Common Preventable Health and Social Problems Encountered by Elderly in Shinyanga Region in the Northern Part of Tanzania

Background: In Tanzania elders are respected as repositories of inherited wisdom, experienced and principal decision makers in the community. However, evidence shows that such repositories are no longer considered important in most societies. As a result elders are neglected with some mistreatment in terms of provision of health and social services for instance; at times they get denied and ignored of their obvious rights, ignoring their retirement benefits and the rights onto free social services as per the Tanzania National Ageing Policy of 2003. Elders are therefore faced with physical, psychological and geriatric social suffering. It is on this basis that this study tries to explore the common preventable health and social problems encountered by elderly in Shinyanga Region in northern part of Tanzania. Methods: Across sectional community based study of 465 subjects randomly selected was done in three wards of Kahama District. The district was selected randomly out of 8 districts of Shinyanga Region, structured questionnaires with both closed and opened endower used; the information was collected from house to house and other information collected from health facilities within the wards as every ward had one public health facility; subjects (respondents) were obtained using purposive sampling technique aiming at elderly with 60 years of age and above. Results: Kahama district has a population of approximately 36,014 of which 1500 (4%) are in the elderly age group of 60 years and above. The study population was 465 which is 30% (465/1500) of the geriatric population of Kahama. Among this group 5% were female while 41% were male and 53% (248/465) were married. 64% (297/465) were taking care Corresponding author. S. E. Ngallaba et al. 116 of themselves, 32% (150/465) cared by relatives and 4% (18/465) cared by the community. Among the respondents, 40% (185/465) were affected by HIV/AIDs in one way or another either living with orphans whose parents died of HIV/AIDS or asking care of the infected patients within the family. It was also found that 73% of the geriatrics were not exempted from medical treatment fees so they had to pay for their medical care. However, only 32% were aware of getting free treatment and 61% of the study populations were not satisfied with the medical care provided at the public health facilities. The common diseases affecting this age group are: Eye problem 59% (273/465); Arthritis 52% (241/465); Dental problems 27% (124/465); Hypertension 23% (107/465); Backache 22% (105/465); Malaria 28% (132/465); Hearing problems 26% (121/645); Urinary tract Infection 35% (165/465); Depression 8% (36/465). Dementia was also a problem though we had no tools to confirm the diagnosis; some of the geriatrics had more than two diseases. Conclusion: The majority of the elderly age group in Kahama District are not aware of their rights that they deserve free treatment according to Tanzania policy, furthermore for assessment and screening of health problems. A majority of the elderly die prematurely due to preventable diseases and more than half of the diseases affecting geriatrics are preventable.


