Download - Elderly mental health in the developing world

Pergamon 0277-9536(94)00434-X Soc. Sci. Med. Vol. 41, No. 7, pp. 983-1003, 1995

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ELDERLY MENTAL HEALTH IN THE DEVELOPING WORLD*

SUE E. LEVKOFF, IAN W. MACARTHUR, and JULIA BUCKNALL Division on Aging, Department of Social Medicine, Harvard Medical School, 643 Huntington Avenue,

Boston, MA 02115, U.S.A.

Abstract--Growing numbers of elderly in countries of the developing world presage an increase in those affected by organic, age-related mental diseases such as dementia. A simultaneous rise in the burden of non-organic mental disorders in elderly populations is likely because stressors in many countries are affecting the mental health of the elderly directly and/or indirectly by altering the ability of families to provide care for them. This paper reviews studies on the disease burden of mental health problems of the aged in the developing world. It examines evidence on how demographic change, economic change, education, urbanization, war and displacement, and widowhood influence elderly mental health. A look at policies and programs improving the condition of elderly mentally ill throughout the developing world emphasizes positive options for policymakers. Recommendations for future research both identify areas in which investigation would be particularly useful and highlight current methodological problems.

Key words--elderly, mental health, developing countries, family care, policy

The mental health of the world's elderly is an increasingly important issue as the numbers of aged grow at unprecedented rates. Most discussion of demographics regarding countries in the developing world [ 1, 2] has traditionally focused on issues, such as high birth rates and low life expectancies, relating to non-elderly parts of the populations rather than on issues concerning the elderly. Whereas we have thought of populations in these countries as predominantly comprised of the young, soon they will also hold most of the elderly in the world [3]. Current evidence indicates rapid increases in numbers and proportions of elderly people in developing countries. In 1950 the 200 million people aged over 60 in the world were evenly distributed between developed and developing countries [2]. By 2000 the total will have grown to 614 million, with 62% living in developing countries, and by 2025 this percentage will reach 72%, corresponding to 1.2 billion people.

Not only is the distribution of the world elderly population shifting, but the rates of change are remarkable. Between 1980 and 2025, the global population over 60 will grow by 198%, in comparison to less developed countries, in which it will rise by almost 293% [4]. Older age groups will see the highest rates of growth. The UN predicts that the overall population in the developing world will expand 47% between 1980 and 2000, but the age groups 60 + , 70 +

*An earlier version of this manuscript was prepared as a background, working paper for Worm Mental Health: Problems, Priorities, and Responses in Low-Income Countries, a report compiled by the Department of Social Medicine, Harvard Medical School, forthcoming by Oxford University Press.

and 80 + will grow 75, 85 and 104%, respectively [5]. Projected numerical increases, especially for the older age groups, are greater for women than men. Between 1985 and 2025, the UN expects the number of males aged 70 and above in the developed world to increase by 32 million and the number of females by 38 million. Corresponding figures for the developing regions are 284 million for males and 317 million for females.

Existing data does not allow for certainty in determining whether or not incidence and/or prevalence rates of organic and non-organic mental illnesses are on the rise among the aged, but the increase in absolute numbers and proportions of elderly in populations portends a greater global burden of mental illness. Population aging will result in an inevitable expansion in organic, age-related mental diseases, such as the dementias. Also, forces in the developing world, such as urbanization [6, 7] and war and displacement [8,9], have been linked to increased levels of non-organic, minor psychiatric morbidity among the elderly. Demographic and economic trends and access to education for the young may alter family structure and function and correspondingly damage traditional (often rural) care patterns for the aged (for example, Refs [10, I l]). Empirical studies from the anthropological literature show that new care patterns, reflecting a changed society, frequently are inferior to those that previously existed (for example, Refs [12, 13]). Possible results for the aged are a variety of poor mental health outcomes, such as depression, anxiety and suicide, as well as serious constraints on the quality of life [14, 15].

Not all researchers, however, support the idea that certain forces, like urbanization, cause mental health problems and that new patterns of family care in developing countries result inevitably in poorer care

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984 Sue E. Levkoff et al.

for the elderly. For example, studies have arrived at different conclusions regarding the direct effects of urban living on mental health (see [6] for review). Also, at least a few studies indicate that despite rapid socioeconomic change, care systems in some societies still accomplish their function in a satisfactory, albeit different, manner [16, 17]. Also, care systems in industrialized societies, where the nuclear family is more prevalent, may involve institutional care resources and social security that allow the elderly to live independently from their families [18]. Thus, the popular concept that 'modern' care systems are not as adequate as 'traditional' ones, where the extended family is said to provide care, may not be accurate.

What does seem probable, however, is that the rapid pace of demographic, economic and social change in developing countries does not always allow for the development of alternative care mechanisms to the extended family and the community, as occurred historically in countries where changes proceeded more slowly. Moreover, when such changes occur without concurrent economic improvement, and/or in a context of poverty, the elderly are often isolated from their previous roles and left more vulnerable to lack of care (see Refs [19-21] for discussion). The "intimacy at a distance" pattern of care of Western industrialized nations [18] may not be easily duplicated in countries without communication and transpor- tation infrastructure and where the elderly have very little or no income to live apart from family members [21, 22].

Evidence from the empirical literature indicates that, for the most part, there is cause for concern about the changing nature of family care in many parts of the world, especially where formal care mechanisms are weak. Moreover, recent evidence shows that the elderly may be particularly vulnerable to the process of urbanization in poverty and to war and displacement. Countries will need to design care systems that build upon strengths inherent in their societies in order to lessen the strains of social change and their impact on mental health.

In the first section of this paper we review existing evidence on the mental health of the elderly in the developing world. Second, we examine empirically- based literature regarding forces in developing countries that affect mental health and family care. Third, we reconsider some common assumptions concerning family care. The fourth section discusses policies and programs providing care for the elderly in developing countries, with special consideration for those who are mentally ill. In conclusion, we recommend research in areas that would fill important gaps in the existing literature on the mental health of the elderly in the developing world.

MENTAL HEALTH OF THE ELDERLY

In the absence of many rigorous large-scale epidemiological studies examining mental health

among the elderly in Africa, Asia (with the exception of China) and Latin America, we include mainly small studies in this review. Comparisons among these small-scale studies are difficult because they differ in terms of purpose (i.e. measuring different types of mental illness), methodology (i.e. use of different diagnostic tools and criteria for caseness), and study samples (i.e. community vs clinical, and total adult population vs strictly the elderly). Furthermore, sociocultural factors contribute to the differential manifestation of psychiatric disorders, making comparisons of studies on these disorders from different societies problematic [23]. Due to the great heterogeneity within populations in developing countries, results from some studies cannot even be generalized to the whole population of a country or even a particular region of a country. Despite these limitations, the following studies collectively offer our best insight into the burden of mental illness among elders in the developing world. Throughout the review we focus on cultural interpretations of observed differences among dissimilar societies.

Organic disorders

Researchers have studied incidence and prevalence rates for dementia in different areas of the world, including North America, Europe, Scandinavia, Russia, Japan, China, Singapore and Australasia [24, 25]. Most studies indicate higher prevalence rates of Alzheimer's disease (AD) in comparison to vascular dementia in North America and Europe. On the other hand, Russia, China and Japan reveal the opposite pattern [25] (p. 10). Researchers in the United States have cited elevated levels of hypertension and other cardiovascular risk factors to explain evidence that African Americans, and possibly Asian Americans, show higher prevalence rates of multi-infarct dementia [26].

Little information exists on the age-related dementias in the developing world, except for China, where researchers have devoted substantial recent effort to their study. In an epidemiological survey of community residents in an urban area of Beijing using a Chinese version of the Mini-Mental State Exam (MMSE), Li et al. [27] observed prevalence rates of moderate and severe dementia of 1.28% and 1.82% for those aged 60 and above and 65 and above, respectively. These rates are considerably lower than those from developed countries. Given that dementia rates increase steadily with age, the authors state that this difference can be partly explained by the relative age distributions of the elderly populations, with more very old persons found in the developed countries. Zhang et al. [28], also using a Chinese version of the MMSE, found a 4.6% prevalence rate of dementia among those over age 65 in a probability sample of 5055 non-institutionalized elderly in Shanghai. Of those demented, the researchers classified 64.7% as having AD and 26.8% as having a vascular dementia (including multi-infarct dementia), which counters the

Elderly mental health

usual observation from China of higher rates of vascular dementias than AD.

