In less developed regions including East Asia and Latin America, there is increased in numbers of older adult in the population. There is evidence of a shift in population age structure worldwide which is caused by rapid declines in fertility and mortality  , and concerns about the significance of population ageing   . As the world’s population continues to age, forecasts show that this trend will continue   , and the proportion of persons 65 years and older is projected to increase sharply in coming years   . Ghana’s population aged 60 and over will account for more than 11% by 2050, the population of people aged 60 and over will account for 21.1% of the global population. Although the population of all countries is ageing, this phenomenon occurring most rapidly in developing countries where 60% of the world’s older people live  . The population can no longer be described as a young population because there has been an increase in both the percentage and absolute number of the elderly (persons aged 60+ years) as seen by the results from census and estimates from other government sources  . Ageing is happening irrespective of socio-economic hardship, widespread poverty, human immunodeficiency virus/Acquired immunodeficiency diseases (HIV/AIDS) pandemic, and the rapid evolution of the traditional extended family structure  .
1.1. Aged Support
Globally, families are the key social groups in which older people are kept and maintained  . In the general absence of comprehensive strict welfare systems, families are critical for understanding challenges and opportunities of ageing  . Indeed, the emergence of gerontological interventions decades ago was motivated largely by concern about destruction of customary family care systems and a pending “disaster” of old-age sustenance which required responses   .
The importance of the role played by the elderly in nation building in the phases of their lives cannot be overemphasised. Asiyanbola  makes the point that they are the guardians of culture and tradition, peacekeepers during conflicts resolution and promoters in enforcing peace in their various communities, adding that the aged tend to live with their families, usually with an adult son and daughter, with some variation across countries as to the preferred co-resident. Living with or near the family is crucial for maintenance of support since the aged tend to need help with activities such as cooking or shopping, as well as physical and psychological support, particularly when they no longer work for a salary and begin to suffer from illnesses that restrict their capacity to carry out activities necessary for day-to-day survival  . Care for needy members is a core element of family life. As also seen elsewhere, older people in Sub-Saharan Africa (SSA) play roles both as care givers to orphans and vulnerable children in situations of HIV, poverty, and labour-related relocations    , and as recipients of long-term care. Many older persons reach retirement age in a state of poverty and deprivation, with poor access to health care and poor dietary intake. In addition to usual physical, mental and physiological changes associated with ageing, old people are very often disadvantaged by lack of social security for their everyday social and economic needs. The care and support by the family and community that was previously taken for granted are not there because of changes in society due to urbanization and expansion  . This leaves the aged with insufficient personal savings to meet their daily needs  -  . They are often denied their right to pension, resulting in poor well-being in the face of poverty and lack of medical attention. The well-being of the elderly is a crucial concern in view of their dependence on family support networks, as is clearly apparent in most parts of Sub-Saharan Africa    .
The aim of this scoping review was to explore and describe evidence in published literature of care given to the aged in their homes in the Ghanaian society. The results will help policy makers plan integrative care for the age in Ghana.
A PRISMA scoping review method was used to guide this study. As described by  , “A scoping review is a literature review that collects and critically analyses multiple research studies or papers, using methods that are selected before one or more research questions are formulated”. It offers “the potential to look for gaps in evidence-based practice for nursing”  . Considering the absence of evidence of care of the aged living at home, this method was chosen as the most appropriate way to explore what literature is available from a range of scientific sources. It is well known that combining diverse methodologies can lead to lack of rigour, inaccuracy and bias   . This issue occurs mainly because methods of analysis, synthesis and conclusion-drawing remain poorly formulated  . For additional rigour in the review process, this review followed the four stages recommended in the review framework developed by Moher et al.  : problem identification, literature search, data evaluation and data analysis.
2.1. Literature Search Stage
The literature research was done using PubMed, EBSCOhost (CINAHL, Science Direct), and Google scholar. The search was developed during January 2017 and March 2017 and updated in April and May 2017. A thirty-one-year interval (from January 1985 to December 2016) was adopted as the time frame of published articles in view of the fact that current studies in aged care mostly focus on institutional care. Grey literature (unpublished studies, review papers, policies and memoranda) was included as a source of search. Only studies written in English were considered. The search terms used were elderly care/aged care AND policy AND assisted living AND Cape Coast Metropolitan area/Ghana/sub-Saharan African AND caretakers/caregivers AND community care/home care.
Inclusion and exclusion criteria
Studies considered eligible for inclusion in the review were those that reported findings and presented data on elderly care and on issues and conditions associated with aged persons living at home in Ghana and the sub-Saharan African region. Studies using qualitative, quantitative and mixed methods published in peer-reviewed journals were included. The inclusion criterion for study populations was subjects aged 50 years and upwards but excluding the aged living in the institutions (e.g. nursing homes, convalescent homes, day Centres or hospitals).
2.2. Data Collection Stages
Using the above engine searches, three reviewers with distinct roles undertook the study. The first reviewer, the main researcher came out with the construct idea and appropriate keywords that were in line to help answer research questions. The second and third reviewers were fed with the idea and they also made their input. The first and second reviewers designed a data collection template by means of google folder using the agreed keywords. The two reviewers independently extracted data focusing on the keywords and the title of papers on issues involving the aged in homes and community care (ageing in place) globally. This approach pulled out about a million and a half articles. The procedure was repeated with a time frame limited to 1985 and 2016. A total of 490 articles were accepted by the two reviewers. The data was edited, those that were overlapping had the duplicated ones removed thereby arriving at 391. To further narrow the articles to be considered for the study, another template was designed with limitation in geographical access to sub Saharan Africa and to aged being cared for in the community (ageing-in-place) looking at abstract only. Reviewers started abstract screening and realized that there were still 31 studies that overlapped and were subsequently removed. So abstract screening started with 360 articles. Abstract of papers meeting the inclusion criteria were obtained and independently reviewed by the first and second reviewers. This phase generated 128 papers after rejecting 232 papers which did not meet reviewers laid down criteria. Data was again edited, and duplicated papers were removed. The third reviewer always met the two reviewers for discussion before a next phase began. After a decision was reached by the three reviewers the 128 papers were given a full text review taking into consideration the research questions and issues of caregivers in assisted living, Ghana and home care. Eighty-seven studies were rejected because they were studies that concentrated on caregivers and restricted to SSA but not on care of the aged. Forty-one papers were conclusively accepted by the reviewers after it was edited, and duplications removed. The team decided to intuitively read selected articles considering the geographical location of the study and excluding data from institutional care. 18 papers were finally agreed on to be used by the reviewers for the study. From an initial total of 391 studies, 304 were excluded because on closer inspection they did not fully meet the inclusion criteria, resulting in an eventual total of 128 papers of which, 41 were conclusively accepted for the review and 18 finally agreed with.
2.3. Data Evaluation Stage
Finally, 18 completed studies were identified for inclusion as shown in the flow of studies presented in Figure 1. To validate the quality of the eighteen articles, a checklist of 21 items, satisfying five sections from mixed methods appraisal tools (MMAT), was used to inform judgments on the quality of each article regardless of study type.
Patient and public involvement—No patient involvement
Each of the included articles was independently reviewed for quality by the two reviewers and classified as being good (2, 4, 6, 9, 18, 28, 30, 35, 36, 43), satisfactory (12, 29, 31, 38, 39) or having some limitation (1, 32, 41). When the quality assessment was finished the team had a face-to-face meeting to analyse the findings to establish a full harmony. The review showed scanty literature in caring for the aged in sub-Saharan Africa, and because the purpose of the search was to extract knowledge about the evidence of documented literature on the quality of care of the aged, only (n = 18) articles were included, which is a limitation of this review. Regardless of the approach, the studies were either a case control study or an exploratory descriptive design, only four were critical review papers.
2.4. Data Analysis Stage
Following the PRISMA evaluation, analysis of the studies was developed inductively, focusing on how the aged are cared for in their own homes. The data analysis included reduction, display, comparison, conclusion-drawing and verification of the data  . In the first step of the analysis, the primary sources examined. Predetermined words used to extract data from the specified sources were given other possible meaning in a compiled matrix by the first author. Data from the two reviewers were merged into a single file for display and cleansed to the best of the reviewers’ ability to serve as the starting point for verification. Verification was done by the three reviewers by rigorous discussion and finally agreeing on the 18 papers to be considered for analysis. Rigorous examination of the displayed data from the two reviewers was put into themes. The themes were developed taking into consideration type of study, region of study, number of study participants/respondents and similarities and differences between outcomes in the data. This process of data visualisation and comparison provided additional clarification of empirical information emerging from initial interpretation by the reviewers. Six themes emerged: neglect of the aged, aged caring for younger generation, aged living arrangements, government attitude, preparedness, and care of the aged in Ghana, as presented below. The analysis was confirmed through a discussion among all reviewers.
Description of the data
This scoping review found in the data selection seven qualitative studies,
Figure 1. Modified PRISMA framework for the review.
seven quantitative and four critical reviews, each using either an exploratory descriptive design or a case study design. Articles were limited to the sub-Saharan African region: Ghana (seven studies), Nigeria (two studies), South Africa (two studies), Botswana (one study), Kenya (one study) and sub-Saharan Africa (five studies which included Ghana in the study). Most studies focused on caring and health seeking behaviours of the aged. No substantial differences were found between the themes dealt with in the studies despite their diversity of the regional contexts. Number of participants or samples sizes in the studies varied from 5 (Dosu) to 6206 (Gómez-olive’). In all the studies, the aged were mostly women, with age ranging from 50 years to 79 years.
Evidence of Care
Theme 1: Neglect of care for the aged
While strong arguments exist for giving high priority to health of older people aged 60 years and above, it is equally the ease that, when their health deteriorates to the point where they need care, the responsibility is likely to fall on younger female kin, whose own health, employment and education opportunities will in turn be affected  . Aboderin and Bread make the point that, in sub-Saharan Africa, impaired health in old age affects not only the older individuals themselves, but also families and communities and the wider prospects for development. A large proportion of older Africans lack the requisite care; results of the WHO study on Adult Health and Ageing in Ghana, showed that 96% of older adults with hypertension do not receive adequate treatment for the disorder  . There are also certain aspects of behaviour that are unacceptable, such as neglect of the elderly and lack of respect for the elderly  -  . Caring for people in need is closely linked to the concept of ubuntu and was seen among people in Mpumalanga, South Africa, as an obligation and as a symbol of respect  . In the absence of formal care, older women are the primary caregivers in the community, and have a network of friends and relatives they care for when support is needed  . Care is also extended to older people who are neglected due to frailty or confusion and who lack support from family  . Sometimes older people are abandoned and neglected by their families, and face physical abuse, and widows in particular are more likely to suffer abuse, and some cases may be subjected to accusations of witchcraft  .
Theme 2: Aged caring for younger generations
The caring function is very important in everyday settings of poverty or labour-related parental absence. In the urban slums of Nairobi, Kenya, around 30% of older women and 20% of older men (aged 60 years and over) care for one or more non-biological child  -  . A significant proportion of older adults live with orphaned grandchildren; across the sub-Saharan African region, around 8% of older adults live with a grandchild who has at least one deceased parent, while 1.7% lives with a grandchild whose parents are both deceased due to the AIDS epidemics  . Some older people work because of economic need while others may be attracted by the social contact, intellectual challenges, or sense of value that work often provides  . Elderly women are usually caregivers, instead of being able to relax and enjoy the fruits of their labour. They expect to depend on their children but instead have to care for these children, which is unexpected role changed and very taxing  . Summary of the 18 accepted articles for the study is tabulated study type, author, date, country, aims, description of sample size, weakness of article and these can be located in Table 1.
Table 1. Summary of articles included in the study.
Theme 2: Aged caring for younger generations
The caring function is very important in everyday settings of poverty or labour-related parental absence. In the urban slums of Nairobi, Kenya, around 30% of older women and 20% of older men (aged 60 years and over) care for one or more non-biological child  -  . A significant proportion of older adults live with orphaned grandchildren; across the sub-Saharan African region, around 8% of older adults live with a grandchild who has at least one deceased parent, while 1.7% lives with a grandchild whose parents are both deceased due to the AIDS epidemics  . Some older people work because of economic need while others may be attracted by the social contact, intellectual challenges, or sense of value that work often provides  . Elderly women are usually caregivers, instead of being able to relax and enjoy the fruits of their labour. They expect to depend on their children but instead have to care for these children, which is unexpected role changed and very taxing  .
Kimuna and Makiwane  showed that older people in Mpumalanga are an important social resource as breadwinners in their households, using their meagre, means-tested pensions and providing basic needs, including health care and education for the members of their households. Traditionally, older people, especially older women, cared for their grandchildren when their daughters and son left work in the fields or in the cities, or when high number of HIV/AIDS-related deaths meant that children needed to be cared for who longer had parents to support them. Kimuna and Makiwane also found that even though the primary aim of the old age pension in Mpumalanga was to give support to older people, it went towards supporting members of their household rather than the needs of the old people themselves, with the pension benefit becoming the main source of household income. Older women heading households provided care even though they lacked the necessary resources to sustain a family and were in most cases widows who had not inherited anything from their husbands or from the parents of the orphaned grandchildren under their care  .
Theme 3: Aged living arrangement
There is evidence that education promotes living independently, often cited as a feature of modernization  . The urban elderly are more likely than rural counterparts to live alone or with children only. The results here could be due to cultural norm, with better-off family members being required by tradition to support other family members, and which may include co-existence  . Zimmer and Dayton  add that it is women rather than men and may therefore have more children-in-law and grandchildren with whom to live. Another possibility is that when her husband dies, a woman moves in with her extended family. Men living with children and grandchildren are tied to living with spouse. Household composition is also related to well-being: Well-being of elderly people who are separated is inferior to that of any marital groups. In rural parts of Nigeria, it commonly occurs that women or men who are separated and lived alone are not accorded respect and are often stigmatized and marginalized in ways that can affect their health; thus, they may experience psychological stress which can have a serious effect on their well-being  . Despite increasing urbanization, older people in Ghana lived in rural areas where they may experience psychological stress which serious effect on their well-being  . Despite increasing urbanization, older people in Ghana live in rural areas where health and social services are inadequate  .
Theme 4: Government Attitude
Government indifference toward the elderly leads in some instances to total neglect of their health and financial needs. In Nigeria, no policy or social security system has been put in place to care for people in their old age. The primary health care system makes no special provision for health care for the elderly, and even in the overall health policy no special mention is made of the elderly  . According to Adebowale et al.  , education has a strong positive influence on their well-being; educated elderly people are likely to receive higher monthly pension, be more knowledgeable about prevention and treatment of diseases, and live in a clean environment. Kabir and colleagues have documented that education is inversely related to the incidence of diseases among the elderly (9-6). In the study by Debpuur & Welaga  , most elderly respondents rated their overall health as good, but women were more likely to rate their health as poor. Some older people reported that they had been affected by HIV/AIDS through loss of community support and neglect of their day-to-day needs  . Formal care provision for disabled elderly persons living in the community is not available in Nigeria. Out of the 263 persons who were classified in a study as having any form of disability, 52 did not have a caregiver to help in area of limitation; of these 52 persons, 61.5% were women and 38.5% were men  .
Theme 5: Preparedness for old age
Former employee of public or private organization who are entitled to a gratuity or pension from monthly salary deductions while in active service often never receive these dues because of bureaucratic inadequacies in the organization where they served  . As a consequence of poverty and poor infrastructure, elderly people in Nigeria not only have reduced life expectancy but also spend more of their lifetimes in poor health. Governments have a relaxed attitude to the family structures which have traditionally provided care for elderly are on the verge of collapse. All these factors have an adverse effect on the health of the elderly and compromise their well-being  . For the Ghanaian, a house is a symbol of success, affording its owner respect, love, happiness and security in old age; it is a thing of beauty and it provides a sense of belonging, of ‘home’, both physically and symbolically  . When a participant was asked ‘can a building have influence on the funeral of a person?’ the response was Yes. People with houses have more properly organized funerals than those without a house. If you don’t have a house, any kind of funeral can be organized for you. “A building is like a human being. If you dress it well, it will look nice”  . However, the dream of having somewhere safe to stay when one is old and dependent does not always come true. Van der Geest  was proudly informed by a respondent that when he was a child it was his dream to build a house for himself, which he did by age 45, ‘And now I have my peace, comfort and everything’, Two years later, however, the informant was one of the loneliest and most miserable elderly individuals in the entire research study: He was practically blind, his wife had died, and all twenty of his children were living elsewhere; he spent the whole day lying on a bed without a sheet or cloth  .
