Social and Health Status of Community-Dwelling Older Adults in Nepal

Background: Most developing countries are ageing at unprecedented rates, yet they are relatively under-studied regarding the demographic and health status of the older population. This in turn inhibits appropriate, positive societal responses. This study presents the socio-demographic and health status of older adults in Nepal. Methods: This study is a secondary analysis of structured interview data collected by the Central Department of Population Studies at Tribhuvan University (TU) via a cross-sectional survey of community-dwelling persons age 60+ in the Pharping area of Kathmandu. For this study, there were 1326 valid responses. Results: Respondents’ mean age was 69.92 years (sd = 7.82). The majority (70%) was illiterate. Nearly 3/5 of women were widowed (58.4%), which nearly doubles the male rate (31.8%). Over three-quarters of respondents (78.6%) were living with family members, far more than with spouse only (11.6%), alone (6.2%) or with others (3.6%). Only 9.2% of respondents received a pension, and over seventy percent of respondents (70.7%) were still working. About three-quarters (76.5%) of respondents had physical health problems; 14.6% had some physical disability, and 52.6% self-reported a mental health problem. Statistically significant (p < 0.01) gender differences were found for marital status, literacy, living arrangements, pensions, physical health problems, and mental health problems. Conclusions: Like most nations, Nepal is ageing rapidly. There are gender differences that can differentially affect the experiences of older men and women. Nepal should increase the quantity and quality of data describing its older population so it can continue to develop appropriate, effective social and health programs and services to reduce gender disparities and maximize elderly quality of life.


Background
The world's population is ageing rapidly. The proportion of people age 60+ will double between 2000 and 2050, from about 11% to 22% [1]. Populations are also ageing rapidly in less developed regions. From 2020-2060 the proportion of older adults in these regions is predicted to nearly double from 11.9 percent to 21.8 percent [2]. Thus population ageing is ubiquitous, regardless of a nation's level of development [3]. Ageing has direct and indirect implications for families, health and economics at both micro and macro levels [1]. However, such issues remain relatively under-researched, particularly in poorer and developing countries.
Consequently, there is a dearth of specific initiatives in such nations for developing programs and services to enhance the well-being and quality of life of the older population [4].
One feature of ageing populations is increased longevity. Rising life expectancy brings both societal opportunities and societal challenges [5], including changes in family structure and dynamics [6], living arrangements, marital status, and care and support for the elderly [6] [7]. In Nepal, persons age 60+ are considered elderly [8] and constitute 8.13% of the total population [9]. Nepalese life expectancy, which was 54 years in 1991 [10], is now 71 years [11], an increase of more than one-half year annually [12].
Nearly all elderly Nepalese, whether individuals or couples, live with their children; previous studies found more than 85% living with non-spouse (as well as spouse) family members [3] [10] [13] [14] [15]. Caring for one's parents-one dimension of filial piety-is considered a duty of adult children [3]; government historically had little obligation to provide care for the elderly [7] [13]. However, recent demographic and socio-economic changes, such as the rapid increase of the older population and the out-migration of children from rural areas, have led to changes in the traditional care system [16]. One example is a rise in the number of elderly living in old age homes [17] [18].
An examination of older adults' social and health status issues, whether at micro or macro levels, cannot ignore the impact of gender. Various studies show gender to be an important variable in this line of inquiry (e.g. [3] [19] [20]). Researchers and agencies such as the World Health Organization argue that "to fully understand ageing and health a gender perspective is required" [21].
The demographic transition, effected by falling mortality and fertility, results in an ageing society. Developing and, especially, least developed nations experience a concomitant epidemiologic transition, as the major causes of death shift from infectious, communicable diseases to chronic, non-communicable diseases like heart disease, cancer and diabetes [22]. Relatively little, however, is known about the health status of older populations in poorer developing countries. Available databases are less complete and more recently developed, hindering longitudinal analysis, and governments place less priority on the issues of older adults due to the historical, dominant role of families in caring for their elderly [3]. The economic, social and health status of Nepalese elderly are, however, increasingly important social concerns because, as in many other developing countries, Nepal's older population is growing rapidly while there is no well-developed old age pension (social security) system [16]. The objective of this paper is to explore the social and health traits of community-dwelling older adults in Nepal in order to identify key gerontological issues of elderly well-being and quality of life.

Methods
This research is a secondary analysis of cross-sectional data from a survey con- Nepal had over 3200 of them at the time of the survey [24]. The VDCs in this study were a convenience sample, as they comprise the catchment area of one community hospital in Pharping. Each VDC has nine wards (the lowest-level political unit). This yielded 54 wards, which were considered the Primary Sampling Units (PSUs) for this study.
For each ward, and with the help of the VDC office and community leaders, a list of all households was developed. Random sampling was applied to each ward's list and continued until the goal of 20 households with at least one member age 60+ was reached. This yielded 1080 households, of which 1070 (99%) consented to interviews. All persons age 60+ years in each household were interviewed. Of the 1375 older adults in the 1070 consenting households, 1355 (98.5%) consented to be interviewed. For the purpose of this study, people who reported clinical diagnosis of Alzheimer's disease or another dementia were excluded, as were those for whom some demographic data were missing; there were 29 such cases. Thus the total sample size for this analysis was 1326 older adults.
Interviews were conducted using a structured questionnaire containing demographic, social, economic and health related information. SPSS version 20 was used to analyze the data. Chi-square assessed male-female differences for selected variables, using p < 0.01 to indicate a significant difference.

