessary attention to older relatives, but old people’s homes are still foreign to the African culture. With increasing emphasis on community based rehabili­ tation, it has been suggested that simple rehabilitation centres (or day care cen­ tres) should be established in local com ­ munities in order to help older persons to live independently within their com ­ munities (Amosun & Alawale, 1994). These centres should be non-residential units to which older persons have easy access. Physiotherapists can team up with other health care professionals to train local community workers to run these centres with the participation of older persons themselves. The centres should give opportunity for social interaction among older per­ sons through sports and recreational activities. Sub-cultural theory maintains that older persons adjust more success­ fully to ageing if they interact with those from the same age group (Bruun et al, 1994). Through this process of shared interaction, a group consciousness emerges with its own norms and values, hence a subculture. Health promotion programs should target such subcul­ tures. The benefits of an exercise pro­ gram carried out in such a centre has been reported (Kunda & Amosun, 1998). Regular screening of older persons, leading to early identification of needs, should also be carried out in the centres. These centres should offer opportunty to educate communities on the process of ageing from a lifelong and natural perspective, as well as the need for healthy lifestyles (Kalache & Sen, 1992). While appreciating that cultural back­ ground influences health behaviours and that cultural health beliefs should be respected, physiotherapists need the skills to assist older persons identify when certain health practices may be unhelpful. One of the most common medicinal plants used and recommended by older persons is abrus precatorius. While the medicinal values of this plant are not doubted, the toxic effects of the crude extract of the seeds, leaves and SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 ' 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) roots on neuromuscular transmission have been reported (Wambebe & Amosun, 1984). Older persons, as custodians of these health practices, may be vulnerable to the toxic effects. Another challenge in enhancing the status of older persons in Africa is in the area of advocacy (Amosun & Reddy, 1997). Older persons form a special group for a variety of reasons. Many have suffered from multiple pathologies, having a high risk of chronic and disabling diseases. They are also victims of negative attitudes from professionals, from society and from themselves by attributing to old age problems that can be solved or ameliorated. The World Health Organisation has developed specific policies and programs on children, people with disabilities and women, but older persons are yet to be dis­ tinguished as a discrete social group that merits particular attention. Thus there is a lack of legislative and policy frame­ work, leaving the structure and organisation of services for the elderly to be fragmented and confused. There is an urgent need to stir up the interest of African physiotherapists in caring for older persons. It may be advisable to start with physiotherapy students by increasing the time allotted to gerontology (Amosun & Alawale, 1994). Physiotherapists should get involved in highlighting issues affecting older persons. A fourth challenge is the need to prepare for the next gener­ ation of older persons in Africa. This may be carried out through surveys to elucidate the attitudes of young adults to ageing and their own old age (Amosun & Alawale, 1994). The outcome will be useful in making adequate preparation to meet the possible future expectations of older people. Meeting all these challenges require proper training o f health care providers, including physiotherapists, within a multi-discipli­ nary and continuing perspective. CONCLUSION In recent years, the world has been alerted of the consequences of a worldwide increase in the numbers of elderly people. The increase varies considerably from country to country, but the implications are of concern to all, and call for commensurate action. Unfortunately there is little reliable information on older persons in Africa. W hile family members still give the bulk of care to older persons, socio-economic changes in the society seem to threaten this support network. This paper has identified a few of the many challenges facing physiotherapists in Africa in making an impact to improve the status of elderly Africans. We need all the assistance to make adequate plans for today and also for the future before the gains made in life expectancy are completely lost. REFERENCES A pt N A 1997 A g e in g in A frica. W orld H ealth Organisation A g e in g and H ealth Program m e, G eneva A m osu n S L 1995 Physiotherapy and the elderly in A frica. A paper presented at the con ference o f the A ssocia tion o f Chartered P h y sio ­ therapists w ith a S p ecial Interest in Elderly P eo p le (A C PSIE P) in B elfast, Ireland, in A pril 1995 A m osu n S L & A law ale 0 0 1994 C h allen ges facin g physiotherapy in caring for older p eo p le in a d ev elop in g A frican country. Physiotherapy 8 0 :6 7 3 -6 7 6 A m osu n SL, M azarire M , M aw ere J 1995 U se o f physiotherapy services by elderly patients at a central hospital in Z im babw e. South African Journal o f G eron tology 4 :2 4 -2 6 A m osu n S L & R eddy P 1997 H ealthy a gein g in A frica. W orld H ealth 4 :1 8 -1 9 Bruun FJ, M ugabe M , C oo m b es Y 1994 T h e situation o f the elderly in B otsw ana. P roceed in gs from an International W orkshop, L ob o Grafisk, O slo, N orw ay Burton LM 1992 B lack grandparents rearing children o f drug-addicted parents: Stressors, o u tco m es, and socia l serv ice n eeds. 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Journal o f Ethnopharm acology 11:49-58 World C onfederation for P hysical Therapy 1999 M inutes o f the 13th general m eeting June 1995 CALLING ALL STUDENTS AND OTHER INTERESTED PARTIES NOW IS THE TIME FORCHANGE! A New cover page for THE SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY. A competition is being run for the best design for a new front page. The Prize: A BOOK TOKEN FO R TH E WINNER (ACCOLADES FO R TH E UNIVERSITY) All submissions to be in by 1 5 t h S e p te m b e r 1 9 9 9 . What has to appear: ■ N am e o f J o u r n a l ■ S p a c e f o r titles o f a rtic le s ■ Volum e n u m b e r ■ D a te 8 SA J o u r n a l o f Physiotherapy 1999 V o l 55 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )