Perspective Chapter: Social Ageing Challenges Faced by Older Adults Exposed to Conditions of Underdevelopment and Extreme Poverty

Abstract

Ageing is a crucial era at the last stage in the lifespan of human beings, particularly for those who survive and pass through other stages of the life cycle. There has been a considerable increase in the number of people who reach this stage and live longer across the globe. The rampant increase of this population group has yielded unprecedented challenges to the both the developed and underdeveloped world due to the psychological, health, economic and social needs of this population cohort. In most developing countries, these social challenges faced by older the older persons are to a certain extent mitigated by the cohesive structure within the community. However, the social, living arrangements from families and communities that are available to the older population are under threat due ongoing demise in the traditional forms of care is as a result of families having suffered from the impact of social change, including urbanisation, geographical spread, migration, the trend towards nuclear families, and participation of women in the workforce. Ageism as a concept is viewed as the theoretical, policy and practical underpinning for how ageism is perceived and dealt with. The negative stereotypes that often shape the theoretical framework with regard to ageism is the root cause of negative attributes associated with ageing. This chapter therefore, concludes with the key recommendation that governments from the developing economies should strive towards development of policies for the protection of advancement of the wellbeing of older population and make resources available for the implementation of the policies.

1. Introduction

Ageing is one of the essential element of the life cycle of a human being. it is regarded as the last stage in the lifespan of human beings, particularly for those who survive and pass through other stages of the life cycle. There has been a noticeable increase in the number of people who reach this stage and live longer across the globe. The phenomenon of continued increase in the population ageing is prevalent in both developed and developing parts of the world. The rampant increase of this population group has yielded unprecedented challenges to the both the developed and underdeveloped world due to the psychological, health, economic and social needs of this population cohort. Therefore, this may have serious implications for the social policies of governments from both the developed and developing countries as they may find themselves compelled to devise means to secure more resources to meet the increasing needs associated with the growing ageing population. The increase in the population ageing has created many challenges for older persons, especially in developing countries as they are mainly characterised by underdevelopment and poverty. However, there are convergent challenges besetting the ageing population which are detrimental to their well-being and these may range from inadequate healthcare and discrimination as a result of ageism. Despite all the challenges, the population ageing is faced the increase in their numbers has become a global phenomenon.

2. Methods for data collection and analysis

The data used for the writing of this chapter was collected through a literature review. The purpose of this section is to describe the data collection and analysis methods applied during the review of the literature by getting into details about the exact procedures and processes that were followed during data collection and analysis.

2.1 Data collection

The type of data review that was utilised is narrative review. Sylvester et al. [1] describe narrative review as the ‘traditional’ way of reviewing knowledge. On the one hand, the purpose of the narrative review is to summarise or synthesise what has been written on a particular topic, and on other hand, does not see seek to make a generalisation or cumulative from what it is reviewed [2]. It can be helpful in gathering together a volume in a specific subject area and synthesising it [3]. To achieve the objectives of this study, the author utilised the narrative review in order to summarise the literature pertaining to the social challenges faced by the older adults in developing countries. Through the narrative review, the researcher’s undertaking is to accumulate and synthesise the literature to demonstrate the value of a particular point of view [4]. The narrative review was used to summarise the assembled data from the literature to demonstrate social challenges of older adults across the world and in the developing countries. Lastly, the narrative review can be used for writing of educational articles for practitioners to be updated with certain topical issues [2]. The data collection process was implemented through different stages, namely, literature review design and conducting of the review.

2.1.1 Review design

The process of data collection began with the designing of the literature review. This stage of designing literature was implemented by searching the internet for appropriate articles. Mainly, this stage is devoted to searching for the literature and making decisions about the suitability of material to be considered in the review [5]. The appropriate articles were searched by using the phrase ‘population ageing in developing countries’ and challenges of ageing in developing countries. According to Snyder [6], a search strategy for identifying relevant literature must be developed by selecting search terms and appropriate data base that assist in deciding on the criteria to use about which elements of data to be included and excluded. The search terms for identifying the appropriate data could be words or phrases used to identify articles, books and reports and these words, terms and concepts should be related to the research question [6]. Out of the various sources derived out from the search, the author selected those that under the search phrase had words or concepts that relate to healthcare, social protection, socio-economic situations and challenges faces by ageing population in the developing countries. The reason for the author to identify certain sources is that some of the sources were not relevant answering the research question. Snyder [6] asserts that because the initial search almost yields many articles, a strategy may be needed to identify, which are actually relevant and, therefore, inclusion in the literature review should be guided by the research question. As a consequence, the quality of the literature is dependent on, among other aspects, what literature is included and on how it was selected [7].

2.1.2 Conducting review

This stage of data collection refers to the process of how the data was extracted by the author from the literature sources that were selected for review. This stage of data collection involves extracting applicable information from each primary source included in the sample and deciding what is relevant to the problem of interest [8]. In the case of journal articles, the author would first read the abstracts of the journal articles in order to determine whether were there any summary of the literature review, findings and discussions that are related to the healthcare, social protection, socio-economic and challenges faced by older adults in developing countries. With regard to the reports of the international organisations such as the United Nation’s Agencies, the author would first read through the executive summaries and within the table of content to identify the most relevant titles and subtitles for review. The author also made use of the lists of references from some of the journal articles to identify other articles that because of their titles were considered valuable for the review. To avoid reading each piece of extracted literature in full, the author selected to read the abstracts first, made selection of the relevant literature to be reviewed based on the abstracts read and subsequently read the full articles that he finally selected [6]. The nature of data that is recorded from extracted sources depends on the research question [9].

