Health is a central issue and fundamental human right associated with increase in longevity of population ageing. The maintenance of health status and functioning with age is a critical factor impacting upon many other aspects of the lives of aged, their family and communities.
Ageing is a natural process which is inevitable and thus being the end of the human life cycle. Perceiving ageing with fear is recent phenomenon, it seems to be increasing each day, as world become more complex and moreover ageing is associated with decline in functional ability which affects all aged peoples. Aged have limited regenerative abilities and more prone to disease, syndrome and sickness than adults.
“Old age is an incurable disease,
You do not heal old age but
You protect, promote and extend it”. – James Sterling Ross
The number of persons above the age of 60 years is fastly growing, especially in India. India is the second most popular country in the world has 76.6 million people at over the age of 60, constituting above 7.7% of total population. The most obvious manifestations of old age are changes in physical appearance such as wrinkles appearing on the face, graying of hair, restriction of movements and more prone to chronic illness. Too frequently, older adults suffer from the emotional side effects of ageing such as feeling of distress and anxiety regarding their future, loneliness and social isolation. The major area of concern is the health of the aged with multiple medical and psychosocial problems which have an impact on functional ability of aged.
Functional disability in the aged is defined as an acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living Davidson. (2011).
The most common problem confronting aged people is functional disability that leads to dependency and institutionalization. The functional disability in the aged includes three dimensions: physical, emotional, and mental performance.
The population of functionally disabled aged is growing rapidly. The number of aged who suffered with functional disability due to arthritis, stroke, cognitive impairment, anxiety and emotional distress is expected to increase at least 80 percent by 2049.
Functional disability limits the autonomy of older people, introduces dependence, and reduces the quality of life and increase the risk of nursing home admission. Studies have shown that the proportion of aged persons who cannot move and are confined to their bed or home ranges from 77 per 1000 in urban area and 84 per 1000 in rural areas.
The family and community play a vital role in the care of a functionally disabled aged. The supportive care for aged with functional disability is the major concern which includes early rehabilitation with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care and reviewing medical follow up. This will enable to prevent the development of complications such as infection, bed sore, constipation, movement incapability, urinary tract infection, deep vein thrombosis, muscle atrophy and contractures with resultant deformity in the aged.
Studies shown that majority (70%) of the aged over 60 years with functional disability are expecting the need of care by the caregivers to perform their daily activities. Caregivers are the one who is always present with the aged client, satisfying their needs and solving their problems. The caregivers of the aged may be their spouse, childrens or some other paid caregivers. The involvement of caregivers in caring the aged ones has been a help to create a great confidence in the aged to perform some kind of activities of daily living and also it has profound effect on aged reaction to medical treatment, emotional adaptation and rehabilitation. To implement the care for aged it is necessary that caregivers must be aware of functional disability in the aged to provide supportive care.
BACKGROUD OF THE STUDY:
By reviewing the bureau report 2009, globally aged population will increase from 595 million to 2 billion, a four fold rise by 2050, in terms of proportion 10% in 2000, 15% by 2025 and rise to 21.6 % by 2050.
Ageing population is an end product of demographic transition, the number of older adults aged above 60 years is increasing and they are becoming larger percentage of over all population.
In India, it is estimated that the elderly population has grown from 12.6 million in 1901 to 80.93 million in 2010 and India is the second largest country comprising aged in the whole world and is likely to touch 300 million within next half century. Data available from India suggest that almost 50 per cent of the elderly suffer from chronic diseases with the prevalence of diseases increasing with rising age from 39 per cent in 60-64 years to 55 per cent in those older than 70 years.
Research by the National institute of ageing reports that 80% of the aged are living with chronic conditions. Most of them are able to meet their own needs but only 25% of them require a special type of care. More than two third of the aged (22 %) live independently in a family setting. It is estimated that 10% of the aged need some form of long term care in the home.
Prevalence of various functional disabilities gradually increases with advancing age, starts at the age of 60 years and cause a growing need for help especially after the age of 65 years. Ageing process and changes in life style pattern such as chronic alcoholism, smoking, use of tobacco, sedentary life style, obesity, lack of exercise and improper nutrition during the young age has led a risk of chronic disease conditions among elderly population which results in 70% of disability making elderly more dependent on family and caregivers.
Eden. (2000) stated that old age is still perceived as a casual agent for seeking dependence in performing daily activities and the factors frequently causing dependency are age, gender, falls, illness etc.
