Elderly Women in Institutionalized Care: A Situational Analysis of the Elderly in a Colombo City Neighborhood, Sri Lanka

In Sri Lanka with the rapid ageing of the population, the care of the elderly has become an important and urgent issue requiring immediate attention. In this context this study was undertaken in an elder’s home in a Colombo city neighborhood to carry out a situational analysis of the care given to the institutionalized elders. Using the survey and the case study techniques information was collected and processed using the statistical package to ascertain the family support and their opinion regarding the quality of service provided the nature of the relationship between the elderly and their family members and on the perception of the elderly on the services provided. The most important finding of the study was that the elderly women felt isolated from family and community. The study also interestingly demystified the general belief that the potential of the elderly to contribute to developmental activities was limited due to declining health conditions in the later part of their life. This study has reiterated the fact that there is wide scope to strengthening family ties by reintegrating the elderly into family and community, to de-institutionalizing elderly care and augmenting the quality of care given in an institution and by providing noninstitutional services. The study also suggested to establishing integrated model home for the children and the elderly.


Introduction
Care giving to the elderly, the world over, is provided either by the family/relatives and/or friends or by institutions which are considered as informal and formal systems of the care giving sector respectively. Whichever be the system adopted; the manner in which it is provided varies among countries and regions reflecting cultural and geographic differences. The informal system is the most common among many countries, with family and/or relatives taking care of the elderly. This is the traditional form of care given to the senior citizens. The extended family system which functioned as the main element of sustenance of the informal system of elderly care has begun to encounter several life course challenges created by the unprecedented changes in the macro environment.
Drastic changes in society caused by the fast track, to erode the traditional family ties that sustained the closely knit family ties, leaving many of the elderly to seek assistance from the formal care giving institutions. The factors that contributed to these changes include decreasing family size, the greater life expectancy of elderly people, the geographical dispersion of families, and the tendency for women to be educated and work outside the home.
In Sri Lanka, as in many other Asian countries, the rapid ageing of the population, has made caregiving to the elderly an important and urgent issue requiring immediate attention. With the gradual erosion of family ties and the emergence of the nuclear family as the dominant type of family unit, the care giving responsibility of the elderly is gradually shifting to the formal sector. The nuclear families which are unable to take charge of the elderly due to many socio-economic and cultural constraints have begun to seek assistance from formal institutions engaged in elderly care. Though the state has made several attempts to assist the elderly wherever possible, the increase in demand for help has led to several private `homes' mushrooming fast and charging unconscionable rates for questionable quality of service. In the lack of regulatory mechanism the so called `homes for the elderly' mainly located in and around Colombo, are bound to continue to grown.
To illustrate and examine the situation of institutionalized elderly women, a charity home located in the neighborhood of the city of Colombo, engaged in care giving to elderly women was selected as a case study. The main purpose of this study was to carry out a situational analysis of the elderly under institutionalized care in order to identify issues that Copyright © 2013 Horizon Research Publishing

Varathagowry Vasudevan
Horizon Research Publishing need to be addressed to recommend suitable social work intervention strategies to resolve issues identified in the said care giving institution and to share the knowledge thus gained in the formulation of relevant policies and strategies at the national level. The study is presented under the following subheadings; contextual background, methodology, findings and conclusion.

Contextual Background
Sri Lanka is considered to be the fastest aging nation in South Asia with percentages of over 60 years in the total population increasing from a 9.2 percent in 2000 to 12.2 percent in 2012 , and estimated to have reached 28.5 percent in 2050 [Census & Statistics 2012]. The dependency ratio too is shown to increase slowly and steadily. It is generally known that the welfare policies connected to the provision of the basic needs pertaining to education, health and nutrition adopted by the state in the 1940s, have contributed immensely to the post war II social changes experienced in the country. Health facilities improved to reduce mortality and increase birth rates to result in improved longevity of people's lifespan. The population of Sri Lanka continues to grow older with women in the lead. Feminization of ageing is therefore very visible in the population structure of Sri Lanka life expectancy of females has raised to 79 years as against 72 years for men. Though the women elderly population is increasing rapidly, women's labor force participation is declining fast. In the 2000s female labor force participation was 33.9 percent while 67.2 of males participated. These percentages dropped to 29.8.1 % and 66.7 % for female and male respectively in 2012 in Sri Lanka. [Department of Census & Statistics, 2012] The majority of the elderly persons live in the rural areas of Sri Lanka. Their life in the rural settings is trouble free and not too complex when compared to the urban life. They live often in extended family settings with their children; while elderly urban dwellers for various socio-economic reasons, such as high cost of living, lack of proper housing facilities and, inadequate income to live by them. In instances where the sponsors (Family members or previous employers) decided on the residential arrangements for the elderly, according to the sponsor's perceptions of what is good for the elderly. It is a well known fact that these sponsors who are international migrants and /or resident abroad select residential arrangements for the dependent elderly in and around urban areas on the basis of their needs and/or personal agenda. Observations revealed that at no point in time were the elderly consulted on this. This could be interpreted as a brazen act of denial of the fundamental rights of the recipients of the sponsorship/s Many factors have also contributed to choose charity homes or Paying homes in and around the city of Colombo popular choices. This factor appears to be responsible for the continued surfacing of new charity homes in and around Colombo city. The city of Colombo has 32 registered residential homes out of 65 homes of Western province while only a few are found scattered in other areas of the country. According to the Elderly Secretariat estimates indicated that there were 7000 elderly persons living under institutional care in 2003.
The process of globalization brought in its wake worldwide labor migration of skilled and unskilled labor to new destinations/places. This phenomenon functioning as the `push' factor, attracted all types of labor from developing countries like Sri Lanka to positions in far away countries which in turn made the migrants leave per force their near and the dear ones behind. This labor out-/migration at the international level emerged as a major causative factor of several social changes in the island during that period. One of the consequences of such a major re-distribution of people in the labor market was the surfacing of care giving institutions. Institutionalization of the elderly became the only solution for care giving to the needy elderly. In spite of the fact that such institutions have attempted to offer as many services as possible the elderly admitted to such institutions remain lonely and isolated requiring personalized care