2.2 Data analysis

The data analysis is conducted after literature review was conducted and the decision is taken about the final sample and which standardised means of extracting appropriate information from the literature sources to be used [6]. The data were analysed through identification of key concepts and themes that persistently featured prominently in the literature sources. The concepts identified showed significant relevance to the research question of the chapter. Webster and Watson [10] suggest that when the reading is complete, it must be followed by synthesis of the literature, develop a logical approach to grouping to representing the key concepts that have been identified and followed by discussion of each identified concept. The reciprocal translation analysis was applied as a data analysis technique to identify key metaphors, themes or concepts in each study or literature source [11]. Some of the concepts derived from different literature sources that share common relationship were brought together and discussed under one broad theme. The identified concepts were subsequently discussed as broad themes and sub-themes. The reciprocal translation analysis involves the translation of concepts from individual studies into one another and in the process evolves overarching concepts or metaphors [12].

3. Population ageing: a global phenomenon

The proportion of the world’s population aged 60 and above is increasing more rapidly than in any previous era [13]. This growing trend among this cohort of the world population disregards borders including developed, developing and underdeveloped regions [14]. Population ageing in developing countries is growing at three times the speed of population than in developed countries [15]. This rapid increase even transcends to the world’s poor countries wherein those who survive the disease of infancy and childhood have a very good chance of reaching ageing [13]. The United Nations Population Division has estimated that the number of older adults over the age of 60 years will rise from 800 million (11% of the world’s population) in 2011 to over 2 billion (22% of the world’s population) in 2050 [16]. The number of older adults aged 80 and above is estimated to increase by 270% over the same period and with the greatest increase of older persons expected to occur in low and middle-income countries.

The contributing factors to the increase in the ageing population are declining fertility and increased life expectancy [17, 18]. The improved increased understanding of medicine, major developments in medical technology in recent years [19] and prevention of diseases previously responsible for huge numbers of premature deaths [13] are attributed to the increased life expectancy. While life expectancy has substantially increased, the total fertility has fallen below the stable rate level [19]. The steady increase in the ageing population has enormous implications for population demographics, which may have a direct bearing on already over-burdened global healthcare and social services systems. Population ageing will have a profound impact, especially as many governments around the world have yet to put in place the policy framework to respond to the challenges brought by the ageing of their populations [20]. Bennet and Zaidi [20] further argue that there is a disparity between advances in longevity and in the development of policies that protect and empower older persons. There is a deficiency in the awareness of the potential of older persons in being net contributors to the development process, especially in sub-Saharan, Middle Eastern and Asian countries.

4. Overall social challenges facing older persons

The increasing ageing population indicates that the society may have a large number of people who require special needs due to disability as a result of chronic illness and physical immobility due to old age and mental-related illnesses. These conditions may have a direct impact on the health care and social protection systems.

4.1 Physical immobility and impaired mental ability

Older persons are likely to experience chronic conditions, physical degeneration and frailty as a result of the ageing process [21]. It is also noted by Nabalamba and Chikoko [22] that population ageing is highly correlated with physical and mental disability and an increase in the number of health conditions. According to the 2006 World Health Organisation’s projections, the diseases associated with the ageing such as Alzheimer and other forms of dementia accounted for 6.3% of disability-adjusted years. This percentage is proportionately higher than the contribution to the disability-adjusted years of HIV and AIDS (5.5%), all cancers (5.3%), heart disease (4.2%) and respiratory diseases (4.0%) [22]. Most notably, it is the contribution of Alzheimer and other forms of dementia alone as it accounts for 12% of other neurological disorders [22]. There is a likelihood also to see an increase in other chronic conditions such as strokes, chronic obstructive pulmonary disease and diabetes mellitus [23]. The increase in the number of older persons with chronic conditions will account for greater disability [23]. Physical limitations that older persons endure may lead to functional decline and the inability to care for themselves in addition to increasing risks for falls, a decline in physical activity, depression, loneliness and hospitalisation [24]. Both the increase in physical disability and chronic illness may necessitate the need to provide increased health care and social care as the management of long-term chronic conditions, and related disabilities require a substantial amount of resources (both human and financial) from governments, communities and families [22].

4.2 Inadequate provision of healthcare services

Despite the poor quality of life experienced by many older persons and the challenges faced by the planners and professionals in providing the much-needed health and welfare services for the growing number of frail older persons, it is disturbing to notice the lack of enthusiasm in promoting the joys and triumphs of older persons in the latter part of the twentieth century [13]. The poor quality of life experienced by older persons is characterised by challenges such as inadequate retirement pension, social exclusion, lack of access to basic services, health care, food insecurity and a lack of affordable accommodation [17]. Inouye [25] points out at ageism to be a fundamental causal factor for the inadequate and inappropriate health care services to older persons. Inouye [25] criticises ageism for its adverse impact on the healthcare system by leading to inequities in healthcare delivery and poor clinical outcomes. In the context of healthcare, ageism is defined as age-related discrimination, including explicit age cut-offs for treatment or resource allocation or implicit age-related biases, which limit access or create a barrier to healthcare [25]. The above assertion about ageism is confirmed by a landmark study on COVID-19 whereby healthcare professionals were found to have been significantly more likely to withhold life-sustaining treatments for older persons compared with younger persons even after controlling for prognosis and patient preferences, a practice that is claimed to have persisted to date [26]. Ageism has also led to inadequate or inappropriate care and decreased or delayed access to health care services, resulting in decreased survival, power quality of life, increased cognitive and functional impairment, emergency visits and hospitalisation [27].