The researchers in the Shanghai study also noted that the prevalence rate of AD was low in comparison to a study in East Boston [29] using similar methods (10.3% prevalence rate for those over 65). Katzman [30], (p. 15) proposed that the higher prevalence of AD detected in the East Boston study could have been due to methodological differences, specifically, the accep- tance of subjects in East Boston as cases if they possessed clinically apparent cognitive changes without the stricter DSM-III requirement of formal evidence of functional impairment used in Shanghai. Zhang et al. [28] suggested that there may exist either different incidence rates for dementia or different mortality rates for those with dementia in the two communities, and that there is significant underrecog- nition of dementia symptoms by Chinese families. Ikels [31] argues that delayed recognition of symptoms occurs in China, in comparison to the United States, for many reasons, including the fact that most Chinese elderly live with their families and little is expected of them, as younger members of the family assume responsibility for household affairs. Thus, the family may easily overlook early signs of intellectual deterioration because decline in instrumental activities of daily living, one of the early markers of cognitive loss, is not readily observed [31]. Also, lack of recognition of symptoms allows the family to avoid the stigma associated with mental illness in Chinese society [28].

In a recent review regarding the differential diagnosis and prevalence of dementing illnesses in India, Wadia [32] argues, based on the scant published literature from India and clinical experience, that there is no reason to believe that the prevalence and types of dementing illnesses are significantly different in India than in the West (also see Ref. [33]). Wadia cites two studies [34, 35] from South India where dementia rates among persons over 60 were 6.1 and 10%, respectively. Neki [36, 37] presents information from an early sample survey, showing that of the elderly hospitalized for mental illness in India, approximately one-eighth (12%) suffered from organic brain syndromes (including senile psychoses), compared to over a third from chronic schizophrenia and over a quarter from depressive illness. He posits that the rarity of senile psychoses could be due to: (1) lower longevity; and/or (2) higher tolerance by the community for the demented aged in India as compared to industrialized countries [36]. The implication of the latter explanation is that symptoms of dementia are an expected or at least understandable part of aging in some subcultures of the country [36].

As early as 1966, Lambo [38] offered both of these explanations to account for the apparent scarcity of psychiatric disorders, including senile dementia, in the aged of the developing world, and Africa in particular. Since then, as life expectancy has improved, authors have relied increasingly on the explanation that the

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family harbors the mentally and physically impaired aged from the public gaze in order to preserve their dignity and the respect that African culture confers to them [39, 40], resulting in few elderly with symptoms of dementia being identified either in medical clinics or through door-to-door screening. Makanjuola [41] supports this view in his interpretation of why so few elderly Nigerians attend psychiatric clinics for conditions including dementia. He proposes that families are relatively tolerant of all but the most extreme mental disturbances in the elderly and thus delay or fail to seek care from medical facilities. Furthermore, in a community survey of 18,954 subjects (6% and 4%, respectively, above the age of 60 and 65) in a Nigerian village, Osuntokun et al. [42] discovered no cases of dementia and offered as a possible explanation of this finding the idea that families would not readily provide access of door-to-door interviewers to their disabled elders.

Despite the conventional idea that the family protects demented elders, Osuntokun et al. [43, 44] postulate that lower rates of age-associated dementias, particularly AD, may actually exist in Africa due to the absence of certain as yet unidentified 'risk factors' (see Refs [45-47] for discussion) found in industrialized countries, and they summarize their own studies and observations over the last decade to support their assertion (see [43, 44]). In a door-to-door community study using a modified MMSE to suit the local culture, they confirmed no diagnosis of dementia using ICD- 10 and DSM-III-R criteria in their sample of 326 individuals aged 65 and older. Furthermore, in an autopsy survey of 198 brains of Nigerians aged 40 years and older (45 of whom were 65 and older), they found no psychological changes consistent with AD. Between 1984 and 1989 at the University College Hospital Ibadan, they diagnosed 18 of 37 dementia patients (28 males and 9 females) with multi-infarct dementia but none with AD. Also, in a consecutive series of 2182 new patients (6% of whom were older than 65) in a Nigerian neuropsychiatric hospital, they saw no patient with AD.

One study from Nigeria does point to a higher rate of Alzheimer's type dementia [39]. This study of psychiatric disorders among 73 consecutive patients aged 60 years and older admitted for the first time into a psychiatric hospital reported that Alzheimer's type dementia was more common among females while multi-infarct dementia was more common among males. However, the authors did not provide the specific rates of these dementias. Senile dementia was the most common of the organic psychoses, which accounted for 30% (n = 22) of the total presenting sample.

Non-organic disorders

Data on non-organic disorders specifically among the aged in countries of the developing world are limited. The studies reviewed below describe the burden of non-organic mental health problems among


adult populations (often including the elderly) and elderly populations in the developing world.

Even in adult populations, few studies are comparable because of the use of different sample types and diagnostic instruments. In a village in Lesotho, Hollifield e t al . [48] determined the prevalence of the following disorders among adults in the community: depression, 9.8%; panic disorder, 3.2%; and, generalized anxiety disorder, 4.9%. They were able to compare results with a similar study from the United States and found higher prevalence rates in Lesotho. In Benin, Bertschy et al. [49] documented a western clinical pattern of depressive symptoms, albeit with a higher frequency of somatic complaints and ideas of persecution and a lower frequency of suicidal thoughts and guilt feelings among adults, but on the whole, the study did not lend support to the idea of 'culture-bound' symptoms. One drawback of the study was that the sample of 92 Beninese patients was more westernized than the population of the country at large because they were primarily urban and were all French-speaking. Gureje et al. [50] showed a 27.8% weighted prevalence for DSM-IIIR diagnoses using the 12-item General Health Questionnaire (GHQ) on 787 clinic attenders in a Nigerian city. Those over age 60 in this population sample had the highest levels of generalized anxiety disorder (13.9%) and somatoform disorders (13.1%). An epidemiological study of mental health symptomatology in Indonesia [51] using the 30-item GHQ found a 20% rate of caseness among a probability sample of 1670 adults. The case rate was lowest among individuals belonging to communities that had progressed substantially in their standard of living (i.e. that had shown the most socioeconomic development). Higher rates ofcaseness existed among those having little education and poor housing and living in poverty. Based on these findings the authors conclude that rapid socioeconomic and cultural changes in the industrializing world need not uni- versally contribute to increased mental disorder, as is often believed, but may have a beneficial impact on mental health if they bring substantial economic progress.

Studies focussing exclusively on the aged are equally diverse. Neki's survey of psychiatric disorders among the hospitalized aged in India found 27% suffering from depression [36, 37]. Depression seems to be a common diagnosis in India [52], with prevalence rates in primary health care settings varying from one- twentieth to between two- and three-fifths of attenders, depending on the region of the country and the diagnostic criteria used [53, 54]. In addition to a core of depressive symptoms, Indians typically exhibit high levels of somatic symptoms but low levels of psychoses [52]. Makanjuola's [41] study of 51 elderly Nigerians attending a psychiatric clinic revealed that 9.8% suffered major depressive disorder while 55 % exhibited late onset paranoid disorders (of which 20 cases fulfilled criteria for paranoid schizophrenia). From a community survey of elderly black persons in two

South African townships, researchers reported that fully 25% of respondents were regarded as clinically depressed [55]. In the more recently settled township, 53% of men and 76% of women had psychiatric manifestations 'warranting further investigation', and 44% of the women would have been treated for depression if seen by a psychiatrist, having shown more worry, a feeling that life is not worth living, sleep disturbance, early morning waking, headaches, crying and anhedonia (i.e. pleasure not derived from normally pleasurable behavior) than other groups in the study.

Results from the screening of a sample of 111 community-dwelling elderly aged 65 years and older in $5o Paulo, Brazil with the Clinical Interview Schedule (and using ICD-9 classification criteria) showed a 29.7% prevalence of psychiatric problems with the following distribution: dementia, 5.5%; depression, 14.3%; neuroses, 7.7%; personality disorders, 15.3%; substance abuse disorders, 3.3%; and adjustment reactions, 6.6% ([56]; also see Ref. [57]). When the authors compared these data to those from a similar sample of community-dwelling elderly from Mannheim, Germany, they observed much higher symptom rates for minor psychiatric morbidity (MPM), such as sleep disorder, irritability, anxiety, depression and lack of concentration, in the $5o Paulo sample. They believe that these high symptom counts in S~o Paulo relative to those in Mannheim reflected "stresses associated with rapid acculturation, poverty, difficult housing conditions, and low or non-existent retirement pensions for the elderly" [56] (p. 250).