Introduction
Geriatric refers to the elderly age of 60 years and above as agreed by United Nation (UN) [1].It is a physical process of ageing and related with change in social factors.Actually, it is unavoidable process of decay of human body; however medicine and nutrition have shown what was unavoidable by that time; today it is avoidable or the process can be delayed [2].Rapid rate of ageing in now common in many countries especially the developed countries for example in Britain for the year 1985 the elderly population was 5%; today it is 25% and most of the developed countries have experienced the same; such demographic changes were described by Peterson in 1940 [3].
Such demographic changes required additional social service from the family, relatives, community/society and the government.Previously in many parts of the world especially developing countries elderly were considered as resource of inherited wisdom experience also considered as principal decision maker; currently they are not considered as people with wisdom but they are viewed as people with outdated knowledge; in other words they have undergone crystallization of knowledge [4].In addition to that elderly people are faced with social problems due to the fact that they don't have enough energy to stand on their own.Instead, they depend on others, such as relatives and community; at times they live alone helplessly.This make them depressed, oppressed and disappointed.In fact, sometime they experience elderly abuse which is associated with high morbidly and mortality; some die prematurely and for those who live long, their life is unhealthy life and not productive [5].
WHO has come up with new indicators which focus on disability free life expectancy (DFLE) or active life expectancy (ALE).Thus with increase in life expectancy of elderly there is also reduction of disability free life expectancy (DFLE or ALE) [6].Health care provision for elderly is different in developing countries as compared to developed countries; in developing countries health care depends more on their relatives or traditional family care.
In Tanzania at the age of 60 it is considered as government retiring age.This age group has a lot of social and health challenges; due to their status of age, bad physiological changes, thus the function of their body system has deteriorated; hence they become highly susceptible to various diseases, change of behavior and their capacity to work deteriorated [7].Therefore, ageing in Tanzania has created adjustment pressure to improve support and care of this neglected group so as to increase active life expectancy.There are few non-governmental organizations such as HELP AGE which provides a little support e.g.clothing, treatment and food.This support is not enough; what is needed is more than what we think [8].
The Tanzania government introduced cost sharing in health sector which is the user fee for the provision of health services to the people by an exemption of children and elderly group [9].The implementation of this policy has met a lot of limitations such as lack of drugs at the public health facilities so the health facilities have become centers for giving only prescriptions, for the drugs they have to buy from the drug shops.As a result, many elderly people when they are sick look for alternative means of getting treatment and support such as selfmedication or going for traditional healers [10].In fact many elderly die prematurely because some can't afford to pay for drugs.
In Tanzania health improvement has focused more on acute than chronic disease, morbidity and disability than on mortality [11].Therefore, the aim of this study was to find out the exact proportion of the elderly of 60 years and above, because what is known about the prevalence is through extrapolation.This study has gone further to determine the common health and social problems affecting this age group and see whether they can be prevented and at what stage of prevention such as at primary, secondary or tertiary stage.This study therefore, examined the common preventable health and social problems encountered by elderly in Shinyanga northern part of Tanzania.The study also documented on the demographic distribution pattern of elderly by age, sex, marital status and level of education.

Study Design and Study Settings
We conducted a cross sectional community based study involving, the study used random sampling method of 465 households selected from three wards of Kahama District namely Kagongwa, Isaka and Kahama.All households with elderly subject of 60 years or above were invited to participate in the study using convenience sampling.For households with more than one subject, all of them were considered as separate subject.The study used structured questionnaire with both closed and open ended, the data were collected from house to house.Secondary data were also collected from the health facilities within the respective wards to triangulate information regarding health care services in the district.Every ward had at least one public health facility.From the public health facilities, we were able to collect information regarding health facility based prevalence and records of elderly patients, diagnosis and distribution pattern of preventable diseases.
Shinyanga region became an interest of this study due to its history of elderly abuse and mistreatment; it is the leading region with high rate of elderly killing in Tanzania, elderly of 60 years of age and above are incriminated or associated with witchcraft, for this reason it was decided to explore the health and social problems they encounter in their elderly age.This study did not include elders who had lived in the study area for not less than one year as we thought would have not experienced enough regarding the health care delivery in the area and to avoid contamination of information due to experience from other areas.
Data collected from the three wards were analyzed using SPSS Program version 16.Categorical variables were compiled and summarized in ratios, percentages, proportions, means, standard deviation and associations were determined by using odds ratio (OR) and the confidence interval used was 95%, significance value was considered when p value was less than 0.05.

Ethical Considerations
Ethical approval was obtained from Catholic University of Health and Allied Sciences and Bugando Medical Centre joint Research Ethical Committee.Permission to conduct research in Kahama District in Shinyanga Region was obtained from the District Council Health Management Team.Participation in this study was voluntary, and participants were free to leave and/or withdrawal their consent whenever they felt so without impacting the health services at the specific health facility.Participants had to complete a written consent form prior to their participation.Elderly who had health problems during the community household surveys, were referred to the district hospital.aged between 60 and 65 years.Majority being women (n = 278, 60%).Of interest, most of the elders in Kahama did not complete primary formal education (n = 248, 53%) with few who had secondary education and above (n = 63, 13%).Regarding their last occupation history, majority reported being peasants (n = 310, 67%).Even, though 32% (n = 150), reported to be living and taken care of by relatives, majority (n = 297, 64%) reported of living and taking care of themselves.Other health related socio-economic factors are presented in Table 1.Table 2 summarizes the distribution of cases per common diseases in selected wards of Kahama district, 54% of the diseases are preventable while 46% are non-preventable and the leading cause of morbidity in elderly age group is eye problems followed by arthritis.