The older persons also suffer depleted welfare services and a lack of family and community-based care support. This contributes towards making the older persons consistently becoming the poorest in all societies and material security is one of their greatest preoccupations [13]. Despite experiencing the same lack of physical essentials, assets and income suffered by other people, they are without the resources that younger, fitter and more active adults can use to compensate [13]. The problem of poverty among older persons is not only restricted to material needs. Their inability to participate effectively in economic, social and political life finds them socially excluded and isolated from decision-making processes and thus, not only affecting their income and wealth but also contributing to poor housing, ill-health and personal insecurity [13].

The lack of community and family-based care, which used to be rooted in traditional family and community-based care, also negatively impacted the psycho-social and economic well-being of many of the older persons. Ferreira [28] points out that diminishing care that used to be provided to older persons by family members is a result of changes in family structures ushered in by modernisation and urbanisation, particularly in developing countries. Globalisation is also considered to have contribution to the reduction of the family into a non-viable economic institution for older persons as it promotes values of individualism and the pursuit of self-interests [29]. Sen [30] also observes from a vantage point the challenge of strain experienced by families due to chronic and complex problems associated with ageing as they would put pressure on authorities to put their older persons who require more extensive care in residential institutions. The broad overview of the adverse situation of the increasing ageing population as described above has also specific features peculiar to the context of the developing countries.

5. Ageing in the developing countries

It is estimated that the number of older persons in developing countries will be more than double over the next century reaching 850 million by 2025, which will be 12% of the total population [13]. The number of older persons aged 80 years and above is expected to increase by 270% in 2050 with the greatest increase of older persons in the developing countries [16]. Patel [17] attests that the majority of the world’s population of older persons (60%) live in developing countries. In Africa, alone projections show that the older adults could account for 4.5% of the total population by 2030 and nearly 10% by 2050 [22]. Sen [30] argues that though population ageing is a feature in all countries, its consequences are more devastating in poor countries where it is occurring at a very fast pace. This growth in the ageing population in the developing countries presents significant challenges to economic resources and other significant competing health and social challenges [31, 32]. The population ageing poses great challenges to society concerning for example health care, caregiving and a suitable pension system especially for developing and underdeveloped countries that often have limited resources [33]. The Madrid Plan of 2002 provides the framework to incorporate discussions of population ageing into the international debates on development and the implementation of national policies to respond to the challenges of building societies for all ages [34]. The Madrid Plan of 2002 gives priority to ensuring that ageing is made an integral part of the international development agenda; to advanced health and wellbeing into old age and to creating enabling and supportive environments for older persons [34].

5.1 Poverty

The probability of being poor at old age does not only depend on being covered by a pension scheme [34]. The degree of poverty among older persons varies with the level of educational attainment, gender and living arrangements [34]. Nabalamba and Chikoko [22] argue that the efforts to understand poverty have dominated much of the debate on development in recent years, however, the poverty experienced by the majority of older persons, particularly in developing countries, has been largely ignored as a result of competing interests such as education, health, housing, sanitation and water as they were considered as pressing. Hutton [35, 36] affirms that the older persons in developing countries experience disproportional high levels of poverty as it is estimated that about 80% of older adults have no regular income. The poverty facing the population of older persons is exacerbated by a plethora of other urgent and pressing demographic problems such as rapid population growth, high youth population and high unemployment; high infant and child mortality rate and high maternal mortality rates [22]. The increasing population ageing in developing countries has significant implications for poverty reduction strategies [37]. Nabalamba and Chikoko [22] affirm that these urgent and pressing challenges have resulted in governments and societies deprioritising older persons in favour of other more vocal age groups. Nabalamba and Chikoko [22] further aver that government development policies tend to favour expenditure that invests in the long-term productive potential of the younger adults because of high levels of unemployment among this age group and being also aware of their potential to create social and political unrest if their demands and life chances are not fulfilled. The undervaluing of the contribution of older persons by policy makers and planners marginalises them from development thinking and policy and thus contributes to the persistence of the poverty among older adults [38].

Barrientos et al. [38] identified a number of trends in developing countries that could make matters worse regarding old age poverty. Barrientos et al. [38] point out at the economic adjustments brought by globalisation, changes in labour markets and especially social sector reforms have in different manners adversely affected the livelihoods of older persons. The absence of formal pension coverage causes the majority of older persons in developing countries to face considerable income insecurity [34]. The poverty situation worsens for the unprotected who are often small farmers, rural labourers and informal sector workers as for them, the notion of retirement does not exist [34]. As they had not held any formal jobs, they do not qualify for a pension and if they were unable to accumulate enough assets, they have no choice but to work on their own [34]. The situation of poverty often persists for those who were already poor during their working years as they are likely to remain poor in old age [34]. Lastly, those who might have lived above the poverty line but were unable to build up precautionary savings to finance consumption during their old age face the risk of poverty as they grow older [34].