In a four country study on aging in the West Pacific region (Fiji, Malaysia, Philippines and the Republic of Korea) using representational samples of the elderly population (60 and over), Andrews e t al. [58] reported on the presence of five symptoms of MPM: sleep difficulties, worry and anxiety, loss of interest, tiredness and forgetfulness. Their data demonstrated that, in general, the level of all problems remained static or increased with age. In Fiji, older subjects documented loss of interest and forgetfulness more often than younger subjects, with no sex differences. In the Republic of Korea, 30-50% of the study population complained of sleep difficulties, worry and anxiety, loss of interest and tiredness, and these proportions changed very little with age. In Malaysia, the male population showed an increase with age in the reporting of all five mental problems, and the female population showed the same trend with loss of interest, tiredness and forgetfulness (also see Refs [59, 60]). These increases were greatest for loss of interest. Eighteen percent of men and 29% of women aged 60-64 years said they were not as enthusiastic about doing things they used to care about; comparable figures for those 80 years and over were 76% for men and 77% for women. In the Philippines, prevalences of all five mental health problems increased with age. Differences between youngest and oldest age groups appeared largest for loss of interest (about 30% difference for both sexes), tiredness (29% difference for

Elderly mental health in the developing world 987

men), and forgetfulness (48% difference for men) [58] (pp. 43-44). Respondents stating that they were lonely accounted for the following percentages: 24% in Fiji, 22% in the Republic of Korea, 10% in Malaysia and 7% in the Philippines.

Suicide

According to Sainsbury [61] suicide rates peak around 65-75 years of age for males in industrialized countries and a decade or so earlier for women. In both cases this coincides with the time when the individual's primary role in society is declining. Most countries follow this pattern of increasing suicide with age [62], but there are exceptions resulting primarily from strong cultural differences. For example, in a study of suicide in Jordan covering the years from 1980 to 1985, the highest rate among males fell in the 25-34 age range (3.73 per 100,000) and among females in the 15-24 age range (3.38 per 100,000) [63]. The rates for males and females over the age of 65 were 2.58 and 2.06 per 100,000, respectively, above average but still below other age groups. The author suggests that low rates of suicide among the elderly were due to the strong extended family system that protects them against social isolation, which is often cited as a risk factor for suicide among the elderly.

Several studies from Asia confirm that suicide rates are generally higher among the elderly than among younger age groups. In a study of Sri Lankan suicide data, rates climbed sharply after age 44 [64]. Males 65-74 years old had a suicide rate of 60 per 100,000, which jumped to 129 per 100,000 for those over 75 years old. For females aged 65-74 the rate was 14 per 100,000 and 24 for those over 75. The generally high rates of suicide in Sri Lanka may be due to long term and widespread social unrest. In Fiji, one study found that elderly men were killing themselves at increasing rates at least in part because some had been rejected by their families after their economic usefulness had declined and could expect only to live in homes for the destitute elderly [65].

In addition to the variation in suicide rates based on age, rates also differ with regard to sex. Suicide rates are generally higher among males than females worldwide. Lester [66] observed the lowest male/ female suicide ratio (mean of 1.35) in a sample of Asian nations in comparison to countries in other regions. In fact, the observation that suicide rates are higher throughout the world for men than for women is defied perhaps only by China. Some recent analyses, based on limited data, revealed a high suicide rate among women in China [67], and in a study by Lester [68] the female rate (20.4 per 100,000) actually surpassed the male rate (14.9 per 100,000) by a fair margin. Suicide rates among Chinese women peak over age 60, and the highest rate (over 90 per 100,000) occurs at the age of 80 [67]. Li and Baker [67] cite poverty, long-term disease and the decrease of traditional family relationships as possible factors contributing to the very high rates in old age.

FORCES INFLUENCING THE MENTAL HEALTH OF THE ELDERLY

Phenomena throughout the world may impinge upon the mental health of the elderly directly and/or through mediating variables such as family care. For example, war and displacement may directly contribute to psychiatric morbidity, including psychoses, behavioral disturbances, substance abuse and suicide [15] among the elderly and also limit the family's capacity to care for its elders. Factors such as rural-urban migration will likely continue to indirectly impact elderly mental health by undermin- ing family and social structures ensuring care for the elderly and traditional mechanisms for buffering distress, especially among those who are mentally ill. Of course, variables such as age, gender, income and culture (i.e. specific local realities) determine how changes affect caregivers and elderly [14].

In Fig. 1 we show some of the main forces affecting the mental health of the elderly and the relationships among them. Economic change, increasing rates of education among the young and urbanization are all very closely interrelated, and we distinguish between them mainly in order to organize information into subsections in this part of the paper. Family care is presented both as a mediating variable, because it acts as a conduit through which the proposed forces influence mental health, as well as a predictor variable [69], since it also directly impacts the mental well-being of the elderly. Although we know of no studies that have explored specifically the link between breakdown or lack of family care and poor mental health outcomes among the elderly, some researchers state that changes in family care and social support likely contribute to depression and other types of minor psychiatric morbidity [7, 14, 15, 69, 70]. Both demographic change and widowhood (as well as the other variables presented in the model) hold implications for levels of family and social support. For the sake of simplicity, other critical variables do not appear in Fig. 1. For example, migration (primarily of the young) is often a determinant of the family's ability to support their aged, but we assume it to be an integral component of several forces in the model, including economic change (i.e. industrialization), urbanization, the motive to gain education, and war and conflict. The following discussion examines the ways in which the forces in Fig. 1 act to influence the mental health of the elderly.

Demographic change

Population aging in the developing world bears implications for the mental health of the elderly both in terms of organic and non-organic disorders. As already mentioned, since rates of certain dementias increase with age, there will be a greater percentage and absolute number of demented elders in populations as they become older. Also, as basic health technology reaches populations and as their standard of living improves, more frail elders are likely


to survive, and for longer periods of time [71]. A possible consequence in many traditional societies is poor treatment of these growing groups of frail elderly and subsequent increases in their levels of minor psychiatric morbidity. For example, Guillette [72] explains that the Tswana of Botswana recognize a distinction between the economically/socially productive elder and the frail old and treat them differently. Specifically, they treat the frail old with less respect, and support for them is more uncertain. In their statistical analysis of coded ethnographic data from 57 non-industrial societies, Glascock and Feinman arrive at the same conclusion in explaining how the contrasting norms of supportive and death-hastening treatment of the elderly can co-exist in so many of the societies in their sample:

While an aged individual is considered young or intact by the other members of the society, support for his or her existence is provided. However, once this individual passes over into the old or decrepit group of elderly, support is withdrawn dramatically, since the non-supportive treatment in all but one instance is death-hastening. Societies manage, therefore, to have both types of behavior without internal strain because the two types of behaviors are directed at different populations. Individuals are selected as recipients for each type of behavior according to which group of old they belong [73] (p. 27).

Logue [71], through an extensive qualitative analysis of the anthropological literature, again confirms the idea that the frail elderly are rarely valued by younger members of society. Thus, a rise in the proportion of frail elderly may correspond to increased minor psychiatric morbidity among the aged on the whole in some populations as a result of the withdrawal of societal and family support for this subgroup.

Despite lack of consensus among researchers on the 'old age security motive' of having many children, there is generally agreement that declining birth rates will equate to fewer potential caregivers for elders in many areas of the developing world [2, 21, 74, 75] (p.20). Most countries are observing lower birth rates, in comparison to former conditions of high fertility, as they undergo the demographic transition [3]. Exceptions do exist in sub-Saharan Africa, and in Kenya where fertility levels and natural population growth have recently reached all time highs of eight children per woman and 4% per year, respectively [76]. High birth rates in developing countries have often been viewed partly as a consequence of people's need for old age security (see Ref. [77] for a review). At least, many parents have used this motive to explain their desire for having more children [77] (p. 88). However, strong cultural norms associated with religion may be the most important factor in maintaining high fertility rates and even spurring increasing rates in the unusual cases of countries in sub-Saharan Africa ([78], and see Refs [76, 79]). Currently, in most countries, the trend of having fewer children poses greater insecurity for the elderly in terms of care and economic well-being.

