case study of old age home in india pdf

• Open access
• Published: 14 July 2022

Dignity and the provision of care and support in ‘old age homes’ in Tamil Nadu, India: a qualitative study

• Vanessa Burholt 1 , 2 ,
• E. Zoe Shoemark 2 ,
• R. Maruthakutti 3 ,
• Aabha Chaudhary 4 &
• Carol Maddock 2  

BMC Geriatrics volume  22 , Article number:  577 ( 2022 ) Cite this article

3101 Accesses

3 Citations

6 Altmetric

Metrics details

In 2016, Tamil Nadu was the first state in India to develop a set of Minimum Standards for old age homes. The Minimum Standards stipulate that that residents’ dignity and privacy should be respected. However, the concept of dignity is undefined in the Minimum Standards. To date, there has been very little research within old age homes exploring the dignity of residents. This study draws on the concepts of (i) status dignity and (ii) central human functional capabilities, to explore whether old age homes uphold the dignity of residents.

The study was designed to obtain insights into human rights issues and experiences of residents, and the article addresses the research question, “to what extent do old age homes in Tamil Nadu support the central human functional capabilities of life, bodily health, bodily integrity and play, and secure dignity for older residents?”.

A cross-sectional qualitative exploratory study design was utilised. Between January and May 2018 face-to-face interviews were conducted using a semi-structured topic guide with 30 older residents and 11 staff from ten care homes located three southern districts in Tamil Nadu, India. Framework analysis of data was structured around four central human functional capabilities.

There was considerable variation in the extent to which the four central human functional capabilities life, bodily integrity, bodily health and play were met. There was evidence that Articles 3, 13, 25 and 24 of the Universal Declaration of Human Rights were contravened in both registered and unregistered facilities. Juxtaposing violations of human rights with good practice demonstrated that old age homes have the potential to protect the dignity of residents.

The Government of India needs to strengthen old age home policies to protect residents. A new legislative framework is required to ensure that all old age homes are accountable to the State . Minimum Standards should include expectations for quality of care and dignity in care that meet the basic needs of residents and provide health care, personal support, and opportunities for leisure, and socializing. Standards should include staff-to-resident ratios and staff training requirements.

Peer Review reports

In recent decades India has witnessed significant improvements in public health, with increases in life expectancy and longevity alongside declines in infant mortality and fertility rates. As a result, the age structure of India’s population has changed with increases in the proportion and absolute number of older adults (60 + years) in the population. Overall, the proportion of older people has increased from 5.4% in 1950 to 9% in 2020. However there are variations in the age structure across Indian states: in 2020, around 14% of the population in Kerala were 60 + years compared to 7% in Assam [ 1 ]. Although there have been gains in increased life expectancy and healthy life expectancy in India, there have also been increases in the proportion of the older population spending more years living with a disability. This is related to the impact of infectious diseases, malnutrition, and the rapid growth in the prevalence of non-communicable diseases (e.g. diabetes, cardiovascular disease, and hypertension), with many older people requiring long-term care and support to manage their daily activities [ 2 , 3 ].

There are a variety of family forms in India, however, the notion of a normative traditional mutigenerational household and extended family prevails [ 4 ]. There is a social expectation that the traditional family will uphold filial piety (respect and obligations towards parents) and familism (prioritizing family needs above all others) [ 5 ] and meet the social, instrumental, economic and emotional needs of older people [ 2 ]. Indeed, this expectation is formally constituted in law. The Maintenance and Welfare of Parents and Senior Citizens Act mandates children, grandchildren and other relatives with sufficient resources to provide support to older people who are unable to maintain themselves. In situations where support is not provided, older people can take relatives to a tribunal to obtain a maintenance order. Non-compliant relatives may be fined or imprisoned. However, this is not a common course of action because there is a lack of awareness of the Act [ 6 ]. Furthermore, older people are reluctant to pursue legal action which could bring shame on the family and criminalise family members or result in a court order requiring the older person to transgress social norms and live with relatives other than sons [ 4 ]. Additionally, not all older people have access to family care: some do not have an extended family and/or have care needs that exceed family care-giving capabilities [ 4 ]. To cater for an increasing number of older people who need extra-familial support in later life, a new ‘old age home’ sector has emerged in India. We use the official terminology ‘old age home’ throughout this article when we refer to the sector in India. We use the expression ‘inmates’ to describe residents of old age homes. We do not condone the use of this term, but use it to illustrate the widespread adoption of the English language word (and meaning) in Indian academic, policy, media and public discourse.

The old age home sector comprises not-for-profit and private homes. The private sector caters predominantly for ‘middle class’ older people, that can afford them [ 7 ] and the charitable (not-for-profit) sector provides for older people without financial assets. The Integrated Programme for Senior Citizens provides basic amenities for older people without access to support (e.g. food, shelter and medical care) and is administered through grants at the state level that are paid directly to providers of registered old age homes and day centres [ 8 ]. Only 310 homes were funded through this scheme in 2018–2019 across all states in India [ 9 ]. There are no accurate records of the number of old age homes in India, nor of the number of residents in facilities, as homes that do not receive funding are not obliged to obtain a license, register, or to be inspected [ 10 ].

In 2016, Tamil Nadu was the first state in India to develop a set of Minimum Standards for old age homes that are delivered by not-for profit organisations [ 11 ]. These focus on physical elements of the facilities (e.g. the size of room, presence of CCTV), access to basic services (e.g. productive activities for residents, housekeeping and assistance with daily activities) and medical services. Although there are no standards relating to the quality of care, the guidance specifically notes, that “each inmates [sic] right to dignity and privacy should be respected” [ 11 ]. This statement is aligned to Article 1 of the Universal Declaration of Human Rights (UDHR) [ 12 ], that all human beings are born free and equal in dignity and rights. However, the concept of dignity is complex and contestable, and is undefined in the Minimum Standards.

There are two main definitions of dignity which distinguish between inherent dignity and status dignity. The Kantian notion of inherent dignity is conceived as equal moral status and personhood which is grounded in humans’ sentience, rationality and capacity for autonomy [ 13 ]. Some authors suggest that this definition excludes people who lack cognitive capacity or autonomy (e.g. older people with severe dementia) from equal respect and dignity [ 14 , 15 ]. Furthermore, many argue that inherent dignity is built on metaphysics or theology concerning the moral standing of human beings in relation to their ‘gods’ versus the rights of other animals [ 16 ], while others have argued that it is concerned with the worth of the individual in relation to other people [ 17 ]. The controversy concerning the concept of inherent dignity tends to detract from the political function of the UDHR which are intended “to protect individuals against the consequences of certain actions and omissions of their governments” [ 18 ]. Consequently, in this article, the concept of status dignity is used to describe the relationship of residents in an old age homes to the State and the agents of the State (staff in old age homes) [ 19 ].

Valentini [ 19 ] defines status dignity as “a status a human being possesses, comprising stringent normative demands” (p. 865). From this theoretical perspective, the duties to ensure the dignity of citizens (and that human-rights are fulfilled) primarily falls on the State and its agents. However, in order to explore whether the state is fulfilling their primary duty requires a definition of ‘normative demands’ essential for dignity [ 20 ]. In this respect, Nussbaum [ 21 ] has posited that governing bodies should secure for all citizens a threshold of ten central human functional capabilities (CHFC). CHFC are “opportunities that people have when, and only when, policy choices put them in a position to function effectively in a wide range of areas that are fundamental to a fully human life” [ 22 ].

The capability approach refers to the opportunities and freedom to undertake the activities necessary for survival, to avoid or escape poverty or serious deprivation and achieve a life that is  “not so impoverished that it is not worthy of the dignity of a human being” [ 23 ]. For example, bodily health (a CHFC) is partly underpinned by nourishment. Nourishment in turn requires resources to prepare meals (i.e. access to food products that are culturally or religiously acceptable and an energy source to cook upon) and the personal ability or external support to undertake the functions of cooking and eating. The capability approach resonates with other authors’ descriptions of the conditions necessary to support dignity in organizational and clinical settings [ 20 , 24 , 25 ]. All ten CHFC are relevant to supporting the dignity of residents in old age homes, however, this article focuses on four: life, bodily health, bodily integrity and play which correspond to Articles 3, 13, 25 and 24 of the UDHR (Table 1 ).

In India, there has been very little research within old age homes. The research that has been published has tended to focus on the private sector [ 7 ]. The available evidence suggests that a majority of homes require residents to be ambulatory, continent, and cognitively able at the time of admission [ 7 ]. Whether the CHFC are supported for residents that become unable to self-care because of physical or cognitive impairment is unknown. Presently, it is unclear as to the extent to which staff in old age homes, as agents of the State, uphold the dignity of residents. To explore human rights issues and experiences of old age home residents in India, this article addresses the following research question:

To what extent do old age homes in Tamil Nadu support the central human functional capabilities of life, bodily health, bodily integrity and play, and secure dignity for older residents?

Sample location

Tamil Nadu state is situated in the south India and covers 130,060km 2 . Tamil Nadu had a population of 72 million in 2011 of which 88% were Hindu. One-tenth ( n ≈ 7.2 million) of the population were age ≥ 60 years.

Sampling procedures

Old age homes were purposively selected from three southern districts in Tamil Nadu: Thoothukudi, Tirunelveli, and Kanyakumari (Fig.  1 ). Forty-three old age homes were located through a mapping exercise: 13 in Thoothukudi, 11 in Tirunelveli and 18 in Kanyakumari. The ratio of fee-paying to free old age homes in each district, and the size of the homes were used to inform our sampling strategy. Participants were randomly selected from lists of residents in 10 facilities, to obtain (as far as possible) a gender-balanced sample of 10 people in each district (Table 2 ).

Map of the states of India showing the location of Tamil Nadu, and map of Tamil Nadu showing location of selected states

Data collection

Face to face guided interviews (17–70 min; M  = 34 min) were conducted in Tamil with 30 residents (15 male, 15 female, age range 60–83 years) and 11 staff in old age homes, between January and May 2018 by three experienced female interviewers who were PhD scholars at Manonmanian Sundaranar University. To standardise approaches to interviewing, training was provided by the first and third author.

Interviewers explained the purpose of the study and established relationships with the residents and staff before the study commenced. All participants were interviewed in a private place where they could not be overheard or interrupted.

Semi-structured interview guides were used for residents and staff. Open-ended questions explored how residents came to be living in the old age home [described elsewhere, 4] and experiences of the old age facility. Examples of questions included: “Tell me about your typical day”, “What is the best thing about living here?” “What is the worst thing about living here?” “If you need help here, does anybody help you?” “What do you do with your time?” Staff were asked questions such as, “What services are provided to residents?” “How are residents’ needs assessed, if at all?” “What happens if a resident becomes sick?”.

The first three interviews were used to pilot the interview guide, and to check the quality of interviewing. Interviews were recorded, transcribed, and translated by a professional translator into English and anonymised. Pseudonyms are used throughout the article.

Framework analysis was used to analyse the data [ 26 ]. Five distinct but inter-connected phases (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) provided a rigorous methodological structure. Familiarisation, conceptual and cultural understanding of the interviews were clarified during team meetings (first and third author with interviewers) in Tamil Nadu. The second author created a list of a priori codes from the interview questions (e.g. support for each activity of daily living, discriminatory practices, food and nutrition, religious practices, leisure and recreation, worst and best things in the home). She applied these codes to transcripts (in NVivo 1.5.1), and while reading through the transcripts simultaneously created a new series of a posteriori codes, in an inductive thematic analysis. The first author read through the transcripts and coding to check validity. She then systematically applied a second coding index based on the capability approach: some thematic nodes became wholly subsumed in the ‘family’ nodes (e.g. ADLs were subsumed under ‘bodily health’) whereas others were relevant to more than one CHFC (e.g. worst thing in home). The first author charted the data into a framework which provided a decontextualized descriptive account of the data in relation to each CHFC.

The first author undertook the preliminary interpretation of data in three steps. First, taking an outcome-oriented approach, examples where each CHFC had/had not been secured were juxtaposed, providing an insight into the breadth of experiences of old age home residents. Second, residents’ and staff interviews were grouped by home and particular attention was paid to exceptions, contradictions and disconfirming excerpts. Third, experiences were contrasted between types of facilities (registered versus unregistered). All other authors (in India and the UK) were used as a sounding board, to check the persuasiveness of the analysis and to provide different ways of interpreting the research phenomenon [ 27 ].

‘Life’ refers to being able to live a normal life-span and not dying prematurely or before one's life is reduced as not worth living. This CHFC is closely related to bodily health. Participants referred to the ceiling of care available to them, if a resident was ill, or unable to carry out activities of daily living. In some cases, this was also referred to as the ‘worst thing’ about the old age home.

The first quote highlights the practical and ethical difficulties of deciding what ‘a life not worth living’ comprises. In this example, the resident perceived that the facility would judge that a sick older person’s life had no quality and would not be worth saving. Maalia explained what would happen if she became ill in the old age home in which she lived:

They will put me in the back room [sick room]. You may get a bath or you may not. You will have to lie there and die… If I become sick, the Sister will pour coffee and porridge. They will do that only when you become too sick. When you are going to die, they will pour water and bid farewell. That’s all. (Female, 65 years, widowed, H11 unregistered)

In other facilities, residents believed that if their health deteriorated to a point at which they were unable to take care of themselves they would be cared for by their children. For example, Rishi who had four daughters and lived with his wife said:

If we become too old and unable to do things, they [daughters] will only take us back. Now we are able to do things. So we are here. If we fall sick, these people will inform them and they will come and take us with them. (Male, 83 years, married, H14 registered)

Similarly, Hitendra said:

What if I become sick in the last stage of my life? Luckily I joined here when I was healthy. The facilities here are good. So, I want to be here for some time... I told my son that I would go to his house in [city > 200 miles away] if my health deteriorated. (Male, 83, separated, H10 unregistered)

The expectations for support at the end of life maybe unrealistic, as the residents were living in the facilities because their families were unwilling or unable to provide support. If support did not materialise, then this would not be problematic for Rishi, as the old age home he lived in provided life-long support. Diya, another resident in H14 noted:

If we are not well, the doctor will immediately attend. All medicines will be provided immediately. These three people [the doctor, the manager and the assistant manager] take such good care. One should have done punniyam [meritorious deeds in previous lives or in the past] to come here. (Female, 77, widowed, H14 registered)

However, there was no health care, personal support, or palliative care in the facility where Hitendra resided, and the manager noted:

The residents should take care of themselves. If they cannot take care of themselves, we cannot help. We do not have any attendant here. (Manager, H10 unregistered)

The Tamil Nadu Minimum Standards note that “each Old Age Home should ensure that the inmates [sic] should continue to receive care till the end of his/her life or up to natural death” [ 11 ]. Despite, mandatory care obligations, the Standards were only enforceable in registered facilities. Consequently, with one exception where a nun provided some personal support (see section on bodily health below), there were no care attendants to support residents in the unregistered facilities (Table 2 ).

Bodily health

This theme incorporated examples of supporting residents’ bodily health through medical and personal care (i.e. support for activities of daily living), adequate nourishment and shelter. Some difference between facilities in the availability of staff to provide health and personal care were mentioned above concerning CHFC life.

Residents in unregistered facilities were more likely to have to retain the ability to self-care or to provide support to each other than those in registered facilities. Dev and other residents in the same facility noted:

Here we don’t have anybody to get help. That is the rule here. One should eat oneself, one should wash oneself, one should sleep oneself. They are strict about it. Suppose you cannot walk by yourself, they, your co-residents may help you. That’s what happened to me for some 10 days. My roommates helped me. They would bring food for me. (Male, 72 years, never married, H15 unregistered)

However, this was not common to all unregistered facilities. Although there were no ‘paid’ attendants, in one facility a nun helped residents with personal care tasks, as Deepak said:

This Sister [name] takes me all by herself from the bed to the wheelchair. Takes me to the toilet for evacuation and cleans, gives me a bath, towels and brings me back here, dresses me and makes me lie down. She helps me eat food. She does everything in a good manner. (Male, 68 years, widowed, H16 unregistered)

In the only unregistered facility with a care attendant (the manager) the ratio of care attendants to residents was 1:20, whereas in the registered facilities, it was around one person for every four or five residents. The difference in levels of staff between registered and unregistered facilities was particularly stark for the largest facilities: whereas the registered facility had 19 staff for 65 residents, the largest unregistered facility had only three staff (one manager and two cooks) for 110 residents. In this facility the manager explained that “ we give work to those who are able among the residents” . Many of the manual jobs described by the manager, such as sweeping and cleaning rubbish are associated with lowest castes in India and are considered degrading [ 28 ].

We assign the older among them such work as making brooms with coconut leaflets. If they are young, we assign cleaning and gardening work. But we rotate the tasks. For the mentally retarded elders [sic], I ask them to take the firewood... I will give the vegetables to them and ask them to handover to the cook… They do such things as sweeping and removing cobwebs. They clear the dustbins. We ask them to help their fellow residents who are bedridden. (Manager, H11 unregistered)

In registered facilities, residents were more likely to receive support with personal care and medical or health care, even if this involved making clinical appointments outside the facility. In one facility some difficulties with personal support were noted: Pratik and Padma highlighted issues associated with assisting men and women to dress appropriately and with dignity.

There is a lady nurse. She takes me to the bathroom and gives me a bath and helps me dress. But she is a woman, and she does not know how to tie the veshti. Other men around will come to help at such times. (Male, 60 years, separated, H18 registered) That nurse gave me this petticoat without any saree. She is a nurse. Doesn’t she know that this petticoat is only suitable for a saree? (Female, age unknown widowed, H18 registered)

To support the nourishment of residents, most facilities had a set weekly menu. Residents in most facilities were satisfied with both the quantity and quality of the food that they received and Hitendra’s comment was typical of many “ The food is good. Even at home we will not get such food”. There were only two facilities in which residents indicated some dissatisfaction with the availability of food and drinks. In the first facility, this was mainly in relation to ‘snacks’ that had to be purchased. This was problematic for residents such as Varsha and Udit who had insufficient income.

Here they make coffee occasionally. It is black coffee. We don’t get it daily. They give biscuits rarely. If we give money, we can ge t. (Female, 75 years, widowed, H11 unregistered) I would like to eat some snacks like biscuits and omappodi. But I cannot get these. (Male, 80 years, separated, H11 unregistered)

In the second facility (H18, registered), the quality and range of food provided did not suit Padma’s food preferences or intolerances, she said:

Sour dosai. I don’t like it. If I eat this I will get leg pain. I don’t eat curd. I was advised not to eat sour things. They give just four idlies and they too will be sour. I will eat wheat dosai, but they will not give me any. (Female, age unknown, widowed, H18 registered)

In terms of providing shelter the cleanliness of the unregistered facilities varied, and this is contrasted in the following quotes from Maalia and Hitendra. Whereas Maalia had to clean faeces from the bathroom before she bathed, Hitendra was very satisfied with the cleanliness of the old age home in which he lived.

It [the bathroom] is befouled with urine and faeces. I clean it up with water and then, if I can tolerate it, I take a bath or wash clothes. I keep the clothes on my thigh and apply soap. What else can I do? Where can I go? (Female, 75 years, widowed, H11 unregistered) The rooms and the beds are neat. They change the bed sheet every month. They sweep daily. Bathroom and toilet are clean. (Male, 83 years, separated, H10 unregistered)

Bodily health is underpinned by opportunities to have good health (i.e. access to health and personal care), to be adequately nourished, and have adequate shelter. The Tamil Nadu Minimum Standards for old age homes specify the services that should be provided to residents. These include three meals (breakfast, lunch and dinner), two refreshment breaks (tea, coffee and snacks), and weekly visits by a medical officer. Furthermore, in-house staff should include a nurse, counsellor, cook and helpers (care attendants). While these services were more likely in registered homes there was still variability in terms of the quality of the services provided, an issue that is not addressed in the Minimum Standards. Overall, unregistered old age homes were less likely to provide opportunities for bodily health for residents: only one unregistered old age home in the study attempted to cater for the personal care needs of residents.

Bodily integrity

Bodily integrity refers to moving freely from place to place, secure against assault. The themes ‘abuse’ and ‘leaving the premises’ (i.e. freedom to move within and beyond the old age facility to the community) were incorporated in this family node.

Residents in H14 (registered) and H10 (unregistered) were permitted to leave the premises if they gave written notice and were accompanied by an attendant. Special occasions such as weddings and birthdays often warranted longer trips away from the facilities, and Joti noted that residents could be accompanied by their relatives. Avinesh also mentioned that residents were permitted to go to local places if they were accompanied by a member of staff:

If a resident wants to go out, like attending a wedding, the person who brought the resident here should come and take the resident. (Female, 84 years, widowed, H14 registered) The reason is that we are all old and if anything happens it will become difficult. If we request and if it is a nearby place, they will send us with an attendant. (Male, 78 years, married, H14 registered)

Only Dev mentioned being permitted to go out alone.

I can go and come alone. They allow for it. But one should go and come back properly. If we do anything unwanted, they will not allow. When they have confidence in us, they allow. (Male, 72 years, never married, H15 unregistered)

H11 (unregistered) particularly stood out in terms of denying residents freedom of movement. In this facility, most residents talked about their desire to leave and lamented the fact that they were not permitted to do so. Aanav’s reaction to a question about access to the local community was typical of residents in this facility, who expressed a desire to leave the old age home for good.

I am only thinking of when to leave this place. Even if I have to beg for food… I want to go somewhere. I don’t want to be here … If you raise the walls and put a tiger alongside, we cannot escape. Now I am with that tiger [the manager] here. (Male, 60 years, widowed, H11 unregistered) .

However, it was not only unregistered facilities that failed to support bodily integrity for residents. Padma noted that she was denied access to other areas of the old age home and said ‘ here we cannot move from one room to another’. She also cited an example of abuse by staff when she was initially left at the home, deserted by her family and distressed:

They first kept me on the staircase. As I kept on shouting, ‘Father Yesappa, save me!’ they took a plastic tea cup and gagged me. I fainted. Madam [the manager] went to her home. When I became conscious, I started chanting a prayer. The woman in the other room informed them. Madam came and ordered, ‘Don’t sing. Don’t pray. Shut up your mouth and lie down’. (Female, age unknown, widowed, H18 registered)

Deprivation of freedom of movement was not only a feature of old age homes in Indian society. A summary of Maalia’s life history demonstrates how actions assumed to improve her life (and that of her daughter) diminished her freedom and subjected her to unequal relations (Female, 75 years, widowed, H11 unregistered). Maalia spent the majority of her life in various facilities run by the same charitable organisation. At a young age, Maalia admitted herself to a children’s home to avoid abuse at home. She left briefly to marry but was abandoned by her husband when she was six months pregnant. Maalia left her daughter in a children’s home, moved into a women’s refuge and worked in the kitchen of the orphanage that she had been raised in. She borrowed ₹3,000 from the organization to arrange her daughter’s marriage (despite the organisational commitment to find suitable grooms for female residents, and meet all of the associated costs), and later required ₹27,000 for hospital fees to treat a burn sustained while working in the kitchen. After the first ‘loan’, the proprietors retained her salary (₹500 per month) for more than two decades. Eventually, Maalia’s sight deteriorated and she needed eye surgery. Unable to work to pay back another loan, Maalia requested to move to an old age home for older people that was located within the cluster of facilities. Thus, Maalia’s experience in the old age home was the result of a cumulative sequence of events. Deprivation of freedom was coupled with coercion through indebtedness to the cluster of charitable facilities. She suggested that death was preferable, “ I want to pass away as soon as possible. I should hurry to vacate this place .”

With the exception H11 (unregistered), most residents were permitted to leave facilities if they were accompanied by a relative or care assistant. However, access to the community was not equal among residents. Padma (H10, registered) noted that she was not permitted to move around the facility, or to leave, whereas other residents in the same facility were able to go out if they were accompanied. Across all facilities, residents who were unable to walk (e.g. confined to bed) were rarely provided with sufficient support to move around the facility, and were not given sufficient support to leave the facility (see section on play). The Tamil Nadu Minimum Standards for old age homes have given scant attention to this particular facet of dignity for residents. The only reference to leaving the facility is in relation to ‘outings’ in which it is stated that “ The inmates should be taken out on local outings like temple, fairs, plays and places of tourist interests at least once in 3 months” . This suggests that old age homes should offer planned activities, rather than facilitating the freedom of movement for residents.

Securing dignity through play, concerns providing residents with the opportunity to laugh and enjoy recreational activities. Several old age homes provided residents with newspapers, books and opportunities to watch the television. One old age home (H14, registered) which provided accommodation and care for Brahmins, appeared to have the most ‘occupied’ residents. This facility provided residents with a range of religiously oriented activities such as chanting mantras, prayers, reading spiritual books, watching religious series on television, and singing devotional songs. On the other hand, residents of H10 (unregistered) were mainly reliant on the television and newspapers for recreational activities, as Hitendra noted:

We will get newspapers at 10 am. We get four newspapers... We also get magazines... Back at home, we had to walk some distance to go to a library… They put the TV on by 9.30 am, but I don’t have the habit of watching TV. I have to read all the four newspapers. (Male, 83, separated, H10 unregistered)

There was evidence that some old age homes (H11 unregistered and H18 registered) did not provide any leisure or recreational activities. Instead, in H11 the residents who were able to work were given jobs. For example, Varsha (Female, 75 years, widowed) said “ I sit at that gate [entrance of the home] and my work is to open and close it” . Saksham (Male, 84 years, widowed) said that residents who were unable to work were “ Sitting quietly… Nothing else” . Despite paying fees, there were no leisure activities for residents in H18, and Pratik noted:

Breakfast will be over by 9.30 am. Then I just sit. At 1 o’clock there is lunch. From 1.30 to 4 pm, we get time to recline. What else do we need at this old age? But we have to pay for all these. (Male, 60+ years, separated, H18 registered)

One old age home deliberately denied residents the opportunities for recreation, as described by Rajiv:

There is a TV in that hall. If we go there to watch it, they will switch off and say that there is no power supply, but if we come back to the room and put on the fan, it will work. So, they don’t like us to watch TV… Sometimes we get parcel food that is wrapped with old newspapers. I would carefully unwrap it and keep it for reading. I used to read the same paper again and again. You know, what they would do? They would select the food parcel with dampened wrapper and give it to me so that I cannot read it . (Male, 63 years, never married, H16 unregistered)

In other registered and unregistered old age homes, access to leisure activities was inequitable for certain residents. For example, there were few opportunities to participate in recreational activities for residents who were nonambulatory or tetraplegic, such as Deepak and Rina.

I can read newspapers. But there is no one to hold the newspaper for me. So, I don’t have anything else to do. It is just sitting or lying. If I am seated, I would keep on sitting until somebody comes and puts me to bed. (Male, 68 years, widowed, H16 unregistered) I cannot get up. I cannot sit… My only problem is that I don’t have anybody else here to talk to. I am always lying down. If they put on the TV, I will listen to the news. I don’t go to the hall and watch TV. Who will take me there? (Female, age unknown, never married, H18 registered)

The narratives indicated considerable variation in the extent to which residents in old age homes are supported to ‘play’. Whereas some homes met the Tamil Nadu Minimum Standards which stated that “games should be played in the evening singing songs (devotional) and other past time activities may be designed depending on the age category and health status of the inmates” and that recreational facilities (e.g. books, indoor games, radio, and television) should be made available, others failed to provide any facilities, or denied residents access to these.

Registration of old age homes is mandatory in Tamil Nadu. However, many remain unregistered. To date, Minimum Standards are only enforced in homes that are registered and receiving funding, as these are the only homes that the State is aware of. The results show that there is considerable variation in the extent to which the four CHFC life, bodily integrity, bodily health and play are met for older people living in these facilities. Furthermore, variation is not necessarily between old age homes that are registered versus those that unregistered. In essence, there is evidence that Articles 3, 13, 25 and 24 of the UDHR are contravened in both registered and unregistered old age homes in India. This suggests that the State (the Government of India) is not meeting its obligations under Article 1 to recognize that ‘all human beings are born free and equal in dignity and rights’ and has failed to mandate and implement safeguards for all older residents. In registered homes, it appears that Standards are not being regulated through inspection, nor is support offered to help maintain quality where old age homes fall short.

Considering the CHFC ‘life’ and Article 25 of the UDHR, in long-term care facilities and other healthcare settings around the world, routine clinical decisions are made about whether to treat older people at the end of life, or to prevent a life from being prolonged. The idea ‘that a life is not worth living’ is used to support these decisions [ 29 ]. However, in this study, in one unregistered home untrained, non-clinical staff (e.g. members of a religious order) were making judgements and withholding both curative and palliative care to residents. Furthermore, in four of the ten facilities, there were no health or support staff to secure appropriate and timely health care for residents, to ensure that they did not die prematurely.

A majority of older people requiring health care and support at the end of life in India – either living in the community or in old age homes—do not have access to services [ 30 ]. This is reflected in India’s poor global ranking on the 2015 Quality of Death Index, that places it 67 th out of 80 countries [ 31 ]. In 2014, the World Health Assembly passed a resolution to strengthen palliative care as a component of comprehensive care throughout the life course and urged national governments to carry out actions to develop palliative care (WHA67.19). In this respect, the education, clinical training, and competence of staff in old age homes are pre-requisites to facilitate dignity [ 24 ]. The State needs to ensure that old age homes are adequately staffed to secure health care for residents, and that staff are sufficiently skilled to uphold the rights of residents to a good life (and death).

Turning to bodily health and the associated Article 25 (emphasising access to health care and personal support, food and shelter as the foundations of health, wellbeing and a dignified life), results indicated considerable variation between old age homes. In some facilities human rights were violated, with residents living in filthy conditions, while others were expected to help each other without any other provision for personal care or support within the facility. Elsewhere in the world, studies identifying risk factors for neglect have found that staff shortages, time pressures, staff turnover, and a high ratio of residents to staff contribute to care quality [ 32 , 33 ]. Thus, the dignity of care and support afforded to residents in some old age homes in India, suggests that the State needs to develop policies and strategies that regulate staffing ratios but also attend to quality of care and the maintenance of dignity.

Considering bodily integrity and Article 13: the right to freedom of movement, the study showed that most of the old age homes considered the safety of the residents and permitted them to leave accompanied by relatives or staff. However, residents are described as ‘inmates’ in policies (e.g. the Tamil Nadu Minimum Standards is published in English), programmes, and in research publications on old age homes emanating from India [ 34 , 35 ]. This is the language of incarceration. The term ‘inmates’ has been rejected for prisoners as it is derogatory, stigmatising, and dehumanising [ 36 ]. We contend that it is inappropriate to use ‘inmates’ to describe old age home residents for these same reasons, but also because it reinforces the notion that imprisonment, deprivation of liberty and segregation from the community is legitimate. While the deprivation of liberty of old age home residents is governed by legal codes in most European Countries [ 37 ], the decision to detain residents in India is arbitrary. The results showed that some residents were detained against their will, violating their human rights and undermining their capacity to live a dignified life.

The results of the study indicated that both bodily integrity (freedom of movement) and play are more frequently overlooked when residents have higher level needs, for example, are nonambulatory. Under these circumstances, some residents were denied their human rights with fewer (if any) opportunities to leave the premises or to engage in recreation. Elsewhere, studies have indicated that many care home residents spend a large proportion of the day inactive [ 38 ]. This is particularly salient for residents with dementia where there is evidence of restrictive practices, confinement and systematic breaches of human rights in care homes [ 39 ]. Severe physical or cognitive impairment is likely to incur greater demands on staff time to support freedom of movement and opportunities for leisure, when compared to the level of support required by residents who are less impaired. However, based on the concept of status dignity, it is the duty of the State (and its agents in old age homes) to uphold the human rights of all older people even if this requires additional staffing to ensure equity in securing CHFC for residents.

Limitations

The study was conducted in only one state in India, Tamil Nadu, and there may be variation in the quality and types of support provided in old age homes across India. However, we have no reason to believe that we would find a higher ‘standards’ of provision elsewhere. In 2019, the Ministry of Housing and Urban Affairs, Government of India developed a set of ‘model guidelines’ that are applicable to real estate developments intended for older residents who are ‘ willing and able to pay for accommodation services and facilities’ [ 40 ]. These model guidelines focus on services and physical aspects of the environment rather than the quality of care. The authors are fairly confident that the types of human rights violations observed in this study, would be found elsewhere in India (see also, [ 41 ]). As Tamil Nadu was the first state to introduce a set of Minimum Standards for old age homes in 2016, one may expect provision in this state to be ‘better’ than elsewhere as the standards have become embedded into practice over time.

This study was undertaken before the COVID-19 pandemic was declared a Public Health Emergency of International Concern by the World Health Organization in 2019. Globally, the pandemic has resulted in human rights violations for older people, especially in relation to the right to health and life [ 42 ]. Policy directives that were developed to protect the life of residents in care homes, have also impacted on bodily integrity and play [ 43 ]. Therefore, the experiences of residents in old age homes in Tamil Nadu are unlikely to have improved over the last two years. As old age homes are largely unregulated it is unlikely that the full extent of the impact of the COVID-19 pandemic on the human rights of older residents in India will be established [ 44 ].

Conclusions

Residents in old age homes can function effectively in the range of areas that are fundamental to a fully dignified human when policy decisions and the legal apparatus of the State provide them with the opportunities to do so. The concepts of status dignity, CHFC, and human rights have been used to describe the relationship of residents in old age homes to the State and the agents of the State (staff in old age homes). The results suggest that a new legislative framework is required to ensure that all old age homes are accountable to the State, regardless of the source of funding. We recommend that Minimum Standards include clear definitions regarding the expectations for quality of care and dignity in care, that meet the basic needs of older people (shelter, clothing and food) but also provide health care, personal support, and opportunities for leisure, socializing and access to the community. The legislative framework should also stipulate staff ratios, staff training and raising awareness of human rights. Standards should be regulated and support offered to help maintain quality. The study has highlighted incidents where human rights have been violated, but these illustrative examples have been juxtaposed with good practice, where residents’ human rights and dignity were protected. The research has demonstrated that it is possible to protect the dignity of residents of old age homes, but highlights areas where the Government of India and/or State Governments have a role to play in strengthening and developing old age home policies and strategies to protect older residents.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available as restrictions apply to the availability of these data (intention of data analysis included in participant information forms) and sensitivity (i.e. human data) but are available from the corresponding author on reasonable request. Data are located in a controlled access repository at the University of Auckland.

Abbreviations

Central Human Functional Capabilities

Universal Declaration of Human Rights

Agarwal A, Lubet A, Mitgang E, Mohanty S, Bloom DE. Population aging in India: facts, issues, and options. In: Poot J, Roskruge M, editors. Population change and impacts in Asia and the Pacific. Singapore: Springer Singapore; 2020. p. 289–311.

Chapter   Google Scholar  

Ugargol AP, Bailey A. Family caregiving for older adults: gendered roles and caregiver burden in emigrant households of Kerala. India Asian Popul Stud. 2018;14(2):194–210. https://doi.org/10.1080/17441730.2017.1412593 .

Article   Google Scholar  

Lau RS, Johnson S, Kamalanabhan TJ. Healthy life expectancy in the context of population health and ageing in India. Asia Pac J Public Health. 2010;24(1):195–207. https://doi.org/10.1177/101053951037666 .

Article   PubMed   Google Scholar  

Burholt V, Maruthakutti R, Maddock CA. A cultural framework of care and social protection for older people in India. GeroPsych. 2020:1–3 https://doi.org/10.1024/1662-9647/a000251

Burholt V, Dobbs C, Victor C. Social support networks of older migrants in England and Wales: the role of collectivist culture. Ageing Soc. 2017, 38(7):1453–1477. https://doi.org/10.1017/S0144686X17000034

Issac TG, Ramesh A, Reddy SS, Sivakumar PT, Kumar CN, Math SB. Maintenance and Welfare of Parents and Senior Citizens Act 2007: a critical appraisal. Indian J Psychol Med. 2021, 43(5_suppl):S107-S112. https://doi.org/10.1177/02537176211043932

Kalavar JM, Jamuna D. Aging of Indian women in India: the experience of older women in formal care homes. J Women Aging. 2011;23(3):203–15.

Government of India. Atal Vayo Abhyuday Yojana. Delhi: Ministry of Social Justice and Empowerment Government of India; 2021.

Google Scholar  

Government of India. State/UT-wise list of NGOs/VOs & projects funded under the Scheme of Integrated Programme for Senior Citizens during last three years 2016-17 to 2018-19. Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019.

Johnson S, Madan S, Vo J, Pottkett A. A qualitative analysis of the emergence of long term care (old age home) sector for seniors care in India: urgent call for quality and care standards. Ageing Int. 2018;43(3):356–65. https://doi.org/10.1007/s12126-017-9302-x .

The Government of Tamil Nadu. Fixing of Minimum Standards / Essential Standards to be Maintained in Old Age Homes run by Non-Governmental Organization (revised). Tamil Nadu: Social Welfare and Nutritious Meal Programme Department, The Government of Tamil Nadu; 2016.

United Nations. 1948. Universal Declaration of Human Rights. Paris: United Nations.

Giselsson K. Rethinking dignity. Human Rights Rev. 2018;19(3):331–48. https://doi.org/10.1007/s12142-018-0501-y .

Brännmark J. Respect for persons in bioethics: towards a human rights-based account. Hum Rights Rev. 2017;18(2):171–87. https://doi.org/10.1007/s12142-017-0450-x .

Kittay EF. At the margins of moral personhood. Ethics. 2005;116(1):100–31. https://doi.org/10.1086/454366 .

Haack S. Christian explorations in the concept of human dignity. Dignitas. 2012;29(3):4-13.

Habermas J. The concept of human dignity and the realistic utopia of human rights. In: Coradetti C, editor. Philosophical dimensions of himan rights some contemporary views. Dordecht, The Netherlands: Springer; 2012. p. 66–79.

Beitz CR. The idea of human rights. Oxford: Oxford University Press; 2011.

Valentini L. Dignity and human rights: a reconceptualisation. Oxford J Leg Stud. 2017;37(4):862–85. https://doi.org/10.1093/ojls/gqx011 .

Griffin-Heslin VL. An analysis of the concept dignity. Accid Emerg Nurs. 2005;13(4):251–7. https://doi.org/10.1016/j.aaen.2005.09.003 .

Nussbaum M. Capabilities and human rights. Fordham Law Rev. 1997;66:273.

Nussbaum M. Frontiers of justice: disability, nationality, species membership. Cambridge, MA: Harvard University Press; 2006.

Nussbaum M. Women and human development: the capabilities approach. Cambridge: Cambridge University Press; 2000.

Book   Google Scholar  

Franco H, Caldeira S, Nunes L. Dignity in nursing: a synthesis review of concept analysis studies. Nurs Ethics. 2020:0969733020961822 https://doi.org/10.1177/0969733020961822

Kadivar M, Mardani-Hamooleh M, Kouhnavard M. Concept analysis of human dignity in patient care: Rodgers’ evolutionary approach. J Med Ethics Hist Med. 2018;11(4):4.

PubMed   PubMed Central   Google Scholar  

Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Huberman AM, Miles MBT, editors. The qualitative researcher’s companion. Thousand Oaks, California: Sage Publications Inc; 2002. p. 305–29.

Hunter A, Lusardi P, Zucker D, Jacelon C, Chandler G. Making meaning: the creative component in qualitative research. Qual Health Res. 2002;12(3):388–98.

Sinha C, Kumar M. Conceal or Not? Management of dehumanized work identity among lower caste domestic workers and non-domestic scavenging workers. South Asian J Hum Resour Manage. 2018;5(2):173–93. https://doi.org/10.1177/2322093718787097 .

Farsides B, Dunlop RJ. Is there such a thing as a life not worth living? Br Med J (Clin Res Ed). 2001;322(7300):1481–3. https://doi.org/10.1136/bmj.322.7300.1481 .

Article   CAS   Google Scholar  

Chan N, Menon S. Goh Cr: Policies on palliative care for older people in Asia. In: Van den Block L, Albers G, Perieira SM, Onwuteaka-Philipsen B, Pasman R, Deliens L, editors. Palliative care for older poeple: a public health perspective. Oxford, UK: Oxford Univesrity Press; 2015. p. 60–8.

Economist Intelligence Unit. The 2015 Quality of Death Index: ranking palliative care across the world. London: Economist Intelligence Unit; 2015.

Goergen T. A multi-method study on elder abuse and neglect in nursing homes. JAdult Prot. 2004;6(3):15–25. https://doi.org/10.1108/14668203200400016 .

Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. Eur J Public Health. 2019;29(1):58–67. https://doi.org/10.1093/eurpub/cky093 .

Baranwal A, Mishra S. The condition of elderly inmates living in the old age homes of mumbai: an exploratory study. Indian J Gerontol. 2021;35(3):390–406.

Ulsah H, Indu PV, Anilkumar TV. prevalence of depression among the inmates of old age homes in Thiruvananthapuram, Kerala: a cross-sectional survey. Indian J Psychiat. 2022;64(Suppl 3):S565-S565. https://doi.org/10.4103/0019-5545.341631

Cox A. The language of incarceration. Incarceration. 2020;1(1) https://doi.org/10.1177/2632666320940859

Lloyd-Sherlock P, Penhale B, Redondo N. The admission of older people into residential care homes in Argentina: coercion and human rights abuse. Gerontologist. 2019;59(4):610–8. https://doi.org/10.1093/geront/gny014 .

Palese A, Del Favero C, Antonio Zuttion R, Ferrario B, Ponta S, Grassetti L, Ambrosi E. Inactive residents living in nursing homes and associated predictors: findings from a regional-based, Italian retrospective study. J Am Med Dir Assoc. 2016;17(12):1099–105. https://doi.org/10.1016/j.jamda.2016.07.010 .

Steele L, Swaffer K, Carr R, Phillipson L, Fleming R. Ending confinement and segregation: barriers to realising human rights in the everyday lives of people living with dementia in residential aged care. Aust J Hum Rights. 2020;26(2):308–28. https://doi.org/10.1080/1323238X.2020.1773671 .

Government of India. Model guidelines for development and regulation of retirement homes. Delhi: Ministry of Housing and Urban Affairs. Government of India; 2019.

Harbishettar V, Gowda M, Tenagi S, Chandra M. Regulation of long-term care homes for older adults in India. Indian J Psychol Med. 2021;43(5_suppl):S88–96. https://doi.org/10.1177/02537176211021785 .

Article   PubMed   PubMed Central   Google Scholar  

United Nations. 2020. Policy brief: the impact of Covid-19 on older persons. United Nations. Available from: https://unsdg.un.org/sites/default/files/2020-05/Policy-Brief-The-Impact-of-COVID-19-on-Older-Persons.pdf .

Green CEDA, Tinker A, Manthorpe J. Human rights and care homes for older people: a typology of approaches from academic literature as a starting point for activist scholarship in human rights and institutional care. Int J Hum Rights. 2021:1–23. https://doi.org/10.1080/13642987.2021.1961753

Rajagopalan J, Hurzuk S, Arshad F, Raja P, Alladi S. The COVID-19 long-term care situation in India. London: International Long Term Care Policy Network, Care Policy and Evaluation Centre, London School of Economics; 2020.

Download references

Acknowledgements

The authors wish to thank Dr R Anitha, Dr S Ponni, Dr R Hemalakshmi for contributions made to the research project. The source of maps for Fig. 1 is https://d-maps.com/carte.php?num_car=24853&lang=en

The cost of Open Access publication was supported by Health and Care Research Wales, Senior Research Leader fund.

Author information

Authors and affiliations.

School of Nursing/School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Room 235B, Level 2, Building 505, 85 Park Road, Grafton, The University of Auckland Private Bag, 92019, Auckland, New Zealand

Vanessa Burholt

Centre for Innovative Ageing, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, Wales, UK

Vanessa Burholt, E. Zoe Shoemark & Carol Maddock

Department of Sociology, Manonmanian Sundaranar University, Tirunelveli, Tamil Nadu, India

R. Maruthakutti

Anugraha, Swabhiman Parisar, Kasturba Nagar, Shahdara, Delhi, India

Aabha Chaudhary

You can also search for this author in PubMed   Google Scholar

Contributions

VB: Conceptualization, Methodology, Project administration, Funding acquisition, Data curation, Formal analysis, Writing- Original draft preparation. EZS: Formal analysis, Writing- Reviewing and Editing. RM: Supervision, Writing- Reviewing and Editing. CAM: Writing- Reviewing and Editing. AC: Writing- Reviewing and Editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Vanessa Burholt .

Ethics declarations

Ethics approval and consent to participate.

Ethical approval was granted by the College of Human and Health Sciences, Human Science Ethics Sub-Panel, Swansea University on the 20 th December 2017. Research was performed in accordance with the Declaration of Helsinki. Informed consent was sought from each participant prior to interview. All participants who were able (managers and residents) signed a consent form. Consent forms were read aloud to residents who were illiterate: residents who agreed to take part provided a thumb print rather than a signature on the consent forms.

Consent for publication

Participant information forms indicated that de-identified data would be used in publications: participants consent forms indicated that they understood this information.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Burholt, V., Shoemark, E.Z., Maruthakutti, R. et al. Dignity and the provision of care and support in ‘old age homes’ in Tamil Nadu, India: a qualitative study. BMC Geriatr 22 , 577 (2022). https://doi.org/10.1186/s12877-022-03272-4

Download citation

Received : 09 January 2022

Accepted : 30 June 2022

Published : 14 July 2022

DOI : https://doi.org/10.1186/s12877-022-03272-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Residential care
• Cross-sectional studies
• Long-term care
• Leisure activities
• Reference standards
• Delivery of health care

BMC Geriatrics

ISSN: 1471-2318

• Submission enquiries: [email protected]
• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Indian J Psychol Med
• v.43(5 Suppl); 2021 Sep

Regulation of Long-Term Care Homes for Older Adults in India

Vijaykumar harbishettar.

1 Padmashree Medicare, Vijayanagar, Bangalore, Karnataka, India.

Mahesh Gowda

2 Spandana Healthcare, Nandini Layout, Bangalore, Karnataka, India.

Saraswati Tenagi

3 Dept. of Psychiatry, Belgaum Institute of Medical Sciences, Belagavi, Karnataka, India.

Mina Chandra

4 Dept. of Psychiatry, Centre of Excellence in Mental Health, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.

The rising aging population in India has led to an increased caregiving burden, and accordingly, the number of residential care facilities is also burgeoning. There is no regulatory framework or registration authority specifically for residential care homes in India. The article’s objective is to understand the need for a regulatory framework in India in the context of historic and global experiences in the UK, USA, and Europe. Although there is a lack of literature comparing the community home-based care and residential care, one study reported a preference for home-based care in the South Asian context. Elder abuse and deprivation of rights of seniors are common, and there is a need to bring in more safeguards to prevent these from the perspective of the older adults, their family members, the care providers, and the state. While the main priority of meeting care needs in long-term care is a challenge given the lack of trained care staff, the quality control mechanisms also need to evolve. A review of adverse incidents, complaints, and litigations also highlights the need for regulation to improve the standards and quality of care. The article explores lacunae of residential care facilities in the Indian context and provides recommendatory parameters for evaluating the quality of care provided. Relevant sections of the statutory new Mental Healthcare Act of 2017 in India could provide a regulatory framework ensuring rights and liberties of the residents are upheld. The authors propose a state-run model for elderly care homes and commencement of framing regulations appropriate to the Indian context.

Introduction

Demographic transition because of increased life expectancy 1 has led to the rise of aging population resulting in huge demand for care. At the same time, there has been a decline in traditional familial, social support because of a reduction in fertility rates, 1 small nuclear families, increased urbanization, a decline in traditional social networks, and migration of children to other cities and countries. 2 – 5 This has contributed to the burgeoning of residential care homes for older adults, globally and in India. 6

In 1980, there was a national average of 54 beds per 1,000 elderly in the USA, while older people aged 65 and over were 25.5 million. 7 Around 13% of people above the age of 85 years needed residential care in 2010. 8 A Dutch economic survey between 2007 and 2009 found residential care to be expensive than home-based care. 9 Resource limitations deter governments from operating elderly care facilities to meet the increasing demand, leaving the management of elderly care facilities to charities, nongovernmental organizations (NGOs), or the for-profit private sector.

The need to regulate the management of elderly care homes was recognized in Western countries. In 1984, the Department of Health and Social Security in England introduced the Registered Homes Act, Registered Care Home Regulations, Registered Homes Tribunal Rules, and a Code of Practice for residential care home life. 10 With the majority of homes in the UK being run by the private sector, the government had to step in and develop legislations, monitor through regulations, and ascertain the care needs and outcome of long-term care in these homes. 11

Unstructured, unaccounted growth of the number of residential care homes for older adults in India necessitates that similar regulations and regulatory framework would be required in India, 5 and this article aims to study the relevant regulations and legislation of older adults’ long-term residential care homes and explores the lacunae in the Indian system to make appropriate recommendations.

History/Evolution of Care Homes in Europe and the USA

The earliest available information based on record-keeping that began in the 1830s in the UK mentions English workhouses on average had 300-bed spaces. In addition to the aged and the sick, the workhouses had orphaned children, the unemployed, and other people with disabilities. After 1851, the number of people aged above 65 years gradually increased for the next 100 years, and by 1945, post-World War II, the workhouses transformed into geriatric homes. There was also a rise of older people in the so-called lunatic asylums. The older people were considered as inmates segregated from the community and under the care of institutional managers in a master–inmate relationship. Studies suggested that people generally were reluctant to use care homes because of the fear of loss of independence. Thus, the experience of such living showed that the issues of independence, privacy, dignity, and choices became important for the residents, making some older people reluctant to move to these homes. 12 Furthermore, the financial constraints led to identifying a so-called need or incapability for such admissions. Later, legislation divided older people who were ill to care under the health authorities and those needed care otherwise to be under local authorities or social services. 10 , 12

Registered Homes Act of 1984 and subsequent legislations led to defining quality of care and standards for care home. 10 , 12 Periodic inspections began after quasi-inspection bodies were established under each local authority. Over some time, these homes started to run as small businesses. 12 Entry criteria to care homes included conditional “needs” assessment and financial assessment by a social worker. 12 Gradually, the senior care has become an established business in the Western society.

History of Residential Homes for Older Adults in India

The first documented residential care facility for older adults in modern India dates back to 1814. It was founded in erstwhile Madras (current Chennai) where a friend-in-need society comprising British merchants and bankers started to house Anglo-Indians and domiciled Europeans in difficulties. 13 This was followed nearly 70 years later in 1882 when home for the aged was established in Kolkata by “Little Sisters of the Poor” as a focussed initiative from a Maltese man Asphar. 14 These two homes for the aged and needy provided shelter, clothing, and medical care.

The initial focus was on providing basic needs such as shelter and clothing for those capable of taking care of their personal or nursing needs but could not live independently. Several religious organizations also opened ashrams for the elderly, which provided basic care in a spiritual environment. It is only later that nursing care, nutrition, physical and mental health care were incorporated into the care facilities for the elderly. Currently, residential care homes for the elderly are a non-formal sector in India, and the exact official numbers are not available. Nevertheless, in 2009, HelpAge India estimated 1,176 senior living facilities, with Kerala having the highest (182), followed by West Bengal (164), and Tamil Nadu (151). 15 Tata Trusts and the United Nations Population Fund and NGO Samarth, surveyed on a sample size of 480 old age homes and 60+ senior living developments in 84 cities in 2018, concluded that these numbers were low when the actual demand is high. 16

Defining Residential Care Homes

Residential care homes involve caring for elderly persons who cannot manage themselves partially or wholly, supported by unregistered or unqualified support staff who have gained some experience. Care needs mainly involve personal, supportive care, as prompted or requested by the residents themselves. The term Nursing home is generally used when there is a nursing care need for the person with a medical ailment, usually provided by registered nurses. Some care homes are specialized in offering long-term rehabilitation care with the help of a multidisciplinary team involving specialists in medicine, psychiatry, neurology, speech therapists, dietician, physiotherapists, nurses, social workers, pharmacists, etc. for older adults with complex physical, cognitive, or behavioral problems. These are a step down from hospitals providing acute care. The need for such facilities is also increasing because of the high costs of hospitalization. Retirement homes are homes built by private builders in India as a community living where the neighborhood comprises older adults who buy or rent the property. Some of the risks of independent living are managed or aided by the retirement home society. These homes allow the elderly to live autonomously with privacy, exactly similar to living in their own house.

Home-Based Care Versus Residential Home Care for Elderly

A systematic review of studies from high-income settings concluded that there is insufficient quality published research to effectively compare institutional care with community-based care for functionally dependent older people. Institutional care may be associated with reduced risk of hospitalization, better activities of daily living, while community-based care may be associated with improved quality of life and physical function. The impact of both the care models on mortality, healthcare utilization, economic correlations, and caregiver burden needs further research. 17 A meta-synthesis of ten studies from USA, Europe, and Asia found that culture impacts the decision making for a residential care facility, adjustment process, and eventual adaptation there. 18

In the South Asian cultural context, home is the preferred residential setting. 19 The residential option is considered when there is no family member (or male offspring) or when the complex physical and mental health needs overwhelm the caregivers (respite care or long-term care) or when neglect or abuse by familial caregivers exists. 20 Hence, the conditions of elderly and their outcomes in-home care versus residential care home are not comparable in India.

A literature review from India reported that the experiences and perspectives of older adults living in residential facilities are heterogeneous. Several older adults residing in residential facilities view them favorably, citing security, medical attention, and a sense of independence. Still, most prefer their own homes and families despite having experienced neglect or abuse by them. The common stressors associated with living in residential facilities include difficulty in adjusting to the new environment and rigid time schedules, declining functional ability, separation from their family and community, social alienation, sense of powerlessness, and repeated witnessing of death and illness in such settings. 21

Health Concerns in Residential Care Homes for Older Adults and Their Implications

Older age is associated with multiple physical and psychiatric comorbidities. Assessment and management of comorbidities are major challenges for residential care providers. 22 The needs of the residents are complex and multisectoral, and one has to look at addressing various issues than one particular specific health need. 23 There is a lack of data on rates of comorbidities in Indian residential care facilities for older adults, but the trends are likely to be similar to residential care facilities in other countries.

To understand the care needs, the UK national census of care home residents survey (n = 16043 residents in 244 care homes) showed that medical morbidity with an associated disability was the cause for admission in over 90% of cases. Over 50% of residents had dementia, stroke, or another neurodegenerative disease. Around 76% of residents required assistance with their mobility, 71% were incontinent. Twenty seven percent had multiple issues of immobility, confusion, or incontinence. Only 40% of those in residential care were ambulant without assistance. It was concluded that care needs in long-term residential care homes were determined by progressive and chronic illnesses. 24 Similarly, up to two-thirds of residents in care homes in USA have cognitive impairment, with many diagnosed with dementia. 25

The care need issues imply residential care facilities for older adults need-specific adaptations for toilet facilities to ensure hygiene, nutrition planning taking into account specific nutritional needs of the elderly as well as individual comorbidities requiring customized diets, 26 physiotherapy and exercise to maintain range of motion, balance, endurance, strength, and flexibility 27 environmental adaptations for easy mobility and prevent falls, specific measures to prevent pressure ulcers in nonambulatory residents, 28 periodic medical consultation as well as immunization.

In addition, the elderly in old age homes have high rates of psychiatric morbidity. Indian studies have reported high rates of depression, anxiety, and psychotic disorder in residents of old age homes in addition to dementia. 29 – 31

Apart from pharmacotherapy, addressing the mental health care needs of the elderly residents may range from providing cognitive stimulation, pro-social environments, ensuring sleep hygiene to managing agitation and frank aggression. Effective nonpharmacological management can reduce the need of dosage of pharmacotherapy. 32 This requires specialized training. There are only a few centers like the National Institute of Social Defence under the Ministry of Social Justice and Empowerment, which runs courses in geriatric care. However, the number of human resources trained in this and similar settings is minuscule as compared to the requirements of residential care facilities. In addition, the requirement of trained manpower in multiple domains can escalate the cost of services. At the same time, there is no framework for periodic evaluation, inspections, certification, and recertification of such service providers.

Complaints and Litigations

Elderly care facilities in India do not have any formal mechanisms for feedback, appraisal, complaints, or grievance redressal. When the care becomes business, or there is no regulatory framework, there is always a scope for disagreements and complaints against the care-providers by the consumers, with scope for formal lawsuits. Some of the outcomes of such litigation may be beneficial for the residents. For example, malpractice litigation threats have led to an increase in registered nurse to staffing ratios. These may reduce issues like pressure sores among residents and improve quality. 33 High-risk malpractice lawsuits have also led to the change of managers of nursing homes. 33

Since there is no regulatory body or licensing authority, it becomes difficult for the residents and their families, as they are unsure of where to complain if there are disagreements over the care and the responses from care home management. Even for the care providers, it becomes difficult to prove their quality of care when there are no benchmark standards. In the absence of defined regulatory frameworks, complaints against residential care facilities or individual care providers in such facilities have been made to elder’s helpline or Human Rights Commission or the Local Health Authority. 34

Choking, wandering and related risk, falls and related injuries, physical or chemical restraints, malnutrition, pressure sores, medication errors are a common source of litigation against the nursing homes. 35 A study of claims against 1465 nursing homes in USA demonstrated that best-performing nursing homes providing quality care were sued less than low-performing ones. 36 Repeated ongoing complaints or litigations may lead to the closure of poorly performing ones. Thus, there is an incentive to improve business by improving the quality of care and having good working relationships with the residents.

Need for Regulation

Aging-related issues coupled with living in an institutional environment may impact individuals’ autonomy, especially if they have never experienced living in institutionalized spaces earlier. This issue was debated, and consensus that it can be a “relational autonomy” related to the care home policies. 37 , 38 The boundaries of assertive care versus boundary violation to depriving someone of their rights can lead to conflict and stress amongst residents and the staff in the absence of policies.

There is also a concern about complex biopsychosocial needs of the elderly not being met in some of the residential care facilities through oversight, neglect, or deliberate measures. Various stakeholders to address the needs are the care providers, family members and friends of residents, advocacy groups, and State Health Authorities and Departments of Social Justice. Independent regulators have been proposed to regulate older adults’ residential care facilities. 39 Furthermore, regulation requires laws, rules, and minimum standards for such facilities. Unfortunately, such a framework does not exist in India as yet.

In contrast, the Department of Health in the UK established National Care Standards Commission in UK 2002, which has powers to regulate and inspect under the Care Home Regulations (2001) and National Minimum Standards (2001). Standard setting, self-regulation as well government regulation are important. 40 Similar provisions are found in other high-income countries.