5.2 Healthcare

Despite few studies that have been conducted, there is a general consensus in the literature that access to care and health system responsiveness in developing countries is poor and the healthcare system frequently fails to meet the needs of older persons [32, 39]. Developing countries experience high incidents of communicable diseases such as hypertension, obesity, heart disease and diabetes [40]. Boutayeb [41] describes the combined effect of chronic communicable and non-communicable diseases as a burden for developing countries.

Older adults in developing countries have limited resources to access healthcare [34]. Access to health becomes a major challenge for those who reside in rural areas as the hospital resources are concentrated in urban areas [40]. The lack of access to healthcare is aggravated by the inadequate healthcare workers in rural areas and such workers are difficult to recruit and retain [40]. Henriques-Camacho et al. [40] identify the lack of literacy among older persons in rural areas to have a significant role to decrease access to health and similarly, large geographical areas and distant villages are a challenge to providing access to healthcare in developing countries.

5.3 Social protection

In developing countries, alone about 342 million older adults lacked adequate income security and the number would rise to 1.2 billion by 2050 if the coverage current mechanism design to provide old age income security is not expanded [34]. The case in point is the African continent, which is not well prepared for a major increase in its ageing population with regard to expanding social pension coverage [22]. The bigger challenge for Africa is the decline of informal systems of social protection in the form of cash and support from both extended family and community sources [22]. Until recent, contributory pension schemes cover very few older persons due to the informality of most livelihood activities and employment and most of the older persons’ societies are pre-dominantly rural and much of the population operates outside the formal social security sector and wage-dependent markets.

Traditionally, especially among African people, the informal social protection has been effective for generations as it provided a major share of support to the older parents and the most vulnerable [22, 42]. Shetty [42] asserts that depending on various cultural practices, in countries where it is expected for children to look after their older parents, the evidence shows that they do better when living with their families. The provision of social protection by family members is still the basis for determining the nature of social protection policies aimed at older persons in many developing countries. This increasingly filial responsibility of family members to care for the older persons in developing countries is not just culturally expected, it is often legally mandated [42]. Shetty [42] refers to the Maintenance and Welfare of Parents and Senior Citizens Act of 2007 in India, which requires that adult children who neglect their parents either by refusing to make provisions for their care, or by inadequately caring for their older parents in their homes, can be imprisoned up to 3 months or fined an amount of US$10 or both. Through the established tribunals older persons can take their own children to court to demand maintenance of up to US$220 a month and similar laws exist in countries, such as Singapore and China [42]. Despite the harsh nature of these laws, there could be an argument in favour of them given the severe lack of social security and pension schemes as well as government-funded infrastructure for older adults such as old age homes and geriatric clinics [42]. In Southern Africa, the care for older persons is a shared responsibility of the nuclear family, government and voluntary organisations [29]. For example in Lesotho, the government through the Department of Social Development has the responsibility for administering welfare programmes, including personal social services for older persons and it is separated from the old age pension scheme as it is administered by a different Ministry, the Department of Pensions within the Ministry of Finance [29]. Lesotho’s universal old age pension scheme caters exclusively for older persons who are 70 years and above [29]. There is also a public assistance scheme for vulnerable groups in the population including older persons that are administered by the Ministry of Social Development in Lesotho [29]. The public assistance scheme is also means-tested and as a result, not all applicants qualify for it and this inadvertently excludes many older persons as it is operated under very strict eligibility criteria and is always poorly funded [29].

5.4 Ageism

Despite the contributions, many older adults have made to society and their diversity, negative attitudes about older persons continue to persist across societies and are rarely challenged [43]. Ageism is one barrier that prevents older persons from acquiring the essential care and services and it also discourages older persons from active ageing as if often undervalues their active role in society. Ayalon and Tesch-Romer [44] define ageism as stereotypes, prejudice or discrimination against (but also in favour of) people because of their chronological age or on the basis of a perception of them as being old [45]. Barrientos et al. [38] affirm that for individuals, the ageing process is an inescapable biological reality but is the social construction of individual ageing that generates both constraints and opportunities. Ageism can be implicit or explicit and can be expressed on a micro, mezzo or macro or macro level and thus underlines the individual, social and institutional significance of the phenomenon [46].

Chang et al. [27] argue about the rising prejudices over the years that have been spread concerning the older persons who are seen as thwarting productivity and social dynamism. Ageism creates stereotypes about ageing, which go beyond influencing behaviour and ways of managing the care for older persons’ population, but can also impact personal experiences of ageing [46]. The negative self-perceptions of ageing involve reduced self-efficacy, which may directly result in depression [26] along with repercussions for physical illness due to effects on immune system [47]. Ageism tends to reinforce social inequalities as it is more pronounced towards older women, poor people or those with dementia [48]. Ageism as it relates to older persons is most prevalent in the health care sector [49]. This could be attributed to the fact that healthcare utilisation and whereby costs are higher among older persons compared with younger adults and are expected to increase further with the life-span [50]. The ageism phenomenon has led to argument by some philosophers that older adults pose a huge burden on the healthcare system [51]. Harrigan et al. [52] regard healthcare professionals as being more likely to communicate in patronising and disrespectful ways with older persons as compared to younger adults.