The few attempts that have been made to directly assess the impact of decreasing fertility on family care for the elderly indicate that it varies among countries. Using the 1986 percent distribution of elderly according to actual number of living children and fertility preferences, Knodel, Chayovan and Siriboon [80] modelled the future distribution of elderly in Thailand according to their estimated number of children and found that the future majority (57.5%) would have two children in comparison to the majority in 1986 (59.8%) that had five or more children. They

Economic Change ] Demographic Change

Educ ~ l~_y ]

War and Displacement

Fig. 1. Relationships of factors influencing the mental health of the elderly in developing countries.


conclude that care for the elderly, especially in terms of material support, will decline moderately but that, since most elderly will still have at least two children, support through co-residence with one of them will remain a strong likelihood. In perhaps the most extreme case, China's one-child family planning policy puts at risk the 'informal' social security system of the family [81], even though Chinese children are legally responsible to care for their parents in old age [21, 82, 83]. Not only is it difficult for just one child or married couple to care for their parents [84], but if the child is a girl, the parents can expect isolation in old age due to patrilocal residence patterns [82]. Elderly who are childless in countries without strong alternative care systems to the family face particularly difficult situations. Childless elderly among the Gende of Papua New Guinea who have not been able to construct successful exchange relationships in their society are frequently neglected and abused because they are perceived as a burden; with increasing de facto childlessness due to migration of the young away from villages, the plight of the elderly is likely to worsen [85].

Economic change

A shift in the nature of the economy can alter the well-being of the elderly. Many developing countries have primarily rural economies, based on agricultural production. Throughout the world, as countries have industrialized, the values of agricultural products and related assets, like agricultural land, have fallen relative to those of manufactured goods [86]. In rural communities, social status and financial security frequently depend on land or cattle often owned by the elderly [72]. If they become devalued, the elderly person is vulnerable to both financial hardships and social marginalization. For example, according to a review and empirical evidence presented by Guillette [72], economic change from an agricultural subsistence economy to a money market economy in Botswana diminished the importance of the traditional system of 'status construction' for the elderly that was based on agriculture and pastoralism. Remittances from children and other relatives in the main city assumed increasing importance. Moreover, retailing and brewing of beer, food production and cattle raising were particularly hard hit by a drought in the 1980s, and the elderly as a group seemed to suffer disproportionately, since a greater percentage of them were involved in these activities in relation to other age groups [72].

Several studies in Asian societies have produced similar conclusions. In examining the effects of the transition from a kin-based to a cash-based economy on the family system of care for the elderly in rural Northeast Thailand, Caffrey [87] found that households in which the youngest daughter cared for the elder at home according to tradition were significantly larger, had more cultivated land and a higher yearly income than did households in which the elder cared for him/herself. Although very high levels of family


support for the elderly in Thailand are shown in surveys (see Ref. [88]), a portion of elderly in Caffrey's study, those without enough land to establish attractive lives for their children, complained of little support. They cited their children's departure from home in search of education and jobs in explaining their own loneliness, a felt lack of respect on the part of their children, and why they perceived the care from their children as worse than that which their own parents received. In rural Zhejiang province, China, after forced collectivization of the agricultural economy in the 1950s, the commune oversaw the family support system for the elderly and ensured their financial security [10]. According to a study by Goldstein and Ku [10] the shift toward a market system and household production in the early 1980s has not necessarily resulted in a resurgence of filial piety and traditional patterns of extended family care as hoped, and in fact, they found that the nature of family support varied from situations in which the elderly had little power and independence to ones in which they controlled resources and were fairly autonomous. The elderly in the study noted materialism (i.e. consumption for pleasure and to show social status) of the younger generation in the context of the market economy as an important new factor diminishing the respect and support they, as elderly, commanded. In a rural Taiwanese village where Gallin [11] conducted research intermittently since 1957, the almost entirely agricultural economy changed to one based mainly on off-farm employment in a span of 30 years. The old pattern of domination of mothers-in-law over their daughters-in-law began to vary as more of the young gained access to resources through wage employment and involvement in family cottage industry. Daughters-in-law who controlled more resources than their mothers-in-law were able to reverse the power structure and defy norms of filial piety. This created a situation in which older women tried to make themselves useful to daughters-in-law in order to secure adequate care and provision for their basic needs.

Economic forces can transform systems of inheritance of land and other assets that helped secure care for the elderly [89-92]. For example, in the traditional agro-pastoralist system in the Bay region of Somalia, sons' families cared for their fathers until their deaths in order to ensure inheritance of land and animals [93], but if the sons can make money by working in the city, for another agriculturalist or as merchants, they may purchase land and animals before their father dies, making them less dependent on family inheritance. This challenges the customary pattern of inheritance and caregiving and the status and prestige of elderly males in the society. The elderly may attempt to adapt to such changes, but they often suffer in the process. In the Somali case, instead of distributing resources to their sons at times prescribed by the Koran and by custom, fathers manipulate the rules regarding transfer in order to retain economic


power and the greater likelihood of care from sons [94]. Similarly, when the young family members of the Sherpa in Nepal move from the villages to urban centers, and so become unavailable to share the household and take care of the elderly, the old resist established methods of dividing up property and keep their sons' share of the family land for themselves. By doing this, they maintain their economic security, but they also expressed loneliness and dissatisfaction with disruption of old family residence patterns [95].

As documented in many studies throughout the world, perceived employment opportunities in the cities can draw the younger generations away from the rural environment and leave the elderly there with no one to care for them (for example, regarding sub-Saharan Africa, see Ref. [96], and for West Africa [97]). In fact, rural areas are disproportionately older in most of Africa, Asia and Latin America [75, 98]. For example, although 57% of all South Korean men live in cities, only 39% of men aged 55 and older and 29% of men aged 75 and over reside in them [99] (p. 7). In Zimbabwe in 1982, 26% of the population was urban, while only 3.3% of the urban population was aged 60 or more, vs nearly 6% of the rural population [98]. In East, West and Central Africa, 90, 83 and 82%, respectively, of the elderly lived in rural areas in 1980 [100]. Among the Temne of Sierra Leone, the elderly who migrated to an urban area during their productive years often retire to their rural area of origin, and the "rural elderly almost never migrate to live with urban kin if there is anything approaching a viable alternative" [101] (p. 261). The author generalizes this phenomenon to many West African societies. Thus, villages in many African countries have essentially become homes for the very young and very old [39, 72, 96, 102, 103], who must bear responsibility for farming as well as household maintenance. Accentuat- ing this trend, especially in parts of Africa, is the AIDS epidemic which predominately infects and kills people during their reproductive years [104, 105]. Migrants often send money back to their relatives, but the care of the elderly in the villages may become more problematic with increased migration [2, 106, 107]. The situation in Latin America [108], and especially in Brazil [109], is somewhat different from other developing countries because the migrants tend to stay permanently in urban areas and because larger proportions of the populations live in urban areas. Thus, to a greater extent, Latin America has witnessed the phenomenon of migrants "aging in place" after they settled in the cities in their younger years [108].

Not only will economic development spur migration of both men and women, but it will also increase the number of women in the work force in many countries [2, 99, 110], and as women tend to provide the bulk of care for the elderly, this will reduce possibilities for informal care. In some circumstances the caregivers

*The average rate of illiteracy in these countries was 40% for men and 52% for women [116].

may still be meeting the needs of their own children while also juggling the demands of their elders and those of work [111]. Many researchers have documented the stresses of caregiving, including isolation, financial troubles, depression, lack of satisfaction with life, decline in health and adverse effects on family activities (see, for example Refs [112-114]). Those caring for relatives with cognitive impairments are at particular risk [111, 115]. Since life expectancy continues to increase in most developing countries, women caring for older husbands or relatives may be in the later years of middle age or even older [81].

Educat ion

Rates of education have been increasing in many countries of the developing world and should continue to rise [116]. Literacy rates vary from country to country. In the poorest countries more than two-thirds of the population are functionally illiterate, with higher rates of literacy among younger members of the population [116]. Illiteracy is almost always higher among women than men. In 1990 in low income countries, the average rate of illiteracy among women was 30% higher than among men [116], but the gap is closing in many countries for younger age groups [98, 116].

Education levels relate to the mental health of the elderly in two ways:

(1) when the elderly themselves have received formal education, which has positive effects; and

(2) when the young are educated and the elderly are not, which can have negative effects.

Education in early life improves the well-being of the elderly. Longevity correlates positively with education, both because education enhances the individual's economic prospects, and because it helps people adapt to socioeconomic changes [98]. On the other hand, when younger members of the society have received formal education, they often feel they have less of a role in the agriculturally based, traditional society and migrate to cities [102, 115-118], most often leaving the elderly behind.

