Growing Old in Egypt: The Supply and Demand of Care for Older Persons

First published in 2011 by

The American University in Cairo Press

113 Sharia Kasr el Aini, Cairo, Egypt

420 Fifth Avenue, New York, NY 10018

www.aucpress.com

Copyright © 2011 Thomas Boggatz

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Dar el Kutub No. 15268/10

eISBN: 978 977 416 455 2

Dar el Kutub Cataloging-in-Publication Data

Boggatz, Thomas

Growing Old in Egypt: The Supply and Demand of Care for Older Persons / Thomas Boggatz.—Cairo: The American University in Cairo Press, 2011

p.          cm.

ISBN 978 977 416 455 2

1. Older People—Care I. Title

362.6092

1 2 3 4 5 6     14 13 12 11

Designed by Jon W. Stoy

Contents

Introduction

1: Demographic Transition and Its Consequences in Egypt

Aging—an emerging phenomenon in Egypt

Problems of aging

Conclusion

2: Geriatric Care in Egypt

Homes for the aged

Home care services

Nursing in Egypt

Caregivers of older persons

3: Caring for Older Persons: The Caregivers’ Perspective

Investigating caregivers’ experiences

Working in a charitable home

Working in a home care service

How to enlarge the workforce?

4: Care-seeking Attitudes of Older Persons

Situational framework of care seeking

Situation-specific perceptions

5: Attitudes toward Care Services in the Home

Investigating attitudes toward home care services

Rejection of home care services

Acceptance of home care services

Aspects of care seeking and their relevance for home care services in Egypt

6: Attitudes toward Nursing Homes

Investigating attitudes toward nursing homes

Rejection of nursing homes

Acceptance of nursing homes

Aspects of care seeking and their relevance for nursing homes in Egypt

7: Main Aspects of Care Seeking: A Study in Greater Cairo

Studying care-seeking attitudes in Greater Cairo

Characteristics of study participants

Care-seeking attitudes among non-care-service recipients

Care-seeking attitudes among care service recipients

Conclusions

8: Care Needs and Care Dependency

Dependency in general

Attributes of care dependency

Measurement of care dependency

9: Care Dependency in the Egyptian Context

Cultural adaptation of the Care Dependency Scale

Validity and reliability of the Arabic Care Dependency Scale

10: Care Dependency and Unmet Needs: Prevalence and Contributing Factors

Prevalence of care dependency and unmet needs

Factors contributing to care dependency

Conclusions

11: Conclusion

Appendices

1. The Care Dependency Scale (Arabic Version)

2. CDS: Factor analysis

3. Factors related to functional limitations and care dependency: Non-care recipients

4. Factors related to functional limitations and care dependency: Care service recipients

Bibliography

Index

Introduction

This book is the result of eight years of work and research in Egypt. The reader may ask why care for older persons in a developing country deserves so much interest. The common image of the demographic situation in these countries is a high fertility rate combined with low life expectancy at birth. In this context, health problems related to old age seem almost irrelevant. This idea needs to be revised. The developing world is undergoing a demographic transition, with higher life expectancy resulting in a greater number of older persons. At the same time, urbanization and industrialization produce social changes that begin to undermine the traditional family support system. Today, people in Cairo, Alexandria, and other bigger cities in Egypt live in nuclear families. The modernization of Egyptian society has, apparently, a two-sided effect. On the one hand, increased life expectancy indicates an improved standard of living; on the other hand, the conditions of modern urban life reduce the availability of support for older persons while the need for care begins to grow.

These socio-demographic changes interact with traditional Egyptian culture. The question that triggered the research presented on the following pages was, ‘How do the Egyptian people respond to the emerging phenomenon of old age and its related problems?’ The response is shaped by norms and values of cultural traditions. Cultures, however, are not static. Although rooted in traditions, they are also an arena of conflicting ideas and practices. This dynamism enables them to develop new norms and values in response to new situations. An increasing number of care-dependent older persons is such a new phenomenon, necessitating a process of social and cultural adaptation. Currently, this process can be studied in Egypt.

