Mental health articles

 

There is little information on which to directly judge specific policies and programs designed to support or furnish care for the elderly with mental health problems. Due to budgetary constraints, developing countries may be unable to divert large amounts of money from other areas of the health care system to meet the needs of the elderly and mentally ill elderly. Currently, health care spending on average,represents 4% of the GNP in developing countries,compared to 14% in the United States, and anannual expenditure of only $41 per capita. Therefore,we focus our attention on policies that couldpotentially address mental health problems of theelderly and ease the burden of care on families, but thatcould also be relatively easily and inexpensivelyimplemented. Many policies designed for other purposes will indirectly affect the general well-beingand mental health conditions of the elderly. Forexample, pension policies will increase economicstability, and housing policies will help determine the possibility of co-residence to create multi-generationalhouseholds. Several themes are present in ourdiscussion. First, policies should facilitate the ability offamilies to provide care. Second, government shouldattempt, when possible, to support innovative formalcare programs in order to provide a safety net for theelderly without family care. Third, programs shouldserve the elderly's physical and mental health careneeds simultaneously.

Budgetary constraints give poor countries a strongincentive to emphasize the improvement of care givento elderly people by their families and to complementthis care with carefully selected programs. Contrary to popular conception, the promotion of formal servicesdoes not seem to diminish the willingness of familiesto provide economic and social support to older members in need, and in fact, quite the opposite maybe true. When there is no support for formalservices, informal care mechanisms can break downmore quickly because of the unrelieved burden placedon them, especially among the poor. In low income families in Hong Kong, relationships betweenthe elderly and other family members improved aftera day care service was implemented so that the youngerfamily members could work. In many cases,families care for their elderly out of necessity, so idealgovernment policies will make the provision of careeasier. Furthermore, experience in high-incomecountries shows that poor countries should not investin high cost capital equipment and specialized trainingas a matter of course.Investment in formal healthcare technology oftenserves only the rich sectors of society that can bestafford to pay for it. The optimum approach will likelyinvolve less expensive alternatives and will embracethe nation's cultural traditions. For example,community based care systems, friendship networks,clubs, associations and retired person's groups shouldbe promoted, expanded and duplicated when relevantand appropriate.

Many countries have established successful programsthat help family care providers. Multipurposeday-care centers offer recreational activities and otherservices such as medical screening and counsellingboth for the elderly and their families. This providessome respite for caregivers. The Republic of Korea, SriLanka, Thailand, Hong Kong and some LatinAmerican countries, including Costa Rica, are organizing these types of centers. Nursingservices and other forms of home help such as 'mealson wheels' are part of programs in Singapore, HongKong, Angola and parts of Latin America.

Different types of government policies can reinforcefamily care. Housing and social policies nowencourage multi-generational families in some parts ofthe world. In Hong Kong, for example, previouspublic housing policies required married children tomove out of their parent's housing unit, but thegovernment has subsequently changed the rules toallow one married child to stay on when the parentsare elderly and need care. The housing authorityprefers new applicants who are willing to include theirelderly parents in the household. Public housingauthorities in Singapore and Malaysia give priority tomarried children and their parents who apply foradjoining apartments. The KoreanHousing Corporation has adopted apartment plans toaccommodate three-generation families living invarious stages of proximity. Governmentsin Lesotho and Botswana have considered improvingthe living conditions of the elderly by giving familieswith elderly members loans to upgrade their housesand by providing subsidized units to include theelderly, respectively.

Other policies enhance care for the aged in moresubtle ways. Some governments support employersponsoredbenefits. With increasing numbers ofwomen, who are the primary caregivers, in the workforce, small numbers of employers in the developedcountries have begun to give time off work and flexibleschedules to account for elder care.Furthermore, diverse countries such as Singapore,Gabon, Kenya, Botswana, Morocco, the Republic ofKorea, the Philippines, Iran and Kuwait either alreadyoffer or are considering income tax relief for peoplecaring for an elderly dependent.Li et al. propose that the government of Taiwanlower the inheritance tax so that the elderly are notimpelled to transfer property prematurely to theirchildren. This may leave the elderly with moreeconomic security that gives them better bargainingpower when negotiating care from family membersand ultimately preserve their independence. Choi makes a similar recommendation for South Korea,where traditional inheritance patterns are alsochanging.