Case studies from high-income settings have also highlighted the challenges of over-regulation. The Ontario Nursing Homes Study concluded though the regulations and accountability scrutinizing objective was predominantly to improve quality of care, it, unfortunately, ended up increasing workload and paperwork. This meant reduced time to provide direct physical care and missing out on scrutinizing top management such as funding and staffing levels. 41 This indicates that any form of licensing or regulations will come with minimum norms to provide care that can only be scrutinized by examining the documentation in the resident records. Audits are likely to pick up deficiencies and therefore will further increase the workload. More human resources could be directed towards record keeping, and these issues of regulations not serving the real purpose need to be considered while preparing regulatory policies. Another study report from Quebec province, after regulation, found that some smaller care homes were closed; however, the quality of care provided by the private care homes saw improvement. 42

A survey on the status of old age homes in India was conducted by Tata Trusts and assessed 480+ old age homes and 60+ senior living developments in 84 cities, towns, and districts. The report concluded a wide gap between expectations and delivery of services at most elder care facilities, with no mechanism for evaluating the quality and appropriateness of the services leaving the elderly inmates vulnerable and providing no incentive for improvement of services to the facility owners and managers. 16

Quality of Care

Quality of care involves adequate and proper staffing, regular assessments, minimum standards, care planning and provision, appropriate management of behavior and psychological symptoms of dementia (BPSD), physical environment characteristics, innovations, and quality of care provided to residents. 25

A review of adverse events in skilled nursing care facilities in the USA who were medicare beneficiaries by the Office of Inspector General found 22% of the residents had adverse incidents. Half of them were preventable. 43 This was not different from previous studies showing poor safety culture and indicated a need for regular inspection.

In England, residential care for adults including for older adults is provided by public, not-for-profit, and for-profit organisations. A study of 15,000 homes showed that quality of care was significantly lower in the private for-profit organization that managed 74% of the total homes, with the highest quality in the not-for-profit charity organizations that managed 18%. Public sector managed only 8% of homes. The study concluded that regulation would help improve the quality of care. 44

There is attention being paid now for improving the residential care facilities for the elderly and those with dementia. The focus has been to ensure a safe environment, designs that will assist way-finding, orientation, navigation, and access to nature and the outdoors although there is an ongoing need to sensitize policy makers and construction firms on age-friendly design practices. 45

The only comparable initiative is by the Kerala Government Department of Social Justice, which has prepared a manual for old age homes. It describes in detail the procedure for designing and maintenance of old age home, admission procedures, mechanisms for the protection of residents, provision of basic services (food, health care), safety and security, caregivers, rules, procedures, documentation, and rights framework of inmates and family members. 46 No other Indian state has developed any such framework as yet.

Relevant Legislative Framework in India

The National Programme for the Health Care for the Elderly (NPHCE), National Policy on Older Persons (NPOP) in 1999, and Section 20 of the Maintenance and Welfare of Parents and Senior Citizens Act, 2007, all deal with provisions for health and social care of older adults. 47 NPHCE aims to provide accessible, affordable, and high-quality long-term comprehensive care services to the aging population and build a framework to create an environment for older adults to function well. However, both NPHCE and NPOP have not discussed the need for residential care facilities for older people and their regulations. According to the provisions of the Maintenance and Welfare of Parents and Senior Citizens Act of 2007, the responsbility of health and social welfare lies with the legal heirs. 48 The regional state government, where the responsibility of health lies as per the Indian Federal Structure, manages some of its citizens’ health and social needs, including senior citizens. The states may provide staff salaries or funding for training caregivers. Also, there are provisions in some of the regional governments to offer financial assistance to NGOs to run old age homes to take care of the elderly persons providing all the basic amenities and care protection to life.

A systematic review indicated 48% of long-term care residents had dementia, within which 78% had BPSD and 10% had major depression. 49 Depression was found in one third and dementia in two thirds in care home survey in England. 50 In a study of the prevalence of health conditions of elderly in residential homes, 93% had a mental or behavioral disorder, including dementia 58% and depression 54%. 51 In a study of old age homes in Lucknow, it was found that depression was present in 37.7%, anxiety in 13.3%, and dementia in 11.1%. 29 Dementia, with its complications that includes BPSD, depression, anxiety, is common in care homes that need access to mental health care. Therefore, such residential care facilities fall within the purview of the Mental Healthcare Act (MHCA) 2017. According to Section 66 of MHCA 2017, any residential care home caring for person/s with mental illness comes under the definition of Mental Health Establishment (MHE). So, it must be registered with the State Mental Health Authority (SMHA). The SMHA needs to make regulations for the operation of MHE, including the minimum standards of facilities and services, the minimum qualifications for the staff personnel, and maintenance of a registry. There is no data in the public domain whether any residential facility for older adults with or without psychiatric morbidity has been registered under SMHA in any state. Admissions to care homes when they have locked facility when the older adult is not willing or not having competence to decide will have to be under the MHCA 2017. 52

National Accreditation Board for Hospitals and Healthcare Providers (NABH) Accreditation, a constituent of the Board of Quality Council of India, manages quality control and certifies hospitals in India. There is nothing specific for the long stay care homes, specific for the elderly 53 in NABH. The Union Ministry of Housing and Urban Affairs in 2019 developed guidelines for developing regulations for retirement homes 54 but there is no information in the public domain regarding the compliance of these guidelines by retirement homes.

Proposed Areas of Concern for Regulatory Framework (Also See Table 1 )

Authors’ Recommendations on Areas of Regulation

The prevalence of elder abuse is high in India and was found to be around 50%, which during the covid lockdown period went up as high as 71%, and the general factors found were increase in age and lack of formal education. 55 , 56 The elderly population is vulnerable, particularly when dependent and staying in institutional settings. WHO data on institutional elder abuse suggests that 64% of staff members perpetrated it in institutional settings. These acts include physically restraining inappropriately, depriving them of dignity, such as not changing soiled clothes or washing them, withholding or overmedicating them, and inadequate care to cause pressure sores.

The vulnerability of dependent elderly residents can increase the risk of abuse and neglect because of their physical and cognitive functioning limitations in addition to their fear and anxiety. 57 Examples include aggressiveness, yelling in anger, making threats, punching, slapping, kicking, hitting, speaking in a harsh tone or words, or humiliating. Neglect involves not providing food, water, assisting with toilet needs, or medicines. A report from Atlanta ombudsmen long-term residents program in 2000 found 44% of residents reported experiencing abuse. 58

The challenges faced by the staff of the care homes must be addressed by regulation, by ensuring the training needs are met. The majority of the staff members and almost half of them reported violent incidents towards them from residents or their families. They expressed that poor working conditions compelled them to offer inadequate quality of care for the residents. Many thought such incidents of violence happened during their duty as careworkers. 59 Staff training should include techniques and strategies to prevent and manage any form of violence from residents and their families.

When it was found out that the proportion of vulnerable patients or residents could not come under the purview of the Mental Capacity Act of 2005 of England and Wales, which could have impacted their human rights, another legislation called Deprivation of Liberty Safeguards was introduced. 60 This was to ensure the vulnerable elderly persons were not deprived of their liberty to safeguard rights under Article 5 of Human Rights Act and that most of the elderly care homes are locked facilities. No such provision exists in India.

Regulations can be state-mandated by an independent public body, or there could be forces of market competition or self-regulation with accreditation by service providers associations. 61 A Swedish study of the economics of care homes between 1990 and 2009 showed privatization with the associated increase in market competition significantly improved quality as measured by mortality rates. 62

The Karnataka Private Medical Establishment Act rules of the state of Karnataka from 2009 (amended 2018) includes details of the process of registration of private medical establishments, renewal, different types of hospitals, minimum standards for accommodation, equipment, facilities, staffing requirements and their qualification, and maintenance of records. The space requirement for the inpatients or examination room has also been mentioned. 63 However, the act does not include old age homes/elderly care facilities.

The study by Tata Trusts published in 2018 explored the need for minimum compulsory standards for infrastructure and management to ensure attention given to physical needs, safety and security, dignity and respect for elderly persons. Lack of regulation was evident, and they recommended compulsory registration, annual filings, and periodic inspections. They highlighted few broader themes in terms of home healthcare, personal supportive care, social activities, complaints and safeguards, environment, staffing, and management. In addition, they also highlighted the need for a third-party regulator and ombudsmen for safeguards, certification for staff, and establishing model care homes. 16

System in Place for Prevention of Elder Abuse

In December 2019, Indian Central Government proposed a bill to amend the Maintenance and Welfare of Parents and Senior Citizen Act, 2007, which proposes registration of senior citizens care homes/home care service agencies along with maintenance of minimum standards for senior citizen care homes. However, implementing the regulatory framework will be with nodal police officers for senior citizens in every police station and district-level special police unit. This framework is not satisfactory. 64

The authors propose that regulations for residential care facilities for older adults must define minimum standards for living, nutritional care, medical care, palliative, and end-of-life care. There should be ongoing staff training in elderly care, ethics and human rights, and documentation of medical management, including any adverse drug events/complications with an evaluation of care to help improve services. 65

There should be a system to report incidents. All staff members must be trained in filling the incident reporting form, which is to be regularly reviewed by the named senior clinician (see Table 2 ). Prevention strategies include public and professional awareness, training, screening before employing the staff of residential care home, and caregiver training on dementia. Mandatory reporting of abuse to a central independent agency is to be considered. Perpetrators need to be identified, and in the first instance, appropriate education, training program, and work should be supervized until confidence is built. If the abuse is severe, this may need to be informed to social services or senior citizen helpline for appropriate action by the judiciary. The homes may not record or report abuse may try to underplay the issue, for wary of receiving tag of a poor quality care home, despite the obligation to report. The managers of the care home must ensure there are enough safeguards. There could be regular monitoring of common areas with closed-circuit television recording, regular review of the residents, and feedback.

Proposed Minimum Standards

Long-term social care is also the responsibility of the state. Since the government alone cannot meet the huge demand in this area, policies to expand health insurance schemes to include long-term care in a residential care home can be considered.

There is a need for health and social care reforms to manage the rapid aging process, which may help expand services through home care or residential care. 66 With demand rising, India is likely to see more residential care homes in the future. Although MHCA 2017 has provided some legislative framework when the care home has any one or more residents with a mental disorder, it is not enough to regulate and safeguard the residents. The government authorities could take the lead and bring in geriatric experts, NGOs, private care providers, and the main stakeholders, the elderly community, and their children on board to ensure consultations and discussions take place periodically. Appropriate quality control measures in terms of registry, licensing, periodic inspections, and developing minimum standards for all kinds of old age homes should be instituted. At the same time, under-or over-regulation should be avoided. Until the regulations are formulated, the residential care homes must follow general work ethics, safeguard the human rights of residents, provide compassionate care, self-regulate by regular review of their care and impact, and handle complaints and feedback and work on the shortcomings. There must be an appropriate care needs assessment endorsed by specialists and attempts to provide home-based care before admission to residential homes. The government should take the lead by setting up model residential care homes to train the staff in as many regions as possible and then serve as a mentor to the private or NGO bodies.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

Lifestyle Changes and Perception of Elderly: A Study of the Old Age Homes in Pune City, India

Priyanka v janbandhu 1 , santosh b phad 1 , dhananjay w bansod 2.

1 Research Scholar at International Institute for Population Sciences, Mumbai, India

2 Professor, Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India

* Corresponding author Priyanka VJ , Research Scholar at International Institute for Population Sciences, Mumbai, India

Received Date: 13 October, 2022

Accepted Date: 10 November, 2022

Published Date: 15 November, 2022

Citation: Janbandhu PV, Phad SB, Bansod DW (2022) Lifestyle changes and perception of elderly: A study of the old age homes in Pune city, India. Int J Geriatr Gerontol 6: 138. DOI: https://doi.org/10.29011/2577-0748.100038

The increase in old age homes and its residents mandates attention to the living condition of elderly at these institutions. The study is based on the information collected from 500 residents of 23 old age homes of Pune city in India. A multistage random sampling used for the selection of samples. A semi-structured interview schedule was adopted to gather the information from the respondents, the interview schedule was approved by the research ethical board of the institute. To strengthen the study qualitative insights are also gathered using case studies and key informant interviews. About half of the respondents were having issues while adjusting at old age home and similar percent has reported that their life has considerably changed after joining the old age home. Over half (52%) of these have experienced negative impact, such as homesickness, feeling of left alone (abandoned) by family members, feeling of staying at a hostel, follow certain schedule, elderly have to adjust in their daily life, and so on. Due to family attachment, many respondents feel lonely. For instance, 56 percent of the respondents perceive that they are being left out by their family members. While, two-thirds of respondents perceive that other elderly who are staying with their family members are having a better life than themselves. Hence, many respondents would like to go back to their families. Despite the fact that more than half (54%) of respondents know that they will spend their remaining days at the old age home. Whereas, 42 percent of the respondents said they are not certain about their future stay and 2 percent believe that soon they will return to their former homes among family members. Although many respondents experienced positive outcome after joining the old age home. Yet, the issues of uncomfortable living, loneliness, or similar unpleasant feeling is present among some of the respondents. These experiences are mostly due to the absence of family members in surrounding.