Elders and the Family
Many of the senior citizens in the sample studies have expressed feelings of emptiness creeping into their lives with old age. Unlike in the neighboring sub continent our elderly particular men, lose their solid positions very fast due to retirement and non engagement of activities. Though the family continues to give due respect to the elderly both old men and old women seem to have become powerless and disempowered. They used expressions to say that they feel robbed of their power and position. The relative position of elderly women was somewhat different due to the gender factor. Women are usually very passive and submissive. In a few rare instances the elderly women who lived as formidable personalities earlier in life, threatening to take revenge on the younger women in the family unit, felt very much disempowered and disenabled by this transfer into an institution. On the whole when an individual, particularly the older members in a family, is suddenly translocated on account of disaster, conflict even migration, into unfamiliar regimented surroundings, they become disillusioned and hopeless. At such a stage prompt action has to be taken and care given to prevent an individual becoming a victim of separating their family. Since this process has come to stay with hardly any attempt undertaken to research further to improve the system, urgent action needs to be undertaken in this regard to develop suitable strategies to improve the lives of such elderly women and men.

Methodology
To illustrate and examine the situation of elderly women admitted to institutions that provide care to the elderly, a International Journal of Social Work and Human Services Practice 11 Vol.1. No.1 September, 2013, pp. 10-14 charity institution engaged in elderly care and located in the neighborhood of the city of Colombo, was taken as a case study. The primary objective of this study was to carry out a situational analysis of the care given to the institutionalized elders, in order to explore and recommend suitable intervention strategies to resolve issues recognized in the provision of appropriate care for the said elderly women and to share the knowledge.
The survey was based on the sampling approach. Fifty elderly females' members at said institution were identified randomly from the list of names of the elderly in the register maintained by the institution. The survey instrument used was a semi-structured questionnaire administered by a research assistant supervised by the author of this paper. For the case studies, six of the elderly women were identified from the checklist. The data collected were computerized and analyzed using a relevant statistical package. Major findings of the study are summarized below:

Profiles of the Elderly Women
The profiles of the elderly women included demographic data on, age, marital status, religion, educational level, previous occupation, type of family, property, income and expenditure as well as on their perceptions on economic security.

Age
The age wise distribution of the respondents revealed that nearly half (48%) of them belonged to the age group of 70 to 79-years. The average age was almost the same as that of life expectancy of the elderly women in the country as a whole. At this point it may be pertinent to mention that in Sri Lanka, while the proportion of elderly people in the group of elderly (60 to 69 years) group is declining; the proportion of the old people (more than 80 years) group is increasing due to advancements.

Marital status
The details on the marital status of the elderly women interviewed revealed that half of them (50%) were never married and over one third of them (44%)were widowed. This revealed that 94 percent of them belonged to the categories of ever married and widowed elderly women living alone. These elderly women have been living alone for several years due to absence of sustainable social relationships. These data may therefore be interpreted as indicative of the consequences of remaining single and seeking alternative residential arrangements at old age.