Results
Respondents' age ranged from 60 to 99 years (69.92 ± 7.82). Half of the respondents were female (50.5%). The majority (70%) were illiterate, with women significantly more so than men (p = 0.000). Nearly half (45.2%) were widowed; widowhood was significantly more common among women (p = 0.000). More than three-fourths (78.6%) were living with family members; only about one in ten (11.6%) lived with spouse only. Seven in 10 (70.7%) were still working formally (for pay) or informally (unpaid household or family agricultural work). Less than one in ten (9.2%) was receiving a pension; pensioners were significantly more likely to be male (p = 0.008). These results are shown in Table 1.  Physical disability was reported by 14.6% of the sample. This category included visual disability (7.5%), hearing disability (6.5%), mobility disability (4.7%) and other disability (0.4%). There were no statistically significant physical disability differences between males and females.

Discussion
In Asian nations, as in much of the rest of the world, there is an inverse relationship between economic well-being and the rate of ageing [25].  [32]). Another 11.6% lived with only their spouses and 3.5% lived with "others". Only 6.2% of the sample was living alone; this can be a concern, but also is below the prevalence found by other research [13]. Finally, only 9.2% of the older adults in this study received a pension, with males significantly more likely than females to enjoy this economic support.
These findings can be explained by the historical evolution of Nepalese society, culture, economics and politics. First, as in other cultures, Nepali men typically marry women younger than themselves and, if widowed or divorced, are more likely to remarry [10]. A 2011 census found the age at first marriage was 22.1 years for males vs. 17.9 years for females [9]. Next, while overall adult literacy in Nepal is over 50% [33], there are still sex-based differences: male literacy is 71.6% compared to females' 44.5%. Given the increase in literacy over time and the continued male-female differences, it is not surprising that the older Literacy is of course linked to educational attainment; in Nepal a higher percent of men than women complete every level of education above primary school [34]. Educational attainment is linked to occupational status, and higher occupational status can be related to the likelihood and level of a pension. Given these trends in Nepal, it is not surprising that older males are significantly more likely than older females to receive a pension.
In Nepali culture, living with family members has historically been regarded as the best insurance for old age [10] [24] [28], as there was no well-developed social security system [7] [16]. This changed only in late 2018 [35] when the government announced such a program to cover workers in the formal sector and, in the future, the informal sector. Over 90% of the program's revenues are targeted for old-age economic security. In this study, the major reasons given for living alone were no support from children, no children, children living in other areas, and death of a spouse. A few respondents said they lived alone because they chose to, despite other options.
Regarding self-reported health status of community-dwelling Nepalese elderly, this study found over three-quarters (76.5%) of older adults with some physical health problem, over half (52.6%) with some mental health problem, and 14.6% with some physical disability. Nepalese women were significantly more likely than men to report physical and mental health problems. This is consistent with other studies in Nepal [3] [27] among older adults. In the current study, significant sex-based differences were found for gastritis, boredom, loneliness and anxiety/stress, with females more likely to report these conditions. Women are twice as likely as men to be diagnosed with a mental illness and more likely than men to have been treated, especially for conditions like depression and anxiety [39]. Gender-based social inequality is strongly associated with gender disparities in mental health [39].
Overall, although older adults in many South Asian countries contend with similar health problems, the health status of Nepalese community-dwelling older adults seems worse when the data are compared with other research [29]  should employ multivariate analysis of a database of sociodemographic and health variables measured at interval or ratio levels, and a global measure of health status; these changes would make explanatory findings more likely.

Conclusions
Like many other developing nations, Nepal is experiencing the rapid growth of its elderly population that accompanies the demographic transition. As Nepal continues its modernization, social and economic changes occur that have consequences for Nepal as a society but particularly for Nepalese families-their structure, their intergenerational relationships, and their financial and health security.
In addition, among older Nepalese there are significant gender differences in marital status, living arrangements, literacy, pensions, overall physical health and overall mental health. In any society, such differences typically result from a culture that historically engaged in sex-based discrimination against women.
While it is likely that gender disparities will decrease as Nepal continues its modernization, the disparities among the older population will largely persist, since few of them can be significantly addressed at this late stage in older cohorts' lives. However, some positive steps could benefit all generations as quickly as they can be implemented. It is recommended that the government continue to develop age-appropriate policies and programs to promote physical and mental health and to enhance overall quality of life among Nepalese elderly.