Keywords: Adjustment; Living condition; Old age home; Family; Elderly

Introduction

Population ageing is considered to be one of the biggest challenges of demographic transition in the twenty-first century [1-3]. Decreasing fertility rates and increasing longevity have resulted in a higher population of elderly people (aged 60 years and above) compared with the younger and adult population than ever before [4-6]. Although developed regions were the first to witness the phenomenon of population ageing, now the developing regions are witnessing a rapid growth of aged population [7, 8]. The share of persons aged 60 years and above in the world is expected to increase by 56 percent between 2015 and 2030. [9]. As per United Nations Population Division estimates increase the share of old age population from 5.7 percent in 2019 to 7.6 percent in 2030 in lower middle income countries [10]. As per 2011 census [11], India’s older population aged 60 years and above is 103 million and it is expected to increase 319 million by 2050 [12].

Increase in the proportion of older population due to shift in the age structure from younger population to older population create various challenges for policy makers and create burden on younger generation and increase demand for social and economic support care for elderly [13]. Before advancement of demographic transition in India, traditional family system was providing care for elderly especially in joint family system. In the past several years, as a result of advanced demographic transition along with socioeconomic development and urbanization, a large chunk of migration has occurred. As skilled professionals have moved to developed countries and from rural to urban areas for better opportunities, leading to reduction in family size and the erosion of traditional families. It led to growth of nuclear families, reduced socioeconomic support and care for elderly, and increased the demand for old-age homes in India [14].

With increased longevity, many of the elderly would require some form of long-term care, the cost of which needs to be borne by their families. This might result in family members withdrawing from school or employment to care for the elderly member. Hence, older people are viewed as a burden [15,16]. Traditionally, within the familial hierarchy elderly people have enjoyed a high status [17-21]. However recently, with the increase in age, several elderly people experience eroding status. In addition to other factors, it contributes to the behaviour of the elderly towards their families and their living arrangement [22,23].

According to BKPAI report [24] marriage of children is and other reasons such as include death of spouse, family conflicts, and migration of children are reasons for elderly to live alone. In addition, the demand for old age homes increased. Some evidences indicate that the increase in old age homes was seen largely in the southern regions of the country, particularly in Kerala and Tamil Nadu, then in the western state of Maharashtra [25-28], due early demographic transition, urbanization and migration led small family norm compared to other states. There has been changes in the social and family structure which affected the culture and norms of the society. The process of modernization and search for better standards of living and job opportunities forced children to move away leaving their parents behind. In This study we assess the lifestyle of elderly and their perception who live in old-age homes in Pune city of India.

Data Source and Methodology

A list of old age homes was obtained from Help Age India, Pune office [29]. This study was conducted in 23 old age homes of Pune city, India. From these old age homes, a total sample of 500 respondents was selected using the lottery method. The researcher used the purposive sampling technique and limited the sample size to 500 elderly respondents from 23 old age homes. The study includes old age homes which have completed at least 2 years of functioning, avoiding all those old age homes which were established or in function not more than 2 years. The study includes only those elderly who were aged 60 years and above, living in old age homes at least for one year. Elderly persons have experience of living in old age home for less than a year are not considered in this study. Those elderly who was unable to respond to the question or who had any psychological issues (diagnosed by a medical practitioner) are not considered for the study.

Participants

The study population was comprised of 500 elderly people, residents of old age homes. Those elderly who are physically mobile and capable of conducting interviews on their own behalf the respondents should have stayed in the old age home for one year so that they can give a better understanding of the facilities provided in the particular old age home where they are staying. A semi-structured interview schedule was developed for the data collection. This interview schedule received approval for data collection from the ethical board of the institute. Data was coded and analysed with STATA (v.14.0) software.

Sample characteristics of elderly population who are living in old-age homes

Table 1 presents the sample characteristics of elderly living in old age-homes in Pune city, Maharashtra. Among respondents, over three-fifths (63%) are women and 37 percent are men. Higher proportion (42%) of respondents are aged 70-79 years, followed by aged 80 years and above (31%) and aged 60-69 years (26%). Percentage of elderly living in the old age homes increases with the up to certain education level. For instance, 13 percent of respondents live in the old age homes have never attended school, whereas 24 percent of respondents have completed 8-10 years of schooling. Share of female respondents is higher with no schooling than the male respondents (16% against 9%). According to marital status, higher proportion (62%) of respondents are widowed/widower compared to 23 percent are never married, 8 percent are currently married and 7 percent are divorced/separated. Share of elderly men who are never married is higher than the never married elderly women (28% against 19%). While, share of elderly women who are widowed is higher than the widowed elderly men (67% against 54%). With regard to social groups, majority (79%) of the respondents does not belong to Scheduled Caste (SC), Scheduled Tribes (ST) or Other Backward Caste (OBC). While, 12 percent of respondents are belonging to SC and 7 percent are OBC. According to the type of family, higher larger share (73%) of respondents were living in nuclear family and 26 percent came from joint family. Since, women tend to have lower social status compared to men, they are more likely to depend on the male person of the family either father, husband or son. Hence, women are inclined to have lesser significance in the family. In line with other several factors, women are more likely to join the old age home compared to men.

Table 1: Percentage distribution of women and men aged 60 years and above by selected background characteristics, Pune, Maharashtra, 2017.

Lifestyle of the elderly living in old-age homes

Elderly respondents were asked about whether they have experienced any changes in their personal lifestyle and either positive or negative changes after joining the old-age home. The changes in personal lifestyle of the elderly covers various dimensions such as adjusting with the environment of old-age home, feeling loneliness or left alone, home sickness, health issues as chronic and psychological health problems. While, some respondents have experienced positive changes such as improvement in health condition, received good care at old-age home, good social networking as mingling with other old age home residents, peaceful environment, engagement in various activities which is also a part of entertainment for them.

Table 2 shows the percentage distribution of elderly with significant changes in their personal life style. Over half (52%) of the respondents have experienced negative changes after joining the old age home, while about two-fifths (39%) have experienced positive changes and around one-tenth (9%) have neither experienced any positive nor negative changes in their lifestyle at old age home. Share of elderly women with negative changes in higher than the share of elderly men (56% against 35%). Similarly, among widowed elderly more 54 percent have experienced negative changes and 38 percent have positive changes. Whereas, respondents who are from rural areas are more likely to experience negative changes (57%) compared to respondents from urban areas (44%). Share of elderly with experienced negative changes decreases with increase in number of sons (71% elderly with no son to 33% elderly with 3 or more sons). While, percentage of respondents with experienced negative changes increases with increase in number of daughters (48% elderly with no daughter to 81% elderly with 3 or more daughters).

Mr. Singh (name changed) shared - “I could not afford the cost associated with the required health treatment. In order to receive health treatment and basic care, I have joined the old age home. As a result, my health improved after joining the old age home. At old age home, I have been receiving health care services, the availability of care-taker is an additional advantage. Eventually, my health started recovering at old age home.”

Table 2: Percent of elderly with significant changes in their personal life and positive change in their life after joining the old age home of Pune city.

Perception of elderly

The results presented in (Table 3) shows the percentage distribution of elderly’s perception who live in old-age homes about the others (elderly who lives at home with their family) are better-off compared to them and they feel lonely or left out at oldage home, which varies with different demographic and social characteristics. Perception among elderly staying at old age home that other elderly (who are not staying at old age home) are betteroff than themselves is higher among widowed/widower elderly (69%) compared to never married elderly (65%) (χ2 p-value <0.05). According to type of family, perception of elderly from joint family who live at old age homes that other elderly (who are not staying at old age home) are feel better-off than themselves is significantly higher (74%) than nuclear family elderly (64%) (χ2 p-value<0.05). Similarly, perception of elderly whose residence is abroad and lives at old age homes that other elderly (who are not staying at old age home) are feel better-off than themselves is significantly higher more (71%) than whose earlier residence is same district at local (64%) (χ2 p-value <0.05).

Mr. Ganpat (named changed) never married respondent said “Many elderlies have children and still they are staying in the old age home with me. After watching them suffering like this, I feel that it’s better I am not married and I don’t have a family (children). What is the use of having such children who cannot take care of their parents in their last stage of life? Because, in the end, we (never married and ever married elderlies) are sailing in the same boat.”

Higher percent of widower / widowed elderly who live at old age homes perceive (60%) that they feel lonely or left out than never-married elderly (55%) (χ2 p-value<0.1). According to type of family, the joint family elderly who live at old age homes perceive (60%) that they feel lonely or left out is significantly higher than nuclear family elderly (55%) (χ2 p-value<0.05). Other demographic and social characteristics of elderly perceiving those other elderly persons are better –off who are not living in the oldage homes and feeling loneliness who are living at old age homes are not shown significantly.

Radha (named changed) a widow respondent said “An old age home is unable to provide a warm and welcoming environment like home. My family is always on my mind. Being away from them, and the realization that I will never get a chance to return to them, makes me more uncomfortable at old age home. I feel being isolated by my family members, which makes me feel lonely.”

Table 3: Percentage distribution of the elderly perceiving that the other elderly person is better off and the feeling loneliness at old age homes, Pune city.

Future intention of elderly to length of stay in the old-age homes

(Table 4) presents percentage of elderly and their future intention to length of stay in the old-age homes in Pune city, Maharashtra with different demographic and social characteristics. Percentage of elderly and their future intention to length of stay in the old-age homes is significantly associated with educational level. Length of stay in the old-age homes till death is decreases with increasing educational level. More than half of elderly population with no-schooling (55%) have future intention to length of stay in the old-age homes till death compared to graduation and above educational level (46%). The 44% of elderly have no idea about their future intention to length of stay in the old-age homes with no-schooling compared to graduation and above educational level (47%) (χ2 p-value <0.1) The higher percentage of elderly population whose childhood residence is rural and their future intention to length of stay in the old-age homes till death (58%) compared to others (51%) and lower percentage of elderly population whose childhood residence is rural and they did not have idea about their length of stay in the old-age homes (35%) compared to others (45%) (χ2 p-value<0.1). Percentage of elderly people who had no children with them with length of stay in the old-age homes till death is significantly lower (72%) than others who were having children (44.2%) and percentage of elderly who had no idea about their length of stay in the old-age homes is significantly lower (50%) compared to other who were having children (24%) (χ2 p-value<0.001). Other demographic and social characteristics of elderly such as age, sex, martial-status, religion, social groups (SC, ST, and OBC), family type (nuclear and joint family), having sons and daughters have not shown significant association with their length of stay in the old-age homes in Pune city.

Table 4: Percentage of the elderly with future intentions to stay in the old age home, Pune city.

Discussion and Conclusion

The gender difference is quite prevalent in living in oldage homes as elderly women are more likely to live in the oldage homes than elderly men. Majority of widowed/widower elderly and elderly who came from nuclear family live in the oldhomes due to lack of care and support and death of their partners, especially women have prolonged widowhood due to longer life expectancy than men [38]. Previous evidence shows that increasing urbanization and globalization lead toward nuclear family and migration of children for their job leads to unable to care for their aged parents [30]. For elderly persons, without support of their children, caring themselves is very difficult [30,31].