5.5 Gender

By 2050, most of the 80 years old will live in rural areas and most of them will be women [42]. This is due to women living longer than men worldwide and this gender bias is not specific to low-income countries, but in developing countries, there can be less autonomy and less financial independence than in the developed countries [42]. According to Srivastava et al. [53] globally, there are about 90 million older persons who are estimated to be living alone of which about 60 million are females. In addition, a great majority have only been in one union and often decide not to marry after the spousal bereavement at older age [54].

The process of ageing affects males and females differently due to economic, social and cultural factors. The study conducted in five countries (China; Ghana; India; Russia and South Africa) showed that the male participants across generally reported a better quality of life as compared to their female counterparts across all five countries [33]. The study results indicate that gender inequality regarding the quality of life exists and that gender may play a critical role in the quality of life among older adults in low and middle-income countries [33]. According to Denton et al. [55], previous studies have also argued that men and women are exposed to different cultural norms and social factors. Lee et al. [33] assert that female participants’ overall social status was found to be lower than that of their male counterparts and they were likely to have a more limited income, more barriers concerning access to health care and more responsibilities regarding household chores and these factors could affect their perceived quality of life.

5.6 Widowhood

Intrinsic to the exposure of adult women in relation to cultural and social factors is the phenomenon of widowhood, which has a direct effect on inequality regarding the quality of life among older persons. Widowhood is described by Wilcox et al. [56] as a catastrophic event at any stage of life for the surviving partner with serious repercussions on their physical, economic and emotional well-being, particularly in the first year of the loss or for a longer term in some cases. In spite of that, the emotional response as a result of the loss of a spouse is considered to be different depending on various socio-economic demographic characteristics such as age, gender, widowhood duration, living arrangements, functional ability to perform activities, health status and other factors such as community involvement and economic conditions of the survivor [57]. There is also an assertion that differences between two sexes in depression due to the loss of a spouse are argued to differ according to gender roles as women are found to invest less in their financial security and more in familial relationships as compared to their men counterparts [53]. In many instances, after the bereavement of the spouse, their only source of income diminishes, which increases their economic hardship in old age leading to an adverse impact on their psychological well-being [58, 59].

Widowhood plays a significant role in the poverty of older widows especially in developing countries [60]. Hurd [61] argues that the issue of poverty is particularly trouble-some for the population segment of widows since they have fewer possibilities to recover from a drop in income. In the traditional African society, poverty, deprivation, malnutrition, neglect or isolation among older persons were not common as children, members of the extended family and community members provided care and support for them [62]. The care and support for older persons were seen as collective responsibility and expectation of the entire society [62]. Consequently, upon the death of a husband, a widow relied on her children and members of the extended family for her wellbeing [60]. This responsibility for care and support for older persons was premised on the social relationship and structure of the extended family since it promoted closeness among members, thus reducing the problems of poverty and deprivation.

Nowadays as a result of intergenerational relationships, older widows are currently the most vulnerable and marginalised groups in the rural areas [60]. In contrast to the traditional practice, they are now faced with what Eboiyehi [60] describes as a quadruple danger of being old, poor, widowed and alone. Eboiyehi [60] argues that in some cases the customs that were used to protect them in the past are now used to oppress and exploit them. For example, the poverty experienced by older adult widows can be linked to discrimination in inheritance customs, the patriarchal nature of society and the supremacy of the repressive traditional practices and customary rules [60], which take precedence over constitutional guarantees of equality, modern laws and international women’s human rights [63]. This is often characterised in the rural communities by “chasing off’ and ‘property grabbing’, which become the common features orchestrated by brothers of widow’s husband being driven by greed and deceitfulness as they deprive the older widows of their homes, agricultural land and assets [60]. Therefore, the passing of a husband means a loss of income and property that the deceased spouse owned and left for the widow [63]. The psychological maltreatment of older widows exposed them to become more likely to be in poor health conditions and they are either childless or do not have a son or daughter nearby to provide assistance when needed [62]. Another challenge faced by older widows in Africa and in some parts of Asia is traditional mourning and burial rites involving harmful and degrading treatment that constitutes gender-based violence and they are coerced to participate in these rites through their fear of losing status and protection against being evicted from the family home [63].

5.7 Witchcraft accusations

The witchcraft accusation often laid against older women is rife, particularly in Africa. Witchcraft is defined as the ability of a person or group of people to cause harm to others [64]. Those accused of witchcraft are believed to have the evil propensity to harm innocent persons in an inexplicable concealed manner [65]. They are believed to possess the magical powers to fly at night and travel far and wide to kill innocent people, cause diseases in humans, sudden death, impotence, sickness in animals, bad luck and other misfortunes [65]. It is believed that during the process of harming their victims they are able to transform from human beings into animals, birds, reptiles and insects [66]. They are sometimes blamed and punished for being responsible for strong winds, drought, hunger, misery and all other disasters [67]. In many communities, people who have suffered misfortune, illness or death often utilise the services of soothsayers or traditional healers (sangomas) to identify who in the community has been bewitching them [67]. Unfortunately, in most cases, the fingers are often pointed at older women who then have to suffer the consequences [68, 69].