Educational levels
The educational profiles of the elderly women selected reflect the national average literacy levels. Nationally statistics indicate that women outnumber the men in illiteracy. In the sample under study nearly 38 % are shown to be illiterate. This is an unsatisfactory situation and a cause for concern in a country where democratization of education commenced in 1945. A distinct pattern that was discernible in the distribution of the levels of literacy and socio economic status among the elderly in the sample was that there was a close correlation between literacy levels and socio economic status of the elderly. The distribution pattern indicated that 3/4 th of the elderly women who paid for the service were literate and having higher socio economic status while most of those in the availing services for free were illiterate and economically unsound. In consequence, this difference has created dimension in the relative position of the female residents in this particular home. This has resulted in the development of the phenomenon of a wide and unwanted social distance compounding the social issues that remain unresolved. The `haves' and the `have-nots' keep their social distances adding to the unhappiness of the `havenots'

Economic status
While delving deeply into the economic/financial status of the selected elderly it came to light that half (48%) of them had been engaged in unskilled low level jobs such as domestic maids prior to being institutionalized at the charity home mentioned above. Nearly42% of them had not saved money nor purchased any property. It was disturbing to note that nearly half (48%) of them had only total of Rs 50 income each month.
The data also revealed that the income levels of many of the elderly women was limited which may be interpreted as a reflection of their previous economic status. The elderly women living in the paying section were reportedly from affluent families. They had either lived alone (32 %) or with their employer's family 66 % of them had been living with joint families or in extended families. The study clearly revealed that the women, due to their low literacy levels perhaps, had not developed the habit of saving and acquiring assets for their future. Many of them had already distributed what they had to their children and kin. This has apparently weakened their economic status and pushed them into choosing institutional support to spend the rest of their life often with little or no support even from the children/family members to whom they give their limited savings/assets. This separation of the `haves' and `have-nots' in residential arrangements appear to have influenced the type and manner of care giving services provided.

Health
Various health problems were identified among the elderly women in the institution. The most common ailments of the elderly women were hypertension, movements, dental problems, eye (vision) sight problems, cough, tiredness, chronic backache, asthma, chest pain and cardiac problems. It was observed that all of them had at least one of the Varathagowry Vasudevan Horizon Research Publishing ailments which they seemed to accept as signs of old age. Hospitalisation was used as an indicator to measure the extent of seriousness of diseases of an elderly woman. The study showed that 62 percent of them were hospitalised in the past for various reasons. However, accessibility to free medical services has contributed towards maintaining reasonable levels of health condition by the elderly women. Mental health of the elderly is another area that needs to be looked to understand their overall health situation. A majority (62%) of them felt lonely occasionally due to their isolation from their family and community as they adjusted to the new institutional environment. It seemed to be a reaction to their isolation from their family and community.
Within the institution relationships among themselves also had an impact on the mental wellbeing of the women. 71 percent of them claimed to have good relationship with other members. Nevertheless, petty quarrels among the members were reported. There were hardly any relationship problems between the paying members and the non-paying. It was heartening to note that there was harmonious relationship among the women and between the women and the staff at the institution contributing to a trouble free atmosphere. Regards to food the data showed that an overwhelming proportion of them were satisfied with the quality, quantity and taste of the food in the institution. However the menu was different for paying and non-paying sections.

Accommodation& Length of Stay
The place of residence and the related facilities available go a long way towards determining the quality of life of individuals/families. The places of abode determine in many ways the levels of satisfaction of people's life. In the case of the elderly it becomes particularly important.
A close perusal of the information available on the details of their residential arrangements among the sample of elderly, it was found that a majority of 60 % of them had been living in the institution for 2 to 10 years. Majority (28%)of them came to know about the institution through their previous employers. The main reasons for joining the institution were given as "no one to look after", "autonomy from control" and "staying alone" The residential arrangements of keeping the paying and the non-paying separately in separate buildings within the same compound, has not in any way contributed to harmonious relationships. These women in both groups stated that their family members or employers visit them only occasionally. It was also reported that the elderly women do visit their families or employers on special days. On the whole it appeared that their social network functioned irregularly; pointing to the necessity to review and improve the factors/issues that contribute to a satisfactory existence by the elderly The main areas to be reviewed were identified as ; family support, residential arrangements in the institution, type of relationship with other residents/family/other kith and kin, types of contact with family/others .

Activities -Participation in Institutional Programs
The notion that the elderly do not have the capacity to participate in the daily activities of the Institution is a misconception. This is based on the belief that with old age the capacity to participate is limited due to declining status of health. The belief that all the elderly are dependent has been disproved because many (60%) of them would like to engage in activities within the institution. They expressed their desire to participate in the "daily chores", "adult education", "making handcrafts", "staying with children and baby sitting in the children's home of the institution" and other recreational activities. An interesting outcome on this was that the marital status of the elderly women seemed to show certain patterns in the desired activities chosen for participation.
Among those engaged in various activities within the institution ever married elderly women registered a higher proportion (66.7%) Moreover the younger elderly women experience higher level of satisfaction by engaging themselves in activities of the institution as compared to older women. Those elderly women who have no family ties prefer to engage in social caring. The elderly women, who contribute for daily chores at institution, are well adjusted.