Governments can contract non-government organizations(NGOs) to provide residential care forchildless elderly, as the governments of Malaysia,India and China are currently attempting to do.Residential homes should ideally be small and havestrong links to the community in order to avoid theasylum connotations prevalent in western countries. One study in Zimbabwe compares tworesidential care facilities. A relatively rich home withsuperior physical facilities and a complete staff wasstructured on the British colonial model of elder care,and the other was an experimental cooperative run bythe residents with only one staff member. Residentswere far more satisfied in the cooperative, even thoughit had fewer economic resources, as they had greaterself-determination and opportunities for productivework. Similarly, the first home for the aged inPolynesia was popular among its residents and had along waiting list partly because of its 'non-institutional'atmosphere, to which traditional architecture,the use of native foods, liberal policies on visiting,and resident group decision-making all contributed. Another creative type of program thatencourages re-marriage among the elderly in order toreduce the number who live alone has been tried inChina and Korea.

When these programs increase an older person'ssense of self-worth and value, they are particularlyhelpful. In Ecuador, an NGO with help from the UNinitiated a pilot program to provide employment forthe elderly. This was initially problematic becausethe most needy are often the frailest and the mostdifficult to retrain to fill available jobs. In one village,however, the NGO noticed that there was no bakerywithin 40 km, and set up an old people's bakery, usingsimple local technology. Thisprovided employment for the elderly and a productvalued by the community. The NGO then set up arelated sewing workshop for women and a plot of landfor the elderly men to cultivate medicinal herbs. InColombia elderly people are running a recyclingprogram in collaboration with the city by sortingrecyclable waste materials that residents deliver tocenters around the city. The program has providedenough money to give the elderly people a small salary. Such programs have the potential to increase thewell-being of the elderly, contributing to positivemental health.

When possible, programs should care for both thephysical and mental needs of the elderly simultaneously.Because the elderly tend to suffer frommultiple chronic conditions, it is likely that anyonewith a mental health problem will also be sufferingfrom other chronic physical disorders. Since theelderly are more likely to seek treatment for physicaldisorders than for mental ones, any attempt to treat mentaldisorders will be most effective if it is part of theexisting system to treat physical ailments. This type ofpolicy has the added advantage that it is cheaper toestablish than an independent, formal system aimedspecifically at the mental health needs of the elderly.An example of integrating mental health needs into theformal care system is the development of mental healthscreening and geropsychiatry components in institutionsranging from community health centers toacute care hospitals. A promising approachfor poor countries is the use of modified 'barefootdoctor' programs encompassing mental healthproblems. These programs frequently involve communityhealth workers (CHWs) trained in basic healthcare who go from house to house in ruralcommunities making visits. CHWs in such programscould receive rudimentary training in geriatricpsychiatry enabling them to recognize dementiasymptoms, for example, and refer patients with mentalhealth problems to tertiary centers. Abiodun suggests that this approach would be particularlyuseful in meeting the growing mental health needs ofthe elderly in Africa because primary health careworkers are 'nearer to the consumers' in the sense thatthey can reach the largely decentralized, rural populationsin African countries.* In certain places, thepossibility exists for government policies to build onexisting strengths and networks of folk and traditionalhealers.

In general, anything that diminishes older people'ssocial and economic marginality, such as a pension, islikely to help reduce the prevalence of minorpsychiatric morbidity. In countries with high inflation,private savings become riskier and formal pensionsgain importance because they grow with inflation,whereas savings often do not. Pensions for thoseemployed in the formal sector now exist in mostcountries in Latin America and the Caribbean, in mostof Africa, and in approximately one-third of Asiancountries. Pensions often serve only the elitesegments of the population, since those employed in theformal sector of the economy tend to be a privilegedminority. Coverage is generally sparse for ruralpopulations and for those who work in the informalsector, the groups that usually comprise some for thepoorest members of society.

Governments in some developing countries, however,have been successful in extending pensioncoverage to specific groups of old persons. In the Indianstate of Kerala, the state government has designed apension scheme that carries a manageable financialburden because it targets only the destitute elderlyfalling into one or more of these categories: widowed;handicapped; childless; low-income agriculturalworker; and/or workers in selected industries left outof the national Provident Fund Scheme. TheChinese government has used a similar approach inassuming responsibility for the childless elderly (nochildren, no capacity to work and no other means ofsupport) who comprise a small proportion of the entireelderly population and correspond to an acceptableoutlay in resources. This policy is intended to helppromote the one-child family planning policy.Policy-makers reason that adults will not worry asmuch about care in old age if they see the governmentproviding for those without children.Additionally, local governments at the village level areestablishing social security systems to complementtraditional intergenerational support. Based on the successful experiences of Australia and NewZealand with non-contributory, means tested pensions(which are similar in principle to China's system) inproviding for the poor elderly, McCallum recommends them for consideration by developingcountries in general.

In summary, the precise mix of optimal policies foreach country will vary and cannot be generalized. Thechallenge for the nations of the developing world is tolearn from others, both industrialized and lessindustrialized, and develop policies that are realisticand locally determined.

Tags: elderly, ill, mentaly, mentaly ill