When younger members begin to receive education, elderly uneducated members find themselves in a society that no longer values their knowledge and experience in the same way as before [2] (p.48); [72] (p.199). A lack of respect from younger family members bears psychological, social and economic repercussions for the elderly [89]. For example, according to Dorjahn, the elderly Temne of Sierra Leone felt 'short-changed' in the sense that the "knowledge they had gained was not always regarded as valuable by the young, increasingly coopted by knowledge gained through Western schooling . . . " [101] (p. 273). Furthermore, Cattell says that among the Samia of Kenya, even though the elderly generally received good care, they often complained "that young


people 'don' t want to hear what we old people have to tell them, they just go to books'" [119] (p. 389); [120]. After fieldwork in different parts of Africa, and particularly in a Bambara village in Mali, Rosenmayr concluded that contact with aspects of Western society, especially formal education, created a situation where "children learned to become critical of the old power figures in their villages" [12] (p. 37). He believes that a fundamental change in the social fabric of the village is occurring, as the principle of 'seniority,' through which elders have traditionally received their social status and power, declines.

As explained earlier in the description of Fig. 1, access to education, place of residence (i.e. urban vs rural) and the nature of the economy (i.e. level of industrialization) are intimately linked, and together as a group, they affect sociocultural norms regarding the elderly. According to Levine [13], after massive expansion of public education infrastructure in Mexico in the 1970s, parents have invested more in their children's education; yet, an attitudinal survey among schoolchildren in a poor urban area and a longitudinal study of 18 families revealed that children often felt they did not owe their parents anything in a material sense. Seventy-two percent of mothers of childbearing age surveyed in a rural area expected their children to support them in old age and widowhood in comparison to only 26 % of the urban sample. Levine concludes that social change linked to urban residence and education has led to a situation in which "transactions which, in an earlier rural generation, were based on a sense of parental right on one side and filial obligation on the other, now depend to a far greater extent on the capacity of the aging parent to demonstrate his or her value to adult children" [13] (p. 235). Another example comes from Taiwan, where the gradual industrialization of the urban economy has attracted a steady stream of young rural migrants. In order to prepare their children for higher paying urban employment, parents in the rural, agricultural environment send them to high school and college in urban areas [121]. The elderly villagers view the knowledge of their children as superior to their own [121] (p. 167), and when the youth return home on vacation they are not called upon to participate in work on the farm, despite the high cost of paid labor. The eventual consequences of these changes in Taiwanese society for the elderly include a shortage of manual and domestic labor in the rural environment, a longer working life and a lack of respect from the young [121].

Urban living

As described above, patterns of settlement are changing rapidly, as migration from rural to urban areas, induced in part by the search for employment

*The average annual rate of growth from 1980 through 1991 was 6.3% in low- and middle-income countries and a staggering 11.1% in East Asia and the Pacific [1] (p. 299).


and education, augments the rapid natural growth that most urban areas of the developing world have experienced over the past few decades. Between 1965 and 1990 populations have become increasingly urban in all parts of the world. The highest rates of urbanization have occurred in Latin America and the Caribbean, where in 1990, 72% of the population lived in urban areas, compared to 57% in 1970 [1]. In recent years, the most rapid increase in urbanization has been in low- and middle-income countries (see [2] for definitions of income categories).*

There are few studies that investigate a causal relationship between urban residence and mental health symptomology among the aged. Studies conducted in the general population (see Refs [6, 7] for reviews) differ in their findings. For example, some authors [122, 123] support the traditional idea that urban residence is associated with poor mental health. Dohrenwend and Dohrenwend summarize in the following manner:

Despite important studies.., that have led us to question the popular stereotypes of urban living, we have shown that the best evidence suggests that overall rates of psychiatric disorder are indeed higher in urban than in rural areas; not all types (there is no evidence that total rates of psychosis are higher in urban than in rural areas) but important subtypes such as neurosis and personality disorder are responsible for this result. Moreover, within urban areas, not only the total overall rates but total psychoses, schizophrenia, and personality disorder are disproportionately concentrated in the lowest social class [122] (p. 442).

More recent individual studies seem to contradict this perspective. For instance, Cheng [124] observed no significant differences in rates of minor psychiatric morbidity in rural, suburban and urban community samples in Taiwan.

What seems certain is that specific risk factors such as poor environmental conditions, poverty, malnu- trition and low education levels relate individually and/or collectively to poor mental and physical health among the elderly [6, 61]. In conjunction with these threats, the very process of urbanization and migration from rural areas can compound negative health effects. Harpham proposed a model in which increased stressors, including long-term difficulties (e.g. 'poor, overcrowded physical environment,' 'need for acculturation if migrant') and life events (e.g. 'migration'), and reduced social support (e.g. 'reduction of extended families,' 'increase in single parent households') are associated with 'mental ill-health' [7] (p. 241). In a study of psychological distress and depression among the elderly in two South African townships, Gillis et al. [55] propose migration and acculturation, in the context of extreme poverty, as important risk factors associated with poor mental health. Living conditions in both townships were difficult, but the subjects in the newly settled one exhibited higher rates of depression which were associated with respondents' worse perceived health status and inadequate housing (the longer settled residents had better living conditions and greater


perceived health status). Ramos, Blay and Mari [57] produced similar findings from a study in S~o Paulo, Brazil. Elderly residents originating from a rural area (i.e. definite migrants) were almost twice as likely as those born in an urban area to suffer from a psychiatric disorder. Prevalence rates of disorders were also significantly higher for residents who had been living in their homes for less than five years and for those in the lowest per capita income group ( < $50.00 per month), in comparison to those who lived in their homes more than five years and to those in the highest income group (> $250.00 per month), respectively.

Although most aggregate data suggest that urban dwellers have higher income levels than their rural counterparts, the level of aggregation often masks acute income inequalities. Some studies indicate that the poor in urban areas are less well off than the poor in rural areas. Average daily per capita caloric intake was lower among the urban poor than the rural poor in Pakistan, Brazil, India, Thailand, Trinidad, Chad, Korea and Indonesia [125]. In the shanty towns of Northeast Brazil, poor residents interpret common symptoms such as weakness, disorientation, tiredness, confusion and depression through the folk diagnostic category of "nerves" [126]. Scheper-Hughes [126] argues that the complex of mental symptoms relating to 'nerves' results largely from chronic hunger and concern about having enough food.

War and displacement

The effects of catastrophic political changes, such as ethnic conflict, factional fighting and wars can have substantial impacts on the prevalence of psychiatric illnesses, regardless of previous coping strategies [14, 15]. As a result of conflict and political persecution, the world today holds an unprecedented amount of internally displaced persons and international refugees (between 20 and 39 million) [127]. Elderly refugees may suffer from the common mental illnesses associated with old age as well as refugees' typical hardships that can lead to increased rates of posttraumatic stress, severe depression, hostility, phobic anxiety, affective disorders, somatization and psychoses [127-130]. They may be at particular risk for two reasons. First, they may be less able to adapt mentally and physically to changes because of lowered homeostatic reserve [131]. Second, the elderly suffer the cumulative effects of major social change and upheaval in their lives [14, 130]. For example, a 70-year-old Chinese man would have lived through the end of the imperial era, the warlord years, occupation by the Japanese during World War II, the communist revolution, Mao Tse-tung's great leap forward, the vast famine that followed, the cultural revolution with its turmoil, and now a radical shift in the opening of the economy to market reforms [15]. Some research (e.g. see Refs [132]) indicates that chronic stressors (e.g. financial insecurity) are strongly linked to depression in adults and may be better predictors of this condition than acute stressors (i.e. discrete, traumatic life events).

This lends support to the interpretation that the elderly (especially refugees) are at risk for depression as a result of continuous and dramatic social change [132].

Only a few studies have examined elderly refugees. Age was not a significant risk factor for depression among 1348 Southeast Asian refugees shortly after resettlement to Canada, but later it became significant [8]. Elderly migrants experienced more social isolation compared to younger members of their families who became integrated more easily into the majority culture [8]. The elderly are generally less likely to acquire linguistic facility, acculturate comfortably, and find sources of stable meaning and coherence; they are more likely to mourn for a lost home (see Ref. [130]).

Another study described the health needs facing older adults (ages 45 and above) displaced from the Tigray region of Ethiopia to Sudan because of war and famine [9]. Those over 60 years of age comprised between only 1% and 3% of the refugee population, which was less than half of UN estimates. Most of the elderly had been left in Tigray, likely because disability and illness, which disproportionately affect the elderly, forced them to remain behind. The migration of the rest of the population removed most of their social support. Furthermore, relief efforts focused on those displaced to the Sudan, excluding the more disabled, at risk elderly. Among those displaced, approximately one- third experienced social isolation, and 96% were completely economically dependent. Suitable clothing was a frequent request among the older Tigran migrants because it was critical to the maintenance of personal dignity and self-esteem, which are important values in their culture [9].