The first time I became aware of the emerging phenomenon of aging and the beginnings of cultural adaptation in this country was in 1996 when I had the chance to volunteer in a nursing home for older persons in Upper Egypt. The place was owned by a convent of the Coptic Orthodox Church, and, as a male nurse, I was invited for a period of two months to join the work and to provide some practical training for the caregivers in order to improve the quality of care. Five years later, in February 2002, while I was a student of nursing education, I returned with a fellow student to perform a four-week training program in basic nursing skills as requested by the convent. Teaching nursing in a foreign culture, where nursing homes are rather unfamiliar, raised the question of what care might mean for caregivers who dealt with care-dependent older persons for the first time. As teachers, we wanted to bridge the cultural gap between us and our Egyptian students. To improve mutual understanding, it was necessary to hear their perspective.

This perspective is, however, just one aspect of the process of cultural adaptation. First, the socio-demographic changes affect the older persons. Their perspective became the focus of my attention in 2005, when I started a project in cooperation with a Cairene branch of the same Coptic Orthodox convent. The aim of this project was to establish a training center for geriatric care and a home care service for older persons. Here, the care service recipients were paying customers and therefore we needed to understand their motives for demanding this hitherto unknown type of service in order to best meet their expectations. Researching the perspective of caregivers and care service recipients was thus triggered by problems of practical work. Consequently, the studies described in this book were intended to inform and improve practice.

This book addresses three major topics that are related to each other: supply, demand, and need for care. After a short introduction in Chapter 1 with up-to-date figures about the socio-demographic changes in Egypt, the following two chapters describe the currently available supply of care. Chapter 2 contains general information about the number and type of available care facilities, and the qualification of the persons who work as caregivers. Chapter 3 turns to the concrete experiences of these caregivers and explores how they respond to the challenge of caring for older persons. At the same time it illuminates the difficulties of recruiting people for this job.

The next four chapters focus on the perspective of care service recipients and investigate the existing demand for care. Chapter 4 introduces the reader to a theoretical framework of factors that produce different kinds of care-seeking attitudes. As we will see, such attitudes are not simply a result of needs. Older persons may dislike receiving support for several reasons, even though they suffer from reduced self-help abilities. In other cases they may demand some kind of support, but their need may be debatable. After these general theoretical considerations, we will focus on the perspective of older Egyptians. Chapter 5 presents the results of a qualitative study that investigated their attitudes toward home care services. When asked about nursing homes, study participants tended to reject this option despite the fact that nursing homes are the most common care facility in Egypt. This raised a question about the attitudes of older persons who live in such places. Chapter 6 provides an answer based on a qualitative study of nursing-home residents. Both investigations revealed a variety of factors that contribute to the acceptance or rejection of a particular kind of care. These factors interact in multiple ways to produce different results. To determine the central aspects of care seeking, we finally conducted a quantitative study among older Egyptians in Greater Cairo, which will be described in Chapter 7.

After exploring the demand for care and its underlying motives, the final part of this book analyzes existing needs. Chapter 8 introduces the reader to the concept of care dependency, which is defined as the need to receive support in order to compensate for a self-care deficit. Care dependency can be determined only by subjective assessments. For this reason, perceived needs are likely to be related to care-seeking attitudes, although they are not identical. Feeling a need for support and liking to receive it are two distinct phenomena. The assessment of care dependency provides an idea about the amount of care needed to compensate for deficits and limitations, whereas the assessment of care-seeking attitudes informs about the kind of support that is accepted by the older persons. After these general considerations, Chapter 9 turns to the assessment of care dependency in the Egyptian context. It describes how we determined the cultural adequacy of the Care Dependency Scale, an instrument used internationally to assess care needs. Chapter 10 finally turns to the question of where care is needed most. It reports the prevalence of care dependency and unmet needs among non– care service recipients, home care service recipients, and nursing-home residents, and it identifies socio-demographic factors that contribute to care dependency. These findings have practical implications for the future planning and development of care facilities in Egypt.

I would now like to express my gratitude to Professor Dr. Theo Dassen, who accompanied the eight years of research described in this book with his friendly support and advice. He prevented me from getting lost during this long research process and helped clarify many issues of central concern.

My research in Cairo would not have been possible without the valuable support and advice of Dr. Tamer Farid and Dr. Ahmed Mohammedin Shawky from the geriatric department of Ain Shams University Hospital. Both helped me, in the course of many long discussions, to understand the Egyptian research context and to develop the Arabic questionnaire.