The rise in accusations of witchcraft and counter-killing of alleged witches is associated with illiteracy [70], poverty, diseases and ignorance [71]. Meels [68] argues that sometimes even rational and literate people do believe in witchcraft especially when events cannot be explained or when people fail to establish causes of complex issues, such as regular misfortunes and failure to succeed in life. The accusations of witchcraft are also associated with demographic, socio-economic, psychological and cultural factors [65]. Mencej [72] points out at factors such as economic well-being and strained relationships among community members play a major role in accusing older women as witches. The challenge of witchcraft accusations represents a serious violation of the human rights of the victims, more particularly in Africa [73]. As a consequence, people accused of witchcraft are subjected to physical and psychological abuse by their respective communities [74]. This witchcraft accusation is the source of unacceptable levels of mistreatment perpetrated against older women in Africa [73]. The older persons that are prone to be accused of witchcraft are those that are too old, have bad health, have red or yellow eyes, wrinkled skin, missing teeth or have a hunchback stance [75, 76].

5.8 Abuse

The abuse of older persons features prominently in the current literature on ageing as it is becoming one of the significant challenges facing the ever-increasing ageing population. The concern about older person abusers increases as the global population ages [77]. It is recognised internationally as an extensive and serious problem, which urgently requires the attention of health care system, social welfare agencies, policymakers, and the general public [78]. The World Health Organisation (WHO) [43] reveals that in a 2017 review of 52 studies conducted in 28 countries from diverse regions across the world is estimated that 15.7% of people aged 60 years and older are subjected to forms of abuse. Rates of older person abuse are reported to be high in institutions such as nursing homes and other long-term care facilities [43] with up to 64% of staff admitting to elder abuse based on self-report. The abuse of older persons is reported to have increased during the COVID-19 pandemic [43].

The definition of older person abuse sometimes often rests upon various professionals to fit the purpose of the specific disciplines, such as legal, law enforcement, medical and welfare. [79]. Chalise [79] adds that as a result of these disconnected viewpoints about the phenomenon of older person abuse, it is a notion that is also understood differently by older persons themselves and caregivers. Wallace and Bonnie [80] argue that the use of widely varying and sometimes poorly constructed definitions of the older person abuse phenomenon is a major barrier to improving the understanding of older person abuse. To mitigate the misunderstanding as a result of this shortcoming, Wallace and Bonnie [80] proposed a widely accepted definition of older person abuse whereby they define it as intentional actions that cause harm or create a serious risk of harm (whether harm is intended or not) to a vulnerable older person by a caregiver or other person who stands in a trust relationship, or a failure by a caregiver to satisfy the older person’s basic needs or to protect the older person from harm. However, the international accepted definition among scholars is the one that refers to older person abuse as a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person [43]. According to Chalise [79], the definition of older person abuse implies that an abusive act perpetrated against an older person could be either an act of commission or omission by any person in a position of trust such as a family member, friend or neighbour.

The older person’s abuse constitutes a violation of human rights and includes physical, sexual, psychological and emotional abuse, financial and material abuse and abandonment, neglect and serious loss of dignity and respect [43]. WHO [43] adds that older person abuse has serious physical and mental health, financial and social consequences, including, for instance, physical injuries, premature mortality, depression, cognitive decline, financial devastation and placement in nursing homes. According to Ayalon [81], the consequences of older person abuse can be especially serious and recovery may take longer. Albeit there are various categories of older person abuse, for wider use the international scholars reached a consensus on five categories of older person abuse, namely, physical abuse, psychological abuse, financial abuse, sexual abuse and neglect [82]. The older person’s abuse may be manifested by various signs depending on the category of abuse. The types and signs of abuse are demonstrated in Table 1.

Type of abuse	Symptoms
Physical	browses especially on the head or upper body unexplained burns cuts sores or other injuries
Psychological	intimidating or yelling making threats humiliating or ridiculing isolation an older person from friends and keeping them away from activities they enjoy for no good reason
Financial	unusual patterns of spending or withdrawals from an older adult’s account frequent purchases of inappropriate items bills remain unpaid and sometimes the presence of a new ‘best friend’ in the older adults life who accept generous gifts from the older adult
Sexual	presence of unexplained genital infection unexplained and or vaginal bleeding torn or bloodied underwear and bruises around breasts or genitals.
Neglect	lack of clean clothing or clothing that is inappropriate for weather conditions lack of basic hygiene, cluttered home that is dirty, in need of repairs or a home that has fire and other safety hazards. a home that lacks basic needed utilities that are essential for the older adult’s daily sustenance.

Table 1.

Signs of older person abuse.

There are various risk factors that lead to the abuse. The main risk factors that lead older persons to become victims of abuse include the following: being a female, presence of cognitive impairment and being single or living in an older person or couple family, living in rural areas, having a poor self-perception of health and having a disability [83]. According to Pilleemer et al. [78] and WHO [43], these risk factors can be identified at an individual level, thus, both as a victim and perpetrator, victim-perpetrator relationship, community and societal level. The summary of older person abuse at the individual, community and societal levels and the associated risk factors are summarised in Table 2.

Levels	Risk factors
Victim	functional dependency or disability poor physical health cognitive impairment through dementia poor mental health low income and gender
Perpetrator	mental illness abuser dependency
Victim-Perpetrator Relationship	marital status partner/spouse or child–parent relationships
Community	geographical location (rural or urban areas)
Society	negative views on ageism

Table 2.

Risk factors associated with older person abuse.