A large population of today’s ageing is dependent on the family members for their health maintenance. Approximately 54% of the aged above 60 years are dependent, 24% of them are partially dependent and 22% of them are independent in performing their daily activities. The dependence on others for meeting the various needs will generate a felling of physiological and psychological dependence among the aged. The prevalence of unmet needs for functional disability in the aged due to vision problems is about 4.3%, 22.6% due to hearing problem, 32.5% due to immobility, 50% due to cognitive impairment, 62% due to difficulties in activities of daily living, 35% due to chronic illness, 25% due to psychological and social problems among those aged 60 and older.
The involvement of caregivers in caring the aged will help to create a great confidence in aged to perform some kind of activities of daily living. Approximately 4.1 million caregivers are involved in intense care giving. Hence the care giving is not only the responsibility of health professionals but also the family members, relatives, friends and even non- professionals who cares for the aged in home.
NEED FOR THE STUDY:
Advances in technology and the combination of high fertility and declining mortality in twentieth century have resulted in rapid and large number of aged people worldwide especially in developing countries. In every country, the proportion of people aged over 60 years is growing faster than any other age group.
Ageing causes numerous changes in the physiology of human beings which decreases functional ability. This in turn makes them dependent on caregiver. Inadequate care results in falls and depression among older adults.
Among the aged, the focus is not only on reducing disease related morbidity and mortality, but also on promoting optimal health and ensuring disability-free years. The literature states that the effect of functional disability will have an effect on quality of life among aged, as the aged become dependent where the caregivers should play a major role in taking care of such aged person. Caregivers are the one who is always present with the aged client, satisfying their needs and solving their problems. It is necessary that caregivers must be aware of functional disability in the aged to provide supportive care.
Investigator, during her clinical posting and community postings came across many aged with functional disability such as loss of control in body movements, functional immobility and associated coexisting illness who were dependent on their caregivers for their daily activities. While interacting with their caregivers the investigator came to know that they are not having adequate knowledge regarding the effects of functional disability and the care needed for the aged. Investigator felt that, aged with functional disability need some form of long term care in the home. If the caregivers had the knowledge they would help the aged in taking care of their health to prevent further complications. So the investigator felt the need to assess the knowledge regarding functional disability in the aged and its supportive care among caregivers to develop insight on the needs of older adults.
STATEMENT OF THE PROBLEM:
A study to assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai
OBJECTIVES:
To assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai.
To associate the knowledge regarding functional disability in the aged and its supportive care with selected demographic variables among caregivers at selected settings in Chennai.
OPERATIONAL DEFINITIONS:
ASSESS: In this study assess refers to the process of gathering information as expressed by the caregivers in response to the semi-structured interview schedule and analyzing it with the statistical method.
KNOWLEDGE: In this study knowledge refers to the awareness about functional disability and its supportive care as expressed by caregivers as response to the semi-structured interview schedule and analyzing to the statistical method.
AGED: In this study the aged refers to the people above 60 years who are available in the hospital and community.
CAREGIVERS: In this study the caregivers refers to the family members, relatives and paid non – professional persons in the age group from 21 years to 65 years who are taking care of the aged.
FUNCTIONAL DISABILITY: In this study the functional disability refers to deviations from the normal or customary function of an individual within any of the three dimensions i.e, physical, emotional or social skills necessary for an independent life.
SUPPORTIVE CARE: In this study the supportive care refers to the care which is provided to support the functionally disabled aged in meeting their daily needs.
SETTINGS: In this study setting refers to the place or type of surroundings from where the sample is collected i.e, community and hospital setting.
ASSUMPTIONS:
The knowledge on the functional disability in the aged and the supportive care among the caregivers will vary from adequate to inadequate.
The knowledge on functional disability in the aged and the supportive care among caregivers will be influenced by the selected demographic variables.
DELIMITATION:
The samples are the caregivers of the aged available in the community setting i.e, Thoraipakkam, Navalur and those admitted to the two hospitals i.e, V.H.S multi speciality and Dr.Kamakshi memorial hospital. Period of data collection is limited to one month.
PROJECTED OUTCOME:
The results of the study will project the knowledge levels of whom regarding various functional disabilities in the aged and the supportive care needed.
The knowledge levels will highlight the need for educating the caregivers on various problems of functional disability
By assessing this need, we can formulate the various methods of educating the caregivers on common problems of functional disability and it supportive care in the aged.
CONCEPTUAL FRAMEWORK
A concept is an image or symbolic representation of an abstract idea. Conceptual frameworks are interrelated concepts or abstractions that are assembled by virtue of their relevance to a common theme Polit and Beck (2001). It is a device that helps to stimulate research and the extension of knowledge by providing both direction and impetus. A framework serves as a spring board for scientific advancement.