Dr. Ate Dijkstra, from the Northern Center for Healthcare Research at the University of Groningen, and Prof. Dr. Christa Lohrmann, from the Institute of Nursing Science at the Medical University of Graz, provided useful advice for the assessment of care dependency and its statistical analysis.

Special thanks are owed to Dr. Magda Iskender, director of Care with Love, the first home care service in Egypt, and Dr. Nadia El-Afifi, head of the geriatric department of the Palestine Hospital in Heliopolis, Cairo. Both encouraged me in my research, provided access to the field, and always offered help in case of any problems.

Special thanks are due as well to my research assistants, Mrs. Mary Samuel Girgis and Mrs. May Mohammed Zaki, who performed the strenuous task of transcribing and translating the qualitative interviews. Together with Mrs. Mounira Ishaq Qusa, Mrs. Nevin Naim Iskender, Mrs. Nagla Milad, Mrs. Marcelle Assad, and Mrs. Amira Raouf Saadalla, they collected data for the quantitative study. My research owes a lot to their support.

Most of all, however, I would like to thank the caregivers and the older persons who allowed me to share in their experience of care. This book is dedicated to them.

1Demographic Transition

and Its Consequences in Egypt

Health and nursing care for older persons is not a top priority in developing countries like Egypt. Health agendas typically focus on maternal and child health and the prevention of infectious diseases (El-Katsha and Watts 2002; Khattab et al. 1999). Recent investigations, however, indicate a demographic transition, with much of the developing world, from India to South America, experiencing an aging population (Feachem et al. 1992; Martin and Kinsella 1994). As a consequence, the health of older persons will demand more attention in the near future. Some authors even claim a lack of appropriate health care policy in general (Feachem et al. 1992). Assessing the current and future need for medical and nursing care is essential for appropriate planning and delivery of health care services to the older person.

Based on a review of the literature, this chapter explores the present situation in Egypt. It presents up-to-date figures of the increasing number of older persons and the country’s changing age-group composition, and analyzes the social consequences of these current changes. The crucial questions in this context are: how prepared is Egyptian society to cope with an increasing number of older people, and are the traditional social networks still sufficient?

Aging—an emerging phenomenon in Egypt

Prevalence of old age depends on life expectancy at birth. Demographic surveys in Egypt indicate a change in life expectancy at birth over the last fifty years. According to Mason et al. (2001b), life expectancy at birth was as low as forty-four in 1950. That number climbed to sixty-eight by 2000. The Arab Human Development Report provides similar figures: between 1950 and 1955, life expectancy at birth was 41.2 years for men and 43.6 for woman, and by the year 2000 it had reached 64.2 for the male and 65.8 for the female population (UNDP/RBAS 2002). This trend is expected to continue.

Increasing life expectancy results in a higher number of older persons. The available data, however, are conflicting. The Economic and Social Commission for Western Asia (ESCWA 2008) reports that the number of persons over sixty-five in Egypt was 3.497 million, who made up 4.8 percent of the total population. The Egyptian Yearbook 2007 published by the Central Agency for Public Mobilization and Statistics (CAPMAS) refers to 4.554 million persons over sixty, who make up approximately 6.3 percent of the total population. Another report by the Information and Decision Support Center, published one year later, mentions 4.414 million persons over sixty (Egyptian Cabinet 2008).

One source of confusion is the lack of consensus about the definition of old age. Yet even sources using the same definition of old age do not always concur, perhaps due to different data collection methodologies, which unfortunately are not disclosed in these reports. Accepting sixty years, the age of retirement in Egypt, as the beginning of old age, the number of older persons lies somewhere between 4.4 and 4.6 million.

This lack of precise information allows for only a rough estimate of future development. Mason et al. (2001a) propose different scenarios for the population of over-sixty-fives in the year 2025, based on various mortality rates (figure 1). In this model, a medium mortality rate, with a steady increase of life expectancy according to population growth trends during the last few decades, would yield an over-sixty-five population of 7.3 million (compared with 2.4 million in 1995). A high mortality rate, halving the current trend, would lower this to 6.8 million, but a low mortality rate, doubling the current trend, would bring it to approximately 8.3 million by 2025. The above-cited ESCWA report (2008) predicts an increase in the number of over-sixty-fives from 3.497 million in 2005 to 7.487 million in 2025, fairly consistent with the projections of the model in figure 1.

More important than the number of older people is the age-group composition of the overall population. This is driven not only by