Awareness on the Rights of the Elderly
Nearly three-fourths of the elderly women seemed to be aware of the various services provided to the elders by the government and non -governmental organizations in Sri Lanka. However, an overwhelming proportion (92%) of them did not know about the existence of the Elder's Act 2000.Their limited access to information on their rights in addition to their indifference towards knowing their rights are very important areas.
Perceptions of the Elderly on institutionalized care especially their Family support and relationship Perceptions on service-quality were collected. They expressed different levels of satisfaction. In this study satisfaction was assessed through such dimensions as preference to stay in the institution, preference to engage in activities and adjustment with other members in the institution. These dimensions of satisfaction were analysed in the context of their socio economic status.
The perceptions of the elderly women towards institutional living condition and satisfaction of their life under institutional living arrangement were found to be fairly positive. An analysis undertaken on the basis of marital status showed that ever married elderly women have greater satisfaction in institutional living arrangement than others.
Furthermore it was found that the elderly women from the low income group were more satisfied with their present living arrangement. Acceptability of this opinion is an issue here because the elderly in this group were less vocal and were prepared to accept whatever was given. In addition to this group those among the elderly women with no connection to their families too claimed to be satisfied with the present living condition. Thus, socio economic status and Vol.1. No.1 September, 2013, pp. 10-14 degree of family connection of the elderly women seemed to influence their opinion on institutional care. Since these opinions are masked by socio economic status, intervention has to be carried out to air out their feeling and facilitate to provide personalized social care during the stay in an institution.
Ever married elderly women were well adjusted with the institutional living arrangement. Ever married elderly women may feel secure in the institutional living arrangement. The study shows that the majority (70.6% ) of illiterates are well adjusted with other members of the institution. It may be said that there is not much disparity in level of education among the elderly women in the institution. The table shows that an overwhelming proportion (75%) of the respondents of low-income group is well adjusted as compared to the well to do (55%). Thus, those who were institutionalized due to lack of economic "security" seemed to have better life satisfaction as their needs were taken care by the institution.

1) Isolation, loneliness 2) Participation for development 3)
Re-integration into family/community to De-institutionalize elderly care 4) Develop & provide non-institutional services The opinion of the respondents varied on the basis of the group of residents they belonged to, i.e. the paying and non-paying residents. As the quality of services varied on this aspect those in the paying section had positive answers. However, it was not possible to obtain the viewpoints of women living in the non-paying section as they felt that they could not express their views as members living in the non-paying section-free of charge.
A few comments were however obtained on improving their participation. They were; social engagement activities and getting the elderly involved in marketing facility for handicraft products facilitate to maintenance infrastructure and additional recreational facilities. The study noted that the participation of the elderly women in the management and day to day social engagement activities can be enhanced. It appears that with greater utilization of available resources and participation of the elderly women in activities, feelings of loneliness and isolation will reduce and help the elderly women regain their sense of belonging and self worthiness and learn to look at life in a positive manner.
The study clearly revealed that the socio-economic status and living arrangements of an elderly woman play important roles in old age. The residential arrangement & the provision of the required social support within the institutional environment seemed satisfactory. The socio-economic status of the elderly definitely reflected in their opinion regarding the quality of service its satisfaction.
The remedial measure that may be recommended for this state of affairs is the establishment of a regulatory mechanism to guide and monitor such institutions and prevent the mixing between of those availing in different services -paying and non -paying. As expressed by the elderly women a strategy that encompasses a plan that incorporates a link with a children's home under the same management may alleviate the feelings of loneliness by organizing common activities

Conclusion
In conclusion it may be surmised that the type of variables and their influences on the living conditions of the elderly women in institutionalized care differ on the basis of socio economic status. In the analysis it was observed that certain common patterns regarding institutionalization emerged on the basis of the different socio economic groups identifiable among the elderly. These findings on the whole have highlighted a number of issues which need to be researched further before using the relevant data in the formulation of welfare policies pertinent to the elders The outcomes of the study revealed that from the residents' point of view there were seven major issues to be addressed. These issues varied between the two socio-economic groups identified as `haves' and `have-nots' pointing to the necessity to develop appropriate intervention to resolve the issues. The issues identified were 1) Inadequate finances 2) Social Engagements 3) Process of institutionalization 4) Types of care giving 5) Elderly friendly measures 6) Information on Rights of the elders 7) Attitudes of family members, care givers and community member To develop intervention to resolve the issues identified further studies covering wider samples are recommended. It is very pertinent to highlight the fact that almost all outcomes underscore the need for social work intervention to remedy the issues.
It is important and interesting to point out that among the findings the most striking outcome that pervades all issues is the impact of the process of institutionalization, an artificial style of living away from the familiar surroundings. In this process it appears vital that the elderly women be provided wherever necessary friendly alternatives to restore their feelings of being needed.