A conceptual framework serves as a guide, to identify systematically and precisely defined relationship among the variables. It gives an idea to the main view and common theme of the research that is a visual diagram by which the researcher explains the area of interest.
MODEL:
The conceptual framework adopted for the study is based on “PENDER’S HEALTH PROMOTION MODEL (1987)”.
Health promotion is, “directed towards increasing the level of well being and self actualization in a given individual or group”.
This model focuses on the three aspects,
Modifying factors.
Cognitive perceptual factors.
Participating in health promoting activities.
MODIFYING FACTORS:
It refers to the situational, maturational, socio cultural, personal and biological factors.
In this study, it refers to the demographic variables like age, gender, marital status, educational status, occupational status, family income, type of family, any previous experience of taking care of the aged, relationship with the client, history of any present diseases in aged person, degree of physical dependency, hours spent in the care of the aged person, any previous information on functional disability in the aged and its supportive care.
COGNITIVE PERCEPTUAL FACTORS:
In this model, cognitive perceptual factors have important motivational significance. These variables can be modified through nursing actions.
In this study it refers to the knowledge of caregivers regarding functional disability in the aged and its supportive care in the aspects of disability in the aged, vision problems, hearing problems, loss of control in body movements, memory impairment , functional immobility, activities of daily living, importance of exercises, coexisting illness, psychological problems and family support.
PARTICIPATING IN HEALTH PROMOTING ACTIVITIES:
Participation of caregivers in this study is considered as one of the health promoting behavior as this will help the caregivers to be aware of their existing knowledge on functional disability in the aged and its supportive care, which enhance through the advices given.
CUES FOR ACTION:
The responses of the caregivers regarding their knowledge on functional disability in the aged and its supportive care provide cues for nursing action like reinforcement and also creating awareness in terms of early rehabilitation of functionally disabled aged with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care, reviewing medical follow up, providing assistive devices, assisting in daily activities, emotional support, engaging in social activities, promoting comfort and psychological support.
MODIFYING COGNITIVE PERCEPTUAL PARTICIPATING IN HEALTH
FACTORS FACTORS PROMOTING BEHAVIOUR
KNOWLEDGE OF CAREGIVERS REGARDING FUNCTIONAL DISABILITY IN THE AGED AND ITS SUPPORTIVE CARE:
Information regarding health promoting behavior includes,
Disability in the aged
Vision problems
Hearing problems
Loss of control in body movements
Memory impairment
Functional immobility
Activities of daily living
Importance of exercises
Coexisting illness
Psychological problems
Family support
Participation of caregivers in the study and sharing information regarding functional disability in the aged and its supportive care
DEMOGRAPHIC VARIABLES:
Age
Gender
Marital status
Educational status
Occupation
Family income
Type of family
Relationship with the client
Any previous experience of taking care of the aged
Hours spent in the care of the aged person
Any previous information on functional disability in the aged and its supportive care
History of any present diseases in aged person
Degree of physical dependency
Reinforcement
Adequate knowledge
Eliciting the knowledge of caregivers regarding functional disability and its supportive care through semi-structured interview schedule
Moderate knowledge
Inadequate knowledge
Cues for nursing action
FIG.1 CONCEPTUAL FRAMEWORK BASED ON PENDER’S HEALTH PROMOTION MODEL (1987)
CHAPTER II
REVIEW OF LITERATURE
Review of literature aids the researcher to understand what already known in relation to problem of interest and what remains to be known. It helps to plan and conduct the study in a systematic manner. It is defined as reviewing and analyzing the work of literature in relation to the specified topic in research – Simai Haji Mati.
This chapter deals with selected studies and articles which are related to the objectives of the proposed study. For the present study an extensive review of literature relevant to study was undertaken and is presented under the following headings.
Part I: General information about ageing, functional disability in and its supportive care.
Part II: Studies related to functional disability and its supportive care in the aged.
Part III: Studies related to knowledge of caregivers of aged on functional problems and its supportive care.
Part I: General information about ageing, functional disability and its supportive care.
Ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. It applies to both individuals and population groups. Ageing allows people to realize their potential for physical, social, and mental well-being throughout the life course.
According to Stephan John. (2009) Ageing is denoted as,
Young old – 65-74 yrs.
Middle old – 75-84 yrs.
Older old – 85 and older
Darnton. (1995),emphasized that quality of old age people depends mainly on psychological well being, perceived health status with independency in meeting self care needs.