Theme 6: Care of the aged in Ghana
The relative merits of maintaining the tradition of home-based care versus embracing a transition to long-term institutional care (nursing homes or aged-care homes, frail-care homes, etc.) are increasingly a matter of controversy. For most African and African-descent ethnicities, caring for family in the home is regarded as a moral imperative and a family responsibility  . This strong sense of family responsibility is even seen in African- Americans in United States. Traditionally, support in African culture takes the form of intergenerational reciprocal care  , which is an obligation and sign of respect  . An ethnographic study revealed that some South Africans wanted to stay in their homes and did not want to go to an old-age home (i.e. nursing homes) and frail-care services were available in SA. Traditional intergenerational caregiving still came foremost in providing home-based care and community-based care for the sick and the frail. However, as lifespans increase in step with global ageing, family responsibility for maintaining home-based care will be difficult to sustain and more and older South Africans will thus become institutionalized. Urbanization leads to a transition from traditional home care to institutionalized care, as children and grandchildren caregivers relocate to cities  . Increasing numbers, globally, of service-users of long-term care (permanent, continuous care of older adults in their later years), will in turn require more provision of long-term care. Interestingly, nursing practice in the United States has begun a reverse migration, whereby an increasing amount of nursing care takes place in the home and the community rather than in institutional facilities. Hospitals will be accessed only for acute illnesses that cannot be safely or effectively managed at home  .
It is difficult to get a clear picture of the care that old people in Ghana enjoy. Some have been successful in life and have been able to give their children a good education, resulting in a good social position. These people are usually fortunate enough to have their children taking good care of them, buying them everything that they need, including clothes and luxury items such as clocks, watches, radios, lanterns and ornaments  . The houses of such people are often filled with children, nieces, nephews and grandchildren. Their good quality of life attracts relatives who bring company and presents. The quality of life of the less well-to-do elderly is harder to quantity. There are elderly people who seem to continuously contradict themselves, complaining at time that they have no money for food, that their children are far away and seldom visit them, and that their children do not send them enough money to live comfortably, and at other times praising their children for the way they look after them. In admission that their children neglect them would call shame on them. Many emphasized that their children do what they can to assist them  . Whether it was the gloomy side of their situation or the bright side that they emphasized when they were interviewed depended on the situation in which the interview took place. If an old person’s relationship with the interviewer was easy and there were no other people listening, the interviewee would be more inclined to reveal his or her worries; otherwise they preferred to keep up a respectable appearance  . The real situation in receiving care in Ghana is far more complex. Several people are usually involved in providing care, and who does what is very much a matter of who happens to be around. Care is often managed on a day-to-day basis, with considerable improvisation  .
Despite the large number of articles that focused on the issue of the aged, only a few addressed caring of elderly people living at home. The studies reviewed were studies from countries in sub-Saharan Africa that focused on quality of care for the aged. In these studies, the following issues were considered in relation to quality of care for the aged living at home: neglect for the aged, aged people caring for younger generations, aged people’s living arrangements, government neglect, preparedness and care of the aged in Ghana. Not all 18 studies dealt with every one of these themes, but in at least nine of the studies most of them were involved. Neglect of the aged, aged people caring for younger relatives, and aged people’s living arrangements were dealt with in article 4, 34, 1, 18, 2, 9, 28, 29 and 30. Government neglect, preparedness for old age and care of the aged in Ghana were dealt with in article 9, 6, 30, 31, 32, 34, 35, 36 and 37. However, only one study (article 36) explicitly spelt out the type of care elderly people received at home. It was easier to identify support given to younger relatives by the aged and how tired they get. The reviewed article also showed the elderly people’s meagre pensions go to support the welfare of younger relatives, leaving the pensioners with nothing. Men are not strong and brave enough to cope with loneliness and the shame of being single, so they are always either married and living with a spouse or living with a single child  . In the Ghanaian Akan community, investment in building a house thinking that it will be a guarantee of care in one’s old age may be to the detriment of care for one’s children, so that one ends up being left alone in one’s old age  .