Quality of Health Care Services and HIV/AIDS Burden
Majority (n = 204, 44%) of the respondents, indicated that, the quality of health services was fair while 2% (n = 11) responded that the service was excellent and 17% (n = 79) said it was poor and/or unsatisfactory.Table 3 summarizes respondents perceived health care quality.the elderly group, 45% (n = 84) of the elderly were taking care of orphans of whom their parents died of HIV/AID, also 43% (n = 80) experienced death of their children due to HIV/AIDS and only 2% (n = 3) of the elderly were the victim of HIV/AIDS.

Aging and Social Activities
Alcoholism and smoking was relatively similar (23% and 25% respectively) in magnitude among the respon-dents with some doing both.Majority (n = 327, 38%) of the respondents reported to be sexually inactive, while 25% had stopped smoking and 23% had stopped taking alcohol because they can't afford.Table 5, presents the patterns of the socio-activities among the elderly group participated in this study.

Discussion
The study population of elderly age group was 465, of which 59% are women and 41% are male this could be due to difference in life expectancy thus female live longer by 5 years than male or could be due to pattern of population structure thus in Tanzania women are more than male, and it has been observed that women can resist tress than men and hence men die earlier than men [12].
The age group of 60 to 65 years are 50% they dominate other groups followed by the group of 72 years and above which are 36% this indicates that there are many elder at the beginning of elder age (60 years) and at the age of 66 to 71 years the population drop by 21% later at the age of 75 years and above the population rises, the reason for the population to drop at the age of 66 -71 years this could be due to failure to compromise with geriatric pattern of life as many people retire at the age of 60 years and after 5 years they die because they fail to compromise with pattern of life, and hence at the age of 72 years and above they become used to geriatric life [9] [11].
In regards to marital status 53% of the study population are married, 32% widow/ed and 14% divorced, these findings are seminar to a study which was done by Thukur et al., in India where 51.1% of the elderly subjects were married, the reason could be that married population of elders live longer than those who are not married [13].
Among the study population of 465 elders 53% had no formal education while 34% had primary school education.This is due to the nature of life and occupation as majority 67% are peasants so that they keep on moving looking for land and green pasture for their cattle so they had limited time to register for school education [14].Regarding meals 49% eat twice per day, and 38% eat thrice per day and 13% eat once per day, at this age the elders are supposed to take adequate balance food because the function of their cells, tissues and organism have deteriorated.So, in order to prolong their life, they have to eat balanced food frequently, however some can't afford to eat thrice because of financial constraints [14] [15].
Majority of the geriatrics 64% (297/465) take care of themselves and 32% (150/465) are taken care by relatives, only 4% (18/465) are taken care by the community in collaboration with Ministry of Health and Social Welfare.Previously elders in this district used to be cared by their family or relatives who used to live in extended family this was part of their culture, however currently there is a great move of the young people from the villages to town looking for employment as a result the elder are left along in the villages taking care of themselves [16].
Among the geriatric only 12% (57/465) are exempted by the government from cost sharing or paying for health services, the rest 59% (273/465) have to pay for their health services and 29% (135/465) have health insurance, and when they were asked if they were aware that at their age they are supposed to be exempted 32% (150/465) they responded that they were aware.Majority, 68% (315/465) were not aware that at their age they are exempted, this could be due to the fact that they were not informed of such exempted.
Looking at perceived aging advantage and disadvantages, 53% (248/465) of the responded that they felt food, while 22% (n = 104) they field normal and 25% (n = 113) they felt bad.Those who felt bad it could be due to the fact that previously the elder were considered as people with wisdom but currently they are considered as people who are outdated, some said that the life is quite difficult as they don't have energy to work and the government can't support them in terms of basic needs such as food, soap, clothes shelter e.tc.Generally, they felt as if they are victims of ageism from their society as well as from the government similar to other findings elsewhere [17].