In general, programs designed to help refugee populations tend to focus on the needs of the majority of a population and ignore the special needs of the elderly [104]. A major mental health impact on the elderly refugee is that of loss of role and purpose [104]. The disintegration of communities and the dislocation of services leaves the elderly, as well as the young, disoriented, unoccupied and in a state of dependency on relief handouts. To the elder who is used to exercising authority and receiving honor in the community, this indignity may be even greater than the more visible conditions in refugee camps.

Widowhood: a disproportionate threat to elderly women

High percentages of women are widowed throughout the world. In developing countries the proportion of widowed women over 65 varies from 75% in the Republic of Korea, 71% in Morocco, 70% in India, 41% in Mexico, 35% in Cuba to 32% in Haiti [2] (p.95). Percentages of widowed females are much higher than widowed males. For example, in Indonesia 62% of the women over age 60 are widowed in comparison to 12% of males [74] (p. 29). At least three factors account for this difference:

(1) age specific death rates among men are most often higher than among women in older


ages (reflected in a majority of women over the age of 60 worldwide);

(2) men tend to marry women younger than themselves; and

(3) men are more likely to remarry than women if their spouses die [74].

As populations in developing countries age and as life expectancies improve, the older populations may begin to approximate the structure of those in developed countries where there are more older women than men. This will equate to a larger absolute number of widows in many developing countries [133] (pp. 41-43); [47].

The state of widowhood often equates to economic vulnerability for women in developing countries, and this, in combination with associated emotional loss and changes in social status and interactions can affect levels of non-organic disorders, particularly depression. Research from industrialized countries has shown a relationship between widowhood and levels of depression, mortality and mental illness [[134], [ 135] and [136], respectively, cited in [2] (p. 95)]. Anthropological studies from developing countries have, in most cases (for an exception, see Donner [17]), revealed the social plight of widows and negative consequences of widowhood in terms of support. In Bangladesh, following the death of their husbands, the social role of elderly women changes from the head of the domestic realm to that of a quiet and unassuming 'old widow', indicating their loss of authority and status [137]. Folta and Deck assert that, in Zimbabwe, factors such as "the introduction of a cash economy, migration of husbands and now sons and even daughters for employment, the desire of the young to establish independent households and/or increase their own financial positions, national independence and political change have all contributed to the breakdown in tradition especially as it relates to inheritance, respect for the elderly and a sense of responsibility for their well-being" [138] (p. 339). In this context, widows have particularly suffered since their property is often confiscated by relatives of their former husbands, and they are left in a situation leading to "destitution, insecurity and low self-esteem" [138] (p. 340).

It is even possible that rates of organic disorders among older women are higher in some locations due to the socioeconomic adversity that they encounter. As seen in the earlier section on education, women's low social status relative to men and their domestic

*Cowgill defines modernization as 'the transformation of a total society from a relatively rural way of life based on animate power, limited technology, relatively undifferen- tiated institutions, parochial and traditional outlook and values, toward a predominately urban way of life based on inanimate sources of power, highly developed scientific technology, highly differentiated institutions matched by segmented individual roles, and a cosmopolitan outlook which emphasizes efficiency and progress' [19] (p. 56).

responsibilities lead them to receive less education in many parts of the world. Katzman has recently proposed that education may provide protection against dementia. He suggests "that education (secondary school as compared to no education) increases brain reserve by increasing synaptic density in neocortical association cortex, leading to the delay of symptoms by 4 to 5 years in those with AD (and probably other dementing disorders)..." [30] (p. 17). Zhang et al. [10] postulate that higher rates of dementia among women in China, especially in older age groups, could be due to their lack of formal education (also, see Refs [139, 140]).

RECONSIDERING GENERALIZATIONS ABOUT FAMILY CARE AND MODERNIZATION

The previous section, describing the effects of various forces on the ability and willingness of the family to care for their elderly supports some of the ideas in the influential theory of aging and modernization, presented by Cowgill and Holmes [141,142] and revised by Cowgill [19]. This theory, which states that "with increasing modernization* the status of older people declines" [19] (p. 55), has been frequently criticized as proposing overly broad generalizations and an oversimplified vision of reality (for example, see Refs [143]). Thus, in this section we reconsider several ideas about family care born from the theory of aging and modernization in order to clarify some popularly held but questionable generalizations.

One common view derived from this theory is that families in many societies in developing countries respect and revere their elderly and care for them, whereas the societies of highly industrialized countries tend to neglect their older members and place them in institutional care settings [2, 92, 115, 141~ 142]. Ac- cording to this view, modernization causes the family to leave older people behind. A related generalization holds that the elderly tend to have high status in agricultural societies, where the extended family is more common, and lower status in urbanized societies, where the nuclear family structure is said to be more prevalent [19,21,141,142, 144]. The main, and possibly insidious, implication for policy is that the family cares for its elders in developing countries and there is less need for formal services with public funding [115].

Such assertions are oversimplified for several reasons. First, many researchers have contested the ideas that the multi-generational family was the norm for traditional societies and that the modern nuclear family equates to poorer care for the elderly [2] (p. 88); [21,117, 145] (pp. 359-360). Some researchers have argued that, contrary to popular conception, multi-generational families may be more likely to exist in industrialized countries, that have already experienced the demographic transition with its mortality declines and increasing life expectancies, than in less


industrialized countries (see Ref. [146]). Analysis of historical evidence indicates that in England, the United States [92, 146] and China [81] multigenera- tional families were less common in the past in part due to higher mortality throughout the life cycle, meaning that fewer people reached old age. In addition to the nuclear family, kin (especially in African cultures [147]) and wider social groups, including friends, are also important in caregiving and vary in composition both within and between societies to the extent that some authors take issue with overly simplistic generalizations between developed and developing countries [92]. Moreover, where the nuclear family predomi- nates, it often holds the financial resources to create a situation in which the elderly can live independently. Lee points out that "the research picture on the role of the family in supporting the elderly in Western nations shows that while the nuclear family.., may be the most common family form, this has not led to any decline in the family's role in the lives of the elderly" [ 148] (p. 242).

Second, the automatic ascription of power and respect to the aged in rural, less modern societies may not be uniform and widespread. There is real variation in any society among the aged, for example, between the ill and the healthy, the ancient and the elder, the rich and the poor [149]. Control by a privileged group of elderly men cannot be equated with high status for all elderly, and each social group has some members who have little status or power at any age [92]. As seen earlier, Glascock and Fineman's [73] systematic review of ethnographic data from 57 non-industrialized societies generated several propositions including the extensive variation of treatment of the aged, multiple types of treatment within a single society and widespread non-supportive treatment of certain subgroups of elderly, specifically the frail.

Third, the elderly do not rely entirely on the goodwill and affection of the family for care in any society [92], and economic considerations often lie behind certain behaviors, such as co-residence of generations, that are assumed to be natural in developing countries (for instance, see Ref. [110] for discussion). Mechanisms in different societies to ensure that younger family members will care for the elderly have included the use of threats by supernatural powers, the arousal of social criticism, instilling guilt feelings, and inheritance mechanisms [92, 106, 150, 151]. Martin argues that the "status of elderly South Asians appears not to be guaranteed by virtue of their age or coresidence with offspring" but rather by their "sex, health, and economic resources" [110] (p. 110). Also, patterns of co-residence may be determined more by economic conditions than by choice and many older family members would prefer to live alone [92]. For example, Ramos [22] clearly describes this situation in a comparison of family care for the elderly in three neighborhoods of different socioeconomic status in S~o Paulo. Elderly in the high income neighborhood possessed the desire as well as the necessary resources to live apart from their

children. Goldani states that Brazilian elderly "commonly share households not only for cultural reasons but also for lack of economic resources to maintain their own" [152] (p. 534) and that this explains the high percentage of extended and complex family arrangements in Brazil as compared to the United States. In some parts of rural China where the commodity economy has developed, the majority of elderly prefer to live independently because of their decreased status in the family as it becomes more youth-oriented, their increased earnings, and new generational differences in lifestyle [153]. In Shanghai three quarters of the elderly live with their families, although this may only be a reflection of the acute lack of housing, as rates are much lower in Beijing and Tianjin where more housing stock is available [82]. Sankar [82] points out that not all research from China is consistent regarding elderly preferences for co-residence, but in some cases it undoubtedly promotes conflict, rather than harmony, across generations (see review in Ref. [154]).