At an individual victim level, the risk factor is often functional dependency or disability, which generally becomes a challenge across all countries and has been consistently found to be associated with greater risks of older person abuse [78]. Other risk factors at individual victim level identified by [78] are poor physical health, cognitive impairment through dementia, poor mental health, low income and gender. The individual perpetrator risk factors include mental illness, which is viewed as a strong risk factor, substance misuse and abuser dependency whereby the studies have shown that abusers are likely to be depended on their victims for emotional support, financial help, housing and other forms of assistance [78]. At the level of the victim-perpetrator relationship, the older person’s abuse is determined by marital status and varies from country to country [78] and through partner/spouse or child–parent relationships [43]. At community level, the risk factors are likely to be determined by geographical location thus whether it is rural or urban areas and varies with country [78]. In other countries, older person abuse may become prevalent in rural areas while in other countries it may become more prevalent in urban areas. The societal risk factors identified are negative views on ageism and ageism may be attributed as a contributing phenomenon [78]. Negative attitudes and stereotypes associated with ageism may contribute to societal acceptance of older person abuse. The last risk factor for older person abuse is social and cultural norms that normalise violence as acceptable behaviour and may further perpetuate violent behaviour towards older persons [78]. In the South African context, Kotze [77] argues that older persons view poverty, unemployment and the subsequent use of alcohol and drugs as contributing factors to abuse. Kotze [77] also points out the breakdown of family structures, loss of respect for older persons, beliefs in witchcraft and high crime rates, including domestic violence and socio-economic inequalities.

Albeit the high prevalence of older person abuse, even today it continues to be a taboo, mostly underestimated and ignored by societies across the world [79]. The American Geriatrics Society’s Foundation for Health in Ageing reveals that many cases of older person abuse are not reported. Even those who may consider reporting abuse often choose not to do so because they have been abused by a family member, a loved one, or a trusted caregiver [79]. The inability to report could be a result of extreme difficulty to reveal to others that someone trusted and loved by the victim is the one who is the perpetrator of abuse against the victim. Chalise [79] further argues that what makes matters worse is the blame that abusers often put on victims whereby they are told that it is their fault and also threatened if they reveal the abuse to anyone. The non-reporting of older person abuse also happens when the older person is dependent on the abuser for care, he or she may feel as if he or she has no option but to live in fear and pain [79].

5.9 Social care, living arrangements and social support

In most developing countries, the difficulties in supporting older persons are to a certain extent mitigated by the cohesive structure within the community [84]. The inherent responsibility of children to support their parents later on in their life has been an intrinsic part of their culture for many centuries [85]. This conception is supported by United Nations [86] which asserts that in most developing countries a majority of older persons live with relatives and in many instances with their children. Traditionally, multigenerational households have provided the main social context for the sharing of family resources and the provision of mutual support as needs arise over the life course of the older persons [86]. The United Nations [86] further reveals that on average around three-quarters of the older persons over the age of 60 years in the developing countries live with children and or grandchildren as compared with about a quarter of the older population in the developed countries. Soni et al. [84] cite the examples of counties such as India, Nepal and China where family traditions and lineage are important with responsibility for the male children who are referred to as heads of households are expected to care for their parents, consequently creating a strong extended family unit. In Africa, family members are primarily responsible for providing care and support to older persons [87]. The caring by children of older adults is a reciprocated act, which is related to the African expression that roughly translates to ‘Because you (i.e., one’s older parent) have taken care of me (the child) to grow teeth, I will take care of you until your teeth fall out’ [88]. In East and South sub-Saharan Africa, families provide most of the care for children, the sick and older persons due to few formal systems that exist [89]. According to the United Nations Population Fund [15], in East and South sub-Saharan formal care, where paid providers or governmental agencies provide assistance including day care centres, residential and care facilities, outside of urban centres, residential care facilities for older persons are rare and where present, they are generally financially accessible only to elite.

According to Kalache [90], these traditional forms of care available to the older population are under threat. The ongoing demise of the traditional forms of care is, as a result of families suffered from the impact of social change, including urbanisation, geographical spread, the trend towards nuclear families, and participation of women in the workforce [13]. The changes in the traditional forms of care have also been affected by migration whereby young people leave their country of birth searching for better opportunities and lifestyles [91]. The increased urbanisation and migration imply that people have to live a hundred miles away from their parents and simply cannot provide care and increased migration over the decades means that the younger generation may not even live in the same country as their parents [42]. The changes in the family structure have also been hugely affected by the effects of HIV and AIDS, particularly in the African continent.

There is a shift in the traditional form of caring, which is demonstrated by a change in the care responsibility. Instead of children taking care of their parents, older adults are the ones who take care of grandchildren and the sick in the household. Shetty [42] points out an uncertain employment environment whereby people are more likely to migrate for work or work much longer hours, therefore, meaning they can leave their children in the care of their grandparents. Therefore, this means that instead of older persons enjoying their retirement or being cared for, they have increasingly become care providers especially older women as they are becoming overwhelmed with care responsibilities and concern for their well-being and vulnerability is increasing [42]. The shift in care responsibility is also identified by the United Nations [86] when arguing that support typically flows in both directions and the nature and amount of support often varies or changes in response to individual needs. Very often, many older persons in multigenerational households are net providers of care and support for the younger generation instead of the other way around [86]. The United Nations [86] further adduces that even though they remain with the carrying and care responsibility, older persons are not recipients of material and financial support from the child care and other households and community activities. In the developing countries, many older persons also remain active in the labour force and in the households, there are younger children and grandchildren who depend partially or entirely on the older persons for their livelihoods. Instead of being differentially waited upon by their children and children-in-law, older women are often involved in child care for grandchildren and in cooking for the ever busy dual wage earner couple [92].