Normal Ageing process:
The ageing process creates profound changes that there will be 1-2% decline in functional ability per year. Normal Ageing brings about the changes in physiological, Social and Psychological well being – Judith A. McCann. (2003)
Physiological aging process:
Changes in body composition, reduction in bone mass and strength, reduction in blood volume, reduced motility of the large bowel, changes in autonomic function, reduced elasticity of eye lens, high tone hearing impairment and reduced motor and sensory function.
Social and psychological aging process:
Feeling of distress, anxiety regarding their future, loneliness, depression, grief, sadness, and social isolation.
However, some of the above effects of ageing can be slowed by engaging in interventions that improves outcome in the health events.
Functional disability in the aged is defined as an acquired difficulty in performing basic everyday tasks or more complex tasks needed for independent living. It is an important health indicator in the aged, jeopardizing quality of life and causing heavy social impact with long-term institutionalization and increased use of medical care.
Reducing functional disability in the aged is a major challenge for public health- Frazil.(2005), performance in functional disability includes three dimensions: physical, emotional, and mental performance. Physical performance relates to the body’s sensory and motor function. Emotional performance is measured through the individuals’ adaptation to various events in their lives. Mental performance is evaluated through tests that measure the individuals’ intellectual and rational capacity.
The causative factors for functional disability are as follows:
Vision problems, hearing problems, loss of control in body movements, memory impairment, functional immobility, difficulties in performing daily activities, lack of physical exercises, coexisting illness, psychological problems and family support.
The effects of fundamental disability include walking, lifting objects, climbing stairs, reading standard-size print and hearing disturbances, short-term memory loss, disturbance in daily activities, disorientation to time and place, reducing mobility and social activities. The care necessary for the effects of functional disability are early rehabilitation with adequate nutrition, fluids, range of motion exercise, second hourly position changing; skin care, reviewing medical follow up, providing assistive devices, assisting in daily activities, emotional support, engaging in social activities, promoting comfort and psychological support.
By over viewing the various informations regarding functional disability in the aged will thereby helps the caregivers to prevent further complications and also provide supportive care for the aged.
Part III: Studies related to functional disability and its supportive care in the aged.
Felix. (2001) stated that disability is systemic; no body system is immune to its effect. From his statement it is evidenced that meeting the self care activities and physical maintenance are essential for managing the effects of disability.
Nandi Manju. (2002) stated that as ageing increases there will be decline in functional ability, which is compromised with good nutrition, assistive support, with psychosocial concerns and with medical care.
Steffen Been. (2005) proposed a statement that there will de decline in cognitive and functional abilities of old age due to continuous degeneration of numerous brain cells which aid them to obtain a fully dependable care from caretakers.
Frey. (2006) stated that decreased level of physical activity and growing number of chronic illness that often increase with age, frequently create vicious circle of illness, and related functional disabilities that has adverse effect on activities of daily living. In this statement, he highlighted that decrease in functional ability makes the individual to become more dependent and need constant support and supervision.
McDougall.(2006) conducted a cohort study to identify the prevalence of memory impairment among 265 older adults by means of survey method and the results showed that 29.4% (78 individuals) of them had memory impairment in the later adult period .He also concluded that those with declining memory are less aware of their deficits in meeting activities of daily living.
Human research center for ageing.(2006) stated that immobilization, loss of control in body movements and falls need not to be the consequence of living to advanced age all this may be prevented through muscle strengthening and range of motion exercise which has reported benefits of spontaneous activity by the old age people.
Stark.et.al.(2007) conducted a correlational study to assess the health status of functionally disabled aged under the supervision of institution and family by means of health indicator assessment scale and the results showed that the older adults who receiving the care such as adequate nutrition, fluids, range of motion exercise, second hourly position changing, skin care, reviewing medical follow up and participating in family activities are in the family are having moderate health status than the older adults in the institutionalized care.
Zbylut j. (2007) conducted a national survey to evaluate the health status of older persons and prevalence of common health problems among elderly above 60 years. The survey results shows that a large number of older persons were suffering from one of more age-associated chronic diseases like osteoporosis, osteoarthritis, dental problems, visual problems, cognitive impairment and depression which may impair their functional ability and quality of life.
Kart berg. et.al (2010) conducted a descriptive study to assess the functional ability among the aged by means of questionnaire in the aspects of physical, mental and social abilities and the study concluded that low functional ability lead to dependency and stressful environment for the aged which again increase the risk of complications.
Lawton and Brody.(2010) described that assessment of functional ability often includes evaluation of individuals ability to carry out activities of daily living which is an early sensitive indicator to promote quality of life of old age people.
From the above studies the investigator identifies the prevalence, impact of functional disability in the aged and the important aspects of supportive care for the aged. It helped to formulate the need for the study and also helped to identify the major areas which should be included while formulating the objectives.