Finally, in some cases, effective care for the elderly may persist, although possibly altered, in the face of 'modernization' and its accompanying social change. For example, Peil emphasizes the preservation of the important moral norm of providing for the elderly in southern Nigeria. She says that "family support networks are still strong" and that, "Economic assistance to elderly people is widely acknowledged to be less than optimal, but there is no evidence that it was adequate in the past" [155] (p. 98). Moreover, in a random sample of elderly over 55 in Seoul, 94% cited the family support network as the one they would turn to most often for help [16]. Despite the dramatic population shift in South Korea from only 28.3% urban in 1960 [118] (p. 149) to 73% urban in 1991 [2] (p. 299) (largely because of migration of the young to cities for job opportunities in the rapidly industrializing economy), the patrilineal stem family resisted disintegration and continues to offer income and labor for the maintenance of the aged in rural areas [118]. The family has retained its ability to provide support through changes in behavioral norms, such as a delay in the age of retirement among rural elderly and the adoption of different strategies to diversify household labor. However, despite the overall conservation of family function, change has exacted a cost from the elderly. Sorenson says that "industrialization of society has reduced the importance of their [the elderly's] control over the land and made their traditional knowledge obsolete" [ 118] (p. 155).

In sum, the modern/urban/nuclear and traditional/ rural/extended characterizations of family care systems are generalizations that, by nature, do not capture the myriad possibilities of the process of family adaptation that can arise in different cultural settings in response to the forces of change reviewed in the previous section. Inter- as well as intra-societal variability exists in the way in which families react to stressors affecting their ability to care for elders.


POLICIES AND PROGRAMS IN SUPPORT OF THE ELDERLY

MENTALLY ILL

The context: informal and formal care systems

The most important system of care for the elderly throughout the world is still informal, as the family or kin group provides the overwhelming majority of assistance [20, 21]. For example, in an Indonesian study, 80% of the elderly in need of care received it only from their families, whereas the 'community' was responsible for caring for sick younger people [156]. A nationally representative survey of persons over 60 in Thailand revealed that 88% of all respondents and 91% of respondents with living children either live with or have daily contact with a child [80]. Data from a study in Kenya demonstrate that 92% of women and 88% of men received help from at least one child [119]. Ninety-three percent of the elderly in a survey from urban and suburban areas of four major states in Mexico were integrated in their families [157]. Similar rates of caregiving exist in industrialized countries for the elderly that have become frail and dependent on others for functional activities of daily living [2], but rates of coresidence are usually much lower and rates of institutionalization higher [80].

The resilience of the family caregiving unit in many areas of the developing world and the inability of governments in many poor countries, because of financial reasons, to provide alternative forms of care means that the family will remain the primary caregiving unit for the elderly. At the same time, the stresses on the family's role in providing for the elderly are likely to increase the need for formal care systems such as paid in-home helpers, homes for the aged and nursing homes, especially for those elderly who cannot care for themselves and who lack family care. However, formal care systems do not exist in developing countries to the extent that they do in developed ones. For example, of 12 million elderly people needing assistance in their daily life in China, only 0.05% are cared for in an institutional setting [82, 158]; in comparison, 4-6% of the elderly are in some sort of institution in industrialized countries [2]. In most countries institutionalization remains a last resort, usually for cases of severe dependence [4,20,110,115]. Policies aimed at strengthening mechanisms of informal care and developing alternative care mechanisms could help avert pressure to make a more expensive shift toward institutional care [see Ref. [159] (p. 585)].

Successful policies and programs

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 [115, 117]. Currently, health care spending on average,

represents 4% of the GNP in developing countries, compared to 14% in the United States [1], and an annual expenditure of only $41 per capita. Therefore, we focus our attention on policies that could potentially address mental health problems of the elderly and ease the burden of care on families, but that could also be relatively easily and inexpensively implemented. Many policies designed for other purposes will indirectly affect the general well-being and mental health conditions of the elderly. For example, pension policies will increase economic stability, and housing policies will help determine the possibility of co-residence to create multi-generational households. Several themes are present in our discussion. First, policies should facilitate the ability of families to provide care. Second, government should attempt, when possible, to support innovative formal care programs in order to provide a safety net for the elderly without family care. Third, programs should serve the elderly's physical and mental health care needs simultaneously.

Budgetary constraints give poor countries a strong incentive to emphasize the improvement of care given to elderly people by their families and to complement this care with carefully selected programs. Contrary to popular conception, the promotion of formal services does not seem to diminish the willingness of families to provide economic and social support to older members in need, and in fact, quite the opposite may be true [2, 115]. When there is no support for formal services, informal care mechanisms can break down more quickly because of the unrelieved burden placed on them, especially among the poor [22, 111]. In low income families in Hong Kong, relationships between the elderly and other family members improved after a day care service was implemented so that the younger family members could work [160]. In many cases, families care for their elderly out of necessity, so ideal government policies will make the provision of care easier. Furthermore, experience in high-income countries shows that poor countries should not invest in high cost capital equipment and specialized training as a matter of course [1,161,162] (pp. 96-97, 99). Investment in formal healthcare technology often serves only the rich sectors of society that can best afford to pay for it. The optimum approach will likely involve less expensive alternatives and will embrace the nation's cultural traditions. For example, community based care systems, friendship networks, clubs, associations and retired person's groups should be promoted, expanded and duplicated when relevant and appropriate.

Many countries have established successful programs that help family care providers. Multipurpose day-care centers offer recreational activities and other services such as medical screening and counselling both for the elderly and their families. This provides some respite for caregivers. The Republic of Korea, Sri Lanka, Thailand, Hong Kong and some Latin American countries, including Costa Rica [163], are

SSM 41~7--G


organizing these types of centers [115]. Nursing services and other forms of home help such as 'meals on wheels' are part of programs in Singapore, Hong Kong, Angola and parts of Latin America [115].

Different types of government policies can reinforce family care. Housing and social policies now encourage multi-generational families in some parts of the world. In Hong Kong, for example, previous public housing policies required married children to move out of their parent's housing unit, but the government has subsequently changed the rules to allow one married child to stay on when the parents are elderly and need care [159]. The housing authority prefers new applicants who are willing to include their elderly parents in the household. Public housing authorities in Singapore and Malaysia give priority to married children and their parents who apply for adjoining apartments [2, 110, 115, 164]. The Korean Housing Corporation has adopted apartment plans to accommodate three-generation families living in various stages of proximity [16] (p. 444). Governments in Lesotho and Botswana have considered improving the living conditions of the elderly by giving families with elderly members loans to upgrade their houses and by providing subsidized units to include the elderly, respectively [115].

Other policies enhance care for the aged in more subtle ways. Some governments support employer- sponsored benefits. With increasing numbers of women, who are the primary caregivers, in the work force, small numbers of employers in the developed countries have begun to give time off work and flexible schedules to account for elder care [2] (p. 89); [90]. Furthermore, diverse countries such as Singapore, Gabon, Kenya, Botswana, Morocco, the Republic of Korea, the Philippines, Iran and Kuwait either already offer or are considering income tax relief for people caring for an elderly dependent [2] (p. 93); [61] (p. 100). Li e t al . [91] propose that the government of Taiwan lower the inheritance tax so that the elderly are not impelled to transfer property prematurely to their children. This may leave the elderly with more economic security that gives them better bargaining power when negotiating care from family members and ultimately preserve their independence. Choi [ 165] makes a similar recommendation for South Korea, where traditional inheritance patterns are also changing.

Governments can contract non-government organ- izations (NGOs) to provide residential care for childless elderly, as the governments of Malaysia, India and China are currently attempting to do [115]. Residential homes should ideally be small and have strong links to the community in order to avoid the asylum connotations prevalent in western countries [166]. One study in Zimbabwe compares two residential care facilities. A relatively rich home with superior physical facilities and a complete staff was structured on the British colonial model of elder care, and the other was an experimental cooperative run by

the residents with only one staff member. Residents were far more satisfied in the cooperative, even though it had fewer economic resources, as they had greater self-determination and opportunities for productive work [167]. Similarly, the first home for the aged in Polynesia was popular among its residents and had a long waiting list partly because of its 'non-institutional' atmosphere, to which traditional architec- ture, the use of native foods, liberal policies on visiting, and resident group decision-making all contributed [168]. Another creative type of program that encourages re-marriage among the elderly in order to reduce the number who live alone has been tried in China and Korea [115].