There is also another developing trend of skipped-generation households, which is becoming a common phenomenon. The phenomenon of skipped-generation households consisting of grandparents and grandchildren is relatively common in many developing countries and older women are likely to live in this type of household [86]. The skipped-generation households become a reality when children may stay with grandparents when one or both of the parents have died and when parents have migrated for work or divorced [86]. The circumstance of the skipped-generation households varies in many ways depending on the situation that gave rise to the living arrangement. For example, parents who are working elsewhere often send money and return to visit and also grandparents who take care of orphaned children there may be one to help with support [86]. More often than not, skipped-generation households are likely to be found in rural areas, and these households tend to be poor [93]. The proportion of older persons living in skipped generation households has been going up in countries that were heavily affected by HIV and AIDS [86]. In those countries, many of the grandparents who support grandchildren are extremely poor [94].

Another aspect inherent to the lives of older persons who live with their children is household headship. In developing countries, on average, about 90% of older persons aged 60 years and over are identified as heads of households and over half of the men aged 80 or above are regarded as heads of households [93]. Women are much less likely than men to be identified as the head of the households, albeit there are distinct differences between countries in this respect [86]. On average about two third of older women in developing countries are either the heads of households or their spouses are heads of households [86]. While it is uncertain to what extent the household head leadership implies, it is about day-to-day control over resources and decision-making, and male older persons are usually regarded as playing a leading role in their households [86]. Older persons who live with their own children are far more likely to become heads of households than those residing with other relatives or non-relatives.

6. Implications for theory, policy and practice

The theory undergirding the conceptualisation of ageing, policy formulation and practice is premised and influenced by ageism. The negative stereotypes that often shape the theoretical framework with regard to ageism are the root cause of negative attributes associated with ageing. The physical and mental deterioration associated with old age leads to devaluing of older persons and thus becoming isolated from active participation in social, economic and political activities. There is a need for a paradigm shift in theory that informs the current perspective about ageing. There is a need to modify the current theoretical paradigm on ageing by embracing the increasing longevity at old age, their strength with regard to life experience, the great contribution made by an ageing population in society and the active role that they still yet to play due to increasing levels of mental and physical health they still display.

According to World Health Organisation (WHO) [95], the developing countries have much lower national income and infrastructure and capacity for health and social welfare than countries that developed earlier. This necessitates a reconsideration of the policy framework towards addressing the deficiencies in the provision of health and social welfare services. There is also a need to review policies relating to accessibility of labour markets and economic opportunities. The WHO [95] in the Decade of Healthy Ageing 2020–2030 suggests that appropriate laws, policies, national frameworks, financial resources and accountability mechanisms must be established in all sectors and all administrative levels to ensure that older persons experience health and wellbeing and enjoy the human rights. The WHO [95] further urges that national and international partners should also advocate for transforming social, economic and environmental policies for increasing longevity and optimising health ageing for development throughout the life course.

The WHO [96] argues that enhancing mental and physical wellbeing among older persons by delivering accessible, affordable, equitable and safe community-based care for older persons will require a competent workforce, appropriate legislation and regulation and funding. The precondition for having such competent staff is the elimination of ageism mentality among those entrusted with caring for older persons. Because of diminishing informal care in the developing countries, there is a need to think about other alternative models of care in contrast to institutional care. The financial capacity of the developing countries may not match the level of their developed counterparts that often utilised institutional care. The developing countries may consider designing family-based and community-based care models that will adhere to the acceptable norms and standards of providing care to older persons. The family and community-based care models may utilise formal caregivers that have undergone a transformation with regard to ageism mentality. Caring for older persons shall be conducted based on developmental perspective that will strengthen independent living and active participation of older persons in society.

7. Conclusion

The increase in the population ageing seems to be an irreversible phenomenon, especially in the developing countries. There is a consensus in the literature about the perpetual increase in the number of older adults in developing nations. Older persons in developing nations are faced with challenges such as access to health care, social welfare system and social security. The challenges associated with their ageing such as deteriorating physical and mental health require adequate financial and human resources. The older persons are also exposed to high levels of poverty due to inadequate and lack of formal social security support measures. Older women are likely to become poorer than men due to their engendered social roles, which deprive them of participating in labour market when they are still eligible for employment. Older persons are victims of individual, community, institutional, societal and social abuse. Older women are the worse victims of older abuse as they are at the receiving end of older abuse due to patriarchal nature of society. The abuse of older women is perpetuated through cultural practices imposed during the process of bereavement and also after they have turned widows. The accusation of witchcraft laid against older women leads to many older women getting physically attacked and killed especially those who are very old and widowed. Ageism is viewed to have a fundamental effect on non-provision of essential services to older persons as it may determine the way professionals, planners and policy and lawmakers respond to issues of ageing. As the population ageing is increasing, it implies that there will be more people that are going to become vulnerable to all forms of abuse and poverty. Therefore, governments from the developing economies should strive towards development of policies for the protection of advancement of the well-being of older population and make resources available for the implementation of the policies.