The results showed a lot of consistence among these variables, possibly reflecting similar results emanating from use of different data collection instruments and different criteria     and  . Attention was paid to generalization, interpretation and application of the results obtained. Within the broad focus on the care of the aged in their home context, a lot of the emerging data have been developed on frail, demented, adult caregivers and in aged watch information. This meant that data needed to be used with discretion. We suggest that subsequent studies on the elderly should focus on their welfare and on how they thrive in the community and deal more specifically with the Sub- Saharan African region in relation to existing issues. To reduce bias and increase the depth of the analysis, studies were peer reviewed. Hand searching of journals was not carried out, this may have left out some relevant research. However, conducting a scoping review is no guarantee that all relevant articles will be found in the investigation, because there could be papers published in other languages than English that could be relevant to the topic under study.
This review provides an up-to-date overview of the literature on the care of elderly people living at home and indicates there is no obvious difference in the care given to these people, regardless of the cultural context. The review identified useful literature on care of the aged in Ghana. Policy makers needed to emphasise the importance of looking after senior citizens. They also need to help Ghanaians plan properly for their own old age, regardless of where they live and they must be knowledgeable about the needs of elderly in policy making and decision making, especially in an era scarce resource.
4.2. Summary and Conclusion
The review focused on exploring and describing the status of published literature related to the care of the aged who lived at home, using the framework proposed by Moher et al. (2009). Due to lack of evidence of the care of the aged in Ghana in documented literature, the study scope was increased to cover the SSA region. Six themes emerged: neglected of aged care, aged caring for younger generations, aged living arrangement, government neglect, preparedness for old age and care of the aged in Ghana. The review shows that there is lack of information and lack of adequate preparedness for aging on part of the individuals in Ghana. The review also indicates that stakeholders need to give serious attention to taking care of the aged. Notwithstanding resources constraints, attention should be given to the aged and their family members should be encouraged to understand the need for older relatives. There is a need to take note of the information provided and train caregivers and nurses in caring for the elderly. The review also showed a shortfall in studies about care of the elderly at home, identifying a lack of high-quality scientific evidence in these studies. Apart from studies relating to former government employees, no research has been done on preparedness of the elderly for their present stage of life. Challenges for the future are to broaden and enhance the scope of research in this area to provide effective support to intervention projects, services and care to the aged.
Ethical Approval and Consent to Participate
The study was approved by the Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal (HSS/0608/016D) and the Dodowa Health Research Centre (IRB Ghana Health Service) of Ghana (DHRCIRB/06/06/16). Voluntary participation from participants was not accorded because the review used data from various engine search of publications that concentrated on care of the elderly in the SSA.
Availability of Data and Material
The datasets used and/or analysed during the current study are available from the corresponding author (IKA) on reasonable request.
IKA designed, implemented the review, analysed the data and drafted the manuscript. BN and AEN helped in designing the project, analysis of data and read through the manuscript.
Strengths and Limitations of the Study
The strengths of our review are the extensiveness of our data searches which went as far as using five search engines.
Another strength is the inclusion of all methodological studies by the two reviewers.
The exclusion of other languages apart from English could have made the study more rigorous.
The small number of studies found may reflect another limitation of available body of research on the caring of the aged in their own home or ageing in place.
Some studies used did not indicate enough sampling to support their interpretations and conclusions, but they were still included in the results.
Abbreviations and Acronyms
PRISMA—Preferred Reporting Items for Systematic reviews and Meta-Analysis;
PICO—Population, intervention, comparison and outcome;
HIV/AIDs—Human immunodeficiency virus/Acquired immunodeficiency Diseases;
MMAT—Mixed methods appraisal tools.