When these programs increase an older person's sense of self-worth and value, they are particularly helpful. In Ecuador, an NGO with help from the UN initiated a pilot program to provide employment for the elderly [2]. This was initially problematic because the most needy are often the frailest and the most difficult to retrain to fill available jobs. In one village, however, the NGO noticed that there was no bakery within 40 km, and set up an old people's bakery, using simple local technology (for a thorough description of the bakery 'model' in Colombia, see Ref. [104]). This provided employment for the elderly and a product valued by the community. The NGO then set up a related sewing workshop for women and a plot of land for the elderly men to cultivate medicinal herbs. In Colombia elderly people are running a recycling program in collaboration with the city by sorting recyclable waste materials that residents deliver to centers around the city. The program has provided enough money to give the elderly people a small salary [2]. Such programs have the potential to increase the well-being of the elderly, contributing to positive mental health.

When possible, programs should care for both the physical and mental needs of the elderly simultaneously. Because the elderly tend to suffer from multiple chronic conditions, it is likely that anyone with a mental health problem will also be suffering from other chronic physical disorders [131]. Since the elderly are more likely to seek treatment for physical disorders than for mental ones ([169], and see Ref. [170] for an example), any attempt to treat mental disorders will be most effective if it is part of the existing system to treat physical ailments. This type of policy has the added advantage that it is cheaper to establish than an independent, formal system aimed specifically at the mental health needs of the elderly. An example of integrating mental health needs into the formal care system is the development of mental health screening and geropsychiatry components in institutions ranging from community health centers to acute care hospitals [115, 170]. A promising approach for poor countries is the use of modified 'barefoot doctor' programs encompassing mental health problems. These programs frequently involve community health workers (CHWs) trained in basic


healthcare who go from house to house in rural communities making visits. CHWs in such programs could receive rudimentary training in geriatric psychiatry enabling them to recognize dementia symptoms, for example, and refer patients with mental health problems to tertiary centers [171, 172]. Abiodun [ 173] suggests that this approach would be particularly useful in meeting the growing mental health needs of the elderly in Africa because primary health care workers are 'nearer to the consumers' in the sense that they can reach the largely decentralized, rural populations in African countries.* In certain places, the possibility exists for government policies to build on existing strengths and networks of folk and traditional healers (for discussion see Ref. [174]).

In general, anything that diminishes older people's social and economic marginality, such as a pension, is likely to help reduce the prevalence of minor psychiatric morbidity. In countries with high inflation, private savings become riskier and formal pensions gain importance because they grow with inflation, whereas savings often do not. Pensions for those employed in the formal sector now exist in most countries in Latin America and the Caribbean, in most of Africa, and in approximately one-third of Asian countries [175]. Pensions often serve only the elite segments of the population, since those employed in the formal sector of the economy tend to be a privileged minority (30% of the population in Gabon, for example) [2, 104]. Coverage is generally sparse for rural populations and for those who work in the informal sector, the groups that usually comprise some for the poorest members of society.

Governments in some developing countries, however, have been successful in extending pension coverage to specific groups of old persons. In the Indian state of Kerala, the state government has designed a pension scheme that carries a manageable financial burden because it targets only the destitute elderly falling into one or more of these categories: widowed; handicapped; childless; low-income agricultural worker; and/or workers in selected industries left out of the national Provident Fund Scheme [176]. The Chinese government has used a similar approach in assuming responsibility for the childless elderly (no children, no capacity to work and no other means of support) who comprise a small proportion of the entire elderly population and correspond to an acceptable outlay in resources. This policy is intended to help promote the one-child family planning policy. Policy-makers reason that adults will not worry as much about care in old age if they see the government providing for those without children [82, 83, 158]. Additionally, local governments at the village level are establishing social security systems to complement traditional intergenerational support [153]. Based on

*On average, about 69% of the populations in African countries lived in rural areas in 1991 (calculated from World Bank data [2] (pp. 298-299)].

the successful experiences of Australia and New Zealand with non-contributory, means tested pensions (which are similar in principle to China's system) in providing for the poor elderly, McCallum [177] recommends them for consideration by developing countries in general.

In summary, the precise mix of optimal policies for each country will vary and cannot be generalized. The challenge for the nations of the developing world is to learn from others, both industrialized and less industrialized, and develop policies that are realistic and locally determined.

CONCLUSION AND FUTURE RESEARCH PRIORITIES

Developing countries are currently witnessing and will continue to witness large increases in numbers and proportions of elderly members in their populations. Since organic dementias are age-related, a higher prevalence of these disorders will emerge as populations age. Furthermore, the prevalence of non-organic mental disorders, such as depression and anxiety, are directly affected by stressors, such as war, ethnic conflict and the process of moving to urban areas while lacking economic resources. The amount and nature of care received by elderly from their families are also important factors with regard to their non-organic mental health and are determined in part by factors such as the decline in value of agricultural assets and changing inheritance patterns, growing participation of women in the labor force, migration of younger family members from rural to urban environments, and the access of younger family members to education.

Reliance on stereotypes of modern and traditional societies can result in inappropriate policy ideas. By assuming that families in countries of the developing world confer more respect to their elders and are more inclined to care for them, the role of the state in implementing useful policy may be downplayed. However, given the demographic transition and concurrent social, cultural and economic changes in developing countries, careful planning by government is needed to originate policies that strengthen informal and formal care systems. Since many of these countries are financially burdened and face other serious social and political problems, inexpensive targeted and universal policies are desirable. It is ditiicult to make broad policy and program recommendations for developing countries, given their economic and cultural heterogeneity, and planning must occur in local contexts.

Currently available research is incomplete in providing information useful in planning services and prevention efforts. Chandra et al. state, "Differences in rates of occurrence [of dementing disorders].., in different societies will help focus the search for risk factors and etiological clues" [47] (p. 2). Unfortu- nately, despite Harpham's [7] assertion that the "growing number of studies on the mental health


of. . . the elderly" merits a review separate from that concerning general populations, we have found that few studies have actually focussed exclusively on the elderly. Furthermore, a limited number of epidemiological studies on elderly mental health have been completed in developing countries, and the available small-scale studies are rarely comparable in a meaningful way. This is, in part, a result of the use of different instruments and/or diagnostic criteria or the use of the same instruments in different countries but in a way that does not account for bias due to culture, education and socio-economic status. If overall rates of age-related disorders differ among older populations, this may be due to considerable variation in the age structures of the populations. Thus, for example, it is difficult to accurately determine whether dementia is truly less prevalent in sub-Saharan Africa than in other parts of the world, as suggested by some studies reviewed earlier [42-45].

In conclusion, this paper has drawn on empirical evidence from diverse bodies of literature to create a preliminary conceptual 'model of forces' influencing the mental health of the elderly. Each of the model 's components deserves further inquiry. For a phenomenon that can impact mental health directly (for example, war or ethnic conflict), studies need to be designed in such a way as to measure the effect of specific risk factors associated with the phenomenon (for example, in the case of war or ethnic conflict, death of a loved one or repeated exposure to violence) on certain mental health problems (for example, depression) (see [55, 132] for good examples of this type of research). Furthermore, it is quite apparent from the anthropological literature cited during the model 's presentation that the family care system for the elderly is changing in many developing countries, and it is critical to determine how these changes bear upon elderly mental health. Through what specific mechanisms does lack of family and social support influence non-organic mental health? What types of situations of family and social support are associated with low and high levels of psychiatric morbidity among elderly populations? Because the social and cultural dimensions of mental illnesses like depression are often neglected by purely quantitative studies, research intending to answer these types of questions should include a qualitative component [178].

The mental health of the elderly and its demographic, economic, social and cultural determinants deserve increasing attention from researchers as populations age rapidly around the world. Further investigation into topics presented in this paper, keeping in mind the limitations of existing research, will provide knowledge of practical significance for the mental well being of the world's elderly.

Acknowledgements Thanks to Dr Vijay Chandra of India, Dr Zhang Zhenghua of China, Dr Adesola Ogunniyi of Nigeria and Dr Luiz Ramos of Brazil for referring us to specific studies in Asia, Africa and Latin America,

respectively, and for their helpful reviews of our manuscript. Also, Drs Arthur Kleinman, Leon Eisenberg, Robert Desjarlais and Janie Simmons of the Department of Social Medicine of the Harvard Medical School provided useful suggestions and comments on earlier drafts of the paper.

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