Part IV: Studies related to knowledge of caregivers of aged on selected functional problems and its supportive care.
Skalska.et.al. (2007) conducted a cohort study with the aim to evaluate the knowledge on various areas of functional problems among 62 caregivers of aged at risk by means of questionnaire and the samples are (78% family members and 22% non related) results revealed that only 41% caregivers had knowledge on functional problems such as (vision, hearing, and memory problems in the aged) and 59% were not aware of functional problems mainly in cognitive and social problems.
Chelma.et.al. (2009) conducted a explorative study to identify the measures on management of functional problems of elderly among 629 caregivers by means of check list, the result revealed that 47% of them were aware on the common measures and 53% were unaware on common measures on management of functional problems among elderly.
Through these studies the investigator understands the importance of caregivers awareness on functional disability in the aged and its supportive care which helped me to formulate the tool.
CHAPTER – III
METHODOLOGY
This study was undertaken to assess the knowledge on functional disability in the aged and its supportive care among caregivers at selected settings in Chennai.
This chapter on methodology includes research approach, research design, setting, population, criteria for selection of sample, sample size, sampling technique, data collection tool, development and description of the tool, validity of the tool, pilot study, data collection procedure and plan for data analysis.
RESEARCH DESIGN
A non experimental descriptive design was chosen for this study.
RESEARCH APPROACH
Research approach was descriptive in nature.
SETTING OF THE STUDY
The setting of the study was chosen on the basis of feasibility, in terms of availability of adequate samples from hospitals and community.
Voluntary Health Services Hospital, Adyar, Chennai.
Dr.Kamakshi Memorial Hospital, Pallikaranai, Chennai.
Community- Thoraipakkam and Navalur.
POPULATION FOR THE STUDY
The population of the study consists of the caregivers of the aged in selected hospitals and in the community.
SAMPLE OF THE STUDY
The caregivers of the aged within the selected hospital and in the community who have fulfilled the inclusion criteria.
CRITERIA FOR THE SELECTION OF SAMPLES
Inclusion criteria:
The caregivers who are taking care of the aged with functional disability.
The caregivers in the age group of above 20 yrs.
Both male and female caregivers of aged people.
Caregivers who are willing to participate.
Exclusion criteria:
The caregivers who are included in the pilot study.
The caregivers of the aged who are independent in doing their daily activities.
Care givers who do not understand and communicate in Tamil or English.
SAMPLE SIZE
The sample size of this study is 60 caregivers of the aged people at selected settings, Chennai.
SAMPLING TECHNIQUE
Purposive sampling technique is used in this study.
DATA COLLECTION TOOL
The data was collected from the caregivers using semi-structured interview schedule.
DESCRIPTION OF THE TOOL
The tool prepared in this study was based on the information gathered from the review of literature; objectives of the study and the personal and professional experience of the investigator. It consists of two parts
Part – I: It consists of demographic variables like age, gender, marital status, educational status, occupation, family income, type of family, any previous experience of taking care of the aged, relationship with the client, hours spent in the care of the aged person, any previous information on functional disability and supportive care, history of any present disease in aged person and degree of physical dependency of the aged.
Part – II: It consists of 11 questions which have three parts to assess the knowledge on functional disability in the aged and its supportive care among caregivers using semi-structured interview schedule.
SCORING PROCEDURE:
In part II:
In first question, part (A) the correct option carries one mark; the incorrected option carries zero mark. In part (B) each option carries one mark.
For all other question from (2 to 11), The first part of each question carries one mark for each ‘YES’ option and no mark for ‘NO’ options. And the second and third part of each question carries one mark for each option.
Thus a total of 10×1=10 for first part of question
46×1=46 for second part question
38×1=38 for third part question
Total of 94 marks will be awarded under the knowledge regarding functional disability in aged and its supportive care among caregivers. It is interpreted in percentage as:
Adequate knowledge : Greater than 75%
Moderate knowledge : 50-75%
Inadequate knowledge : Less than 50%
VALIDITY OF THE TOOL
The tool used in this study was validated by the experts in the field of general medicine and Medical surgical nursing.
PILOT STUDY
The pilot study was conducted in Voluntary health service hospital, Dr.Kamakshi memorial hospital, Thoraipakkam and Navalur community area, Chennai from 20.7.12 to 25.7.12 after obtaining the permission from the respective heads of the organization.
Totally 6 caregivers (2 from each of the hospitals and community area) who fulfilled the inclusion criteria were selected purposively, to generalize the study. A
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