Walking distance from health facilities; some live a good distance from the health facility 51% (n = 239) live within one hour walking distance to reach the nearby health facility, whereas 29% (n = 135) more than 2 hours of walking distance, and 20% (n = 91) they live more than 2 hours walking distance.This is of particular concern as elderly group they get sick so often as compared to the normal group.When they are sick they can't walk a very long distance to reach the nearby health facility as public transport is not available and when available they would probably can't afford.In this case most would look for another alternative for treatment.This poses a concern that something has to be done for the elders, however the policy of the government is well stipulated that every village should have a health facility, but majority of the health facilities don't have drugs, so they have turned up to be canters for getting prescriptions [18].
Impact of HIV/AIDS for the elderly whether they have been affected by HIV/AIDS, 185 (40%) agreed that they have been affected the rest (n = 280, 60%) have not been affected, for those who have been affected (n = 3, 2%) they were the victim, 45% (n = 84) are taking care of orphans and 80 (43%) have lost their beloved children due to HIV/AIDS, the problem facing this neglected age group are as follows: There is no clinic for geriatrics or a place where they can get information on HIV/AIDS, similarly for other diseases such as worm infestation, diabetes, enlarged prostate [19].If screening is done earlier, then treatment can as well be initiated earlier, otherwise they are attended when their health problems are in advanced stage.
During the study the common diseases affecting geriatrics were as follows: 1) Eye problems which constitute 17% of the top ten disease from the health facilities, they include decreased in visual acuity to focus, funding aging processes the eye loses its elasticity resting in inability for focus clearly, this can be managed in the tertiary stage by using corrective glasses.The challenges facing the health facilities are lack of eye specialist especially in the peripheral areas of Tanzania [20].
2) Arthritis is the second common diseases of the elderly age group, which can progress to joint degeneration, but this kind of degeneration can be reduced in the tertiary stage by giving them drugs that reduce the progression.Also special care along with physiotherapy, however such conditions are managed at special centers where physiotherapy department exist [15] [21].
3) Hearing problems: with ageing the ability of hearing is reduced so screening using audiometer is important because they can benefit from tertiary management by providing them with devices [19] [22].
4) Urinary tract infection is geriatrics is common especially in post-menopausal women; this can be diagnosed earlier before complications [23].
5) Dental problems in geriatric is common thus why in other countries especially the developed countries have expertise in geriatric dentistry or periodontics who deal with dental problems from diagnosis, treatment of the associated problems and prevention also provision of denture [12] [24].
6) Malaria was also some of the disease which ranked number 4, but this can be prevented by using different interventions for instance use of impregnated mosquito nets.
7) Hypertension ranked number 5 sometime it is called a silent killer because at time it density show symptoms but its effect is more focused to some organs such as Kidney, eyes, heart so it is important for geriatric to undergo screening of blood pressure and treat, otherwise many people are suffering from complications such as stroke [12] [19] [25].
8) Backache ranked number 5, at old age bones become weaker with age and there are many causes of which some can be treated medially some by surgical intervention so it is good for geriatric to undergo regular physical checkups [26].9) Prostate enlargement is a disease of old age thus prostate enlarges as man ages, if the enlargement is allowed to continue cab end up into complications e.g., cancer or the prostate, urinaryretention.Early diagnosis and treatment is important; however, the cost of operation is some health facility is exorbitant.This surgical problem can be cured if diagnosis earlier and treated before complications start [27].Undesirable social activities; the following are some of the undesirable activities of the elderly however some have reduced or stopped due to financial constraints but occasionally they practice when they have money are; Smoking Tobacco cigarettes (n = 208, 25%), taking alcohol (n = 193, 23%) all these social activities have bad health effect e.g. they can potentiate stroke, Diabetes, Hypertension etc., especially at their age, so health education should be given to

Table 1
presents some of the socio-economic characteristics of the participants.Most of the elders (50%) were 1. Socio-demographic variable per wards.

Table 4
presents the reported burden of HIV/AIDS on

Table 2 .
Pattern of common diseases among the geriatric group.

Table 3 .
Response of elderly on quality of health services.

Table 4 .
Effect of HIV/AIDS on elderly.

Table 5 .
Reported social activities among the elderly group.