Most of the elderly have experienced negative change in their life after entry in the old age home as they felt home sickness, health issues as chronic and psychological problems, feeling lonely or left alone, need to adjust with environment of old-age homes and responded that neutral as neither satisfied nor felt bad living at old age homes. Many of previous studies have shown similar evidence that elderly who live olde-age homes suffer from Socio-psychological health problem such chronic health issues as stress, loneliness, depression, anxiety and other health and social issues as loneliness and lack of familial relationship. Especially staff of old-age homes lack caring for elderly, empathy, insufficient understanding of aging issue and skill to take care of elderly in old-age home led to worsen the lifestyle of elderly [3236]. Among these elderly persons, widowed/widower and elderly from rural areas have not satisfied much about their life compared to their counterparts. Widowed/widower elderly are forced to join in the old-age homes due to lack care and socioeconomic support, death their partners, and for being from nuclear family. Majority of the women respondents have spent most of their time with family members and taking care of the household chores. While men have played part in both indoor and outdoor activities. As a result, compared to men, women while staying away from home or family members have shown more disappointment [37].

Important emerging finding of this study is that share of elderly who have experienced negative changes decreases with increase in number of their sons, whereas it increases with increase in their number of daughters. Only few of the elderly have experienced positive changes after joining the old age home such as improvement in their health, received good care at old-age homes, good social networks as mingling with other friends and peaceful environment. Old age brings several issues, and health problems and lack of care and support are the key issues for the elderly. At the old age home, elderly receive health services, care and support which are important needs of the elderly. Hence, several respondents stated that their health condition has improved or they received appropriate health services at the old age homes. While many respondents have unpleasant experiences with their family members and old age home avoids such unpleasant events.

Majority of elderly’s perception who live in old-age homes about the others (elderly who lives at home with their family) are better-off compared to them and they feel lonely or left out at old-age home. Of these, perception of widowed/widower elderly and elderly from joint family about other elderly is that they are better-off and they also feel lonely or left out at old age home is significantly higher than their counterparts as never married and nuclear family. A large part of the respondents covers never married elderly or those who never intended to join the old age home. So, this group considers other elderly who are living with their family members having better life than themselves. Majority of elderly’s intend to stay at old-age home till death and some have no idea that how long they will stay at old age home. Of these, the elderly who have no children have more likely to stay at old-age home till death compared to those who have children.

The study mainly suggests that situation of elderly living in old age homes need attention, as several elderly are experiencing homesickness, unable to cope up at old age home, and feel lonely or left out, irrespective of availability of all required facilities at old age home.

• Chen F, and Liu G.(2009). Population aging in China. In International handbook of population aging (pp. 157-172). Springer, Dordrecht.
• Davies A, and James A.(2016). Geographies of ageing : Social pro cesses and the spatial unevenness of population ageing. Routledge.
• Dyson T. (2001). A partial theory of world development: The neglected role of the demographic transition in the shaping of modern society. In ternational journal of population geography, 7 : 67-90.
• Bongaarts J. (2009). Human population growth and the demographic Philos Trans R Soc Lond B Biol Sci. 364: 2985-2990.
• Bloom DE, Canning D, and Fink G.(2010). Implications of popula tion ageing for economic growth. Oxford review of economic poli cy, 26 :583-612.
• Wu L, Huang Z, and Pan Z.(2021). The spatiality and driving forces of population ageing in China. Plos one,16 e0243559.
• Herrmann M.(2012). Population aging and economic development: anxieties and policy responses. Journal of Population Ageing, 5: 23
• Giridhar G, Subaiya L, and Verma S. (2015). Older women in India: Economic, social and health concerns. Increased Awarenes, Access and Quality of Elderly Services. BKPAI (Building Knowledge Base on Ageing in India), Thematic Paper, 2.
• United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Ageing 2019: Highlights (ST/ ESA/SER.A/430)
• United Nations, Department of Economic and Social Affairs, Popu lation Division. (2015). World Population Ageing 2015 (ST/ESA/ A/390).
• Office of the registrar general of India. Census of India-2011. Ministry of home affairs, Government of India.
• The Hindu.(2021). Number of India’s elderly to triple by 2050.
• Subaiya L, and Bansod DW.(2011). Demographics of population Aging in India: Trends and Differentials,BKPAI Working Paper No. 1. New Delhi: United Nations Population Fund (UNFPA).
• Bhattacharya P.(2005). Implications of an Aging Population in India: Challenges and Opportunities. Orlando, Fla. Presented at: The Living to 100 and Beyond Symposium Sponsored by the Society of Actuar
• Lancet, T.(2012). Ageing well: A global priority. Lancet 379:1274.
• Rajan IS, and Aliyar S. (2008). Population ageing in India. Institutional Provisions and Care for the Aged, 39-54.
• Chiu S, and Sam Y. (2001). An excess of culture: the myth of shared care in the Chinese community in Britain. Ageing and Society, 21:681
• Chen X, Liu M, and Li D. (2000). Parental warmth, control, and indul gence and their relations to adjustment in Chinese children: a longitu dinal study. Journal of family psychology, 14: 401-419.
• Dowd J J.(1975). Aging as exchange: A preface to theory. J Geron tol, 30: 584.
• World Health Organization. (2015). World report on ageing and health. World Health Organization.
• World Health Organization.(2001). Health and ageing: A discussion paper (No. WHO/NMH/HPS/01.1). World Health Organization.
• Malhotra R, and Kabeer N.(2002). Demographic transition, inter-gen erational contracts and old age security: an emerging challenge for social policy in developing countries.
• Perlman D, and Peplau LA. (1981). Toward a social psychology of Personal relationships, 3:31-56.
• (2012). Report on the Status of Elderly in Select States of In dia, 2011. UNFPA.
• Dyson T, and Moore M. (1983). On kinship structure, female autono my, and demographic behavior in India. Population and development review, 9:35-60.
• Anderson S, and Ray D.(2012). The age distribution of missing women in India. Economic and Political Weekly, 87-95.
• Ratcliffe J.(1978). Social justice and the demographic transition: les sons from India’s Kerala State. International Journal of Health Ser vices, 8:123-144.
• Sudha S, Suchindran C, Mutran EJ, Rajan SI, and Sarma PS. (2006). Marital status, family ties, and self-rated health among elders in South J Cross Cult Gerontol, 21:103-120.
• HelpAge India.
• Johnson S, Madan S, Vo J, and Pottkett, A. (2018). A qualitative analy sis of the emergence of long term care (old age home) sector for se niors care in India: Urgent call for quality and care standards. Ageing International, 43: 356-365.
• Cohen-Mansfield J, Hazan H, Lerman Y, and Shalom V.(2015). Corre lates and predictors of loneliness in older-adults: a review of quantita tive results informed by qualitative insights. International psychogeri atrics, 28 :557-576.
• Shivarudraiah M, Ammapattian T, Antony S, and Thangaraju, (2021). Views of the elderly living in old-age homes on psychoso cial care needs. Journal of Geriatric Mental Health, 8: 113-114.
• Adhikari P. (2017). Geriatric health care in India-Unmet needs and the way forward. Archives of Medicine and Health Sciences, 5:112-114.
• Indu PV, Remadevi S, Philip S, and Mathew T. (2018). A qualita tive study on the mental health needs of elderly in Kerala, South In Journal of Geriatric Mental Health, 5: 143-151.
• Raj D, Swain PK, and Pedgaonkar S.(2014). A study on quality-of-life satisfaction & physical health of elderly people in Varanasi: An urban area of Uttar Pradesh, India. International Journal of Medical Science and Public Health 3:616-620.
• Viveki RG, Halappanavar AB, Joshi AV, Pujar K, & Patil S.(2013). So ciodemographic and health profile of inmates of old age homes in and around Belgaum city, Karnataka. J Indian Med Assoc 111:682-685.
• Rajan SI, and Kumar S.(2003). Living arrangements among Indian el derly: New evidence from national family health survey. Economic and Political Weekly, 38:75-80.
• Janbandhu PV, and Bansod DW. (2022). A Study on social and psychological conditions of elderly living in old age homes of Pune city in Maharashtra. (Unpublished doctoral dissertation). International Institute for Population Sciences, Mumbai, India.

© by the Authors & Gavin Publishers. This is an Open Access Journal Article Published Under Attribution-Share Alike CC BY-SA : Creative Commons Attribution-Share Alike 4.0 International License. With this license, readers can share, distribute, download, even commercially, as long as the original source is properly cited. Read More .

International Journal of Geriatrics and Gerontology

• About Journal
• Aims and Scope
• Board Members
• Article in Press
• Recent Articles
• Articles Search
• Current Issue

We use cookies for a better experience. Read privacy policy . Manage your consent settings:

Manage Your Consent:

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

SENIOR CITIZENS AND OLD AGE HOMES: A STUDY OF PUSHING FACTORS AND LEVEL OF SATISFACTION IN OLD AGE HOMES OF KASKI DISTRICT A Dissertation for the Fulfillment of Requirements for the Master's Degree of Arts in Sociology Submitted By

Related Papers

Amrita Limbu

Nepal is in the phase of age structure transition with a large proportion of young working-age population. This phase is also commonly known as the phase of ‘youth bulge’, ‘demographic dividends/bonuses’ or ‘window of opportunity’. This present phase and the consistent increment in the share of older-age population over the years signifies that the elderly population will continue to increase in the years to come. Amidst a limited formal support system for senior citizens and a weakening informal support system by family, relatives and society, the situation of senior citizens is destined to become a severe problem, if it is not addressed in time through effective policies. Existing policies in Nepal have incorporated the issues of the senior citizens and a general overview suggests that the policies are in tune with age structure transition. Yet, a deeper analysis of the policies reveal that they do not fully recognize the outcome of the transition. Thus, it is the objective of this policy study to highlight the importance of the transition and analyse the status of the aged population in light of it.The policy questions focuses on understanding the trend of age structure transition of the Nepali population and analysing its implications on the older age group. This policy study proposes enhancement of the informal support system as a policy alternative to address the challenges of the senior citizens in relation to the age structure transition.

Patan Pragya

Gokarna Aryal

Elderly citizens are the sources of knowledge, experiences and collections of different ideas in every society or nation. If we use their ability, long experiences and their conscience, our society or nation will be benefitted to reform national development and prosperity. Ageing population is a global phenomenon and the number is rapidly increasing in developing countries as compared to developed countries. The government of Nepal has declared that people with 60 years or more are elderly citizens. The growth rate of the elderly population is faster than that of the total population in Nepal. The observation shows that the proportion of elderly population is high in mountain and hilly regions as compared to Terai. However, it is noted that female elderly population is the highest among three ecological regions. The growing numbers of ageing population is a major concern in most of the developing countries like Nepal. The social, economic and demographic impacts of ageing population...

Today Publication

Sathyamurthi Karibeeran

The 21st century is generally being considered as the „century of the elderly‟ and population ageing is one of the most important global trends of the period. The problems arising out of it have varied implications for developing and developed countries. In India, as a result of the change in the age composition of the population over time, there has been a progressive increase in both the number and proportion of aged people. The proportion of the population aged 60 years or more has been increasing consistently over the last century, particularly after 1951. According to official population projections, the number of elderly persons will rise to approximately 140 million by 2021. As a development concern, the projected increase of the elderly population in India may pose mounting pressures on various socio-economic fronts. Also, elderly population faces a myriad of challenges - social, physical, psychological and economic which are unique to them. It warrants greater attention to ageing-related issues and for economic and social policies to become elderly friendly. To create opportunities for positive aging, there is a need for understanding elderly persons on various aspects and to initiate policy and programme debates about ageing in India. In this context, a national conference on „Emerging Challenges of Elderly: Implementation of Programme and Policy Making‟ was organized by the Department of Social Work (Aided), Madras School of Social Work, Chennai in collaboration with ASTRA- Social Work Forum of the Department. The conference was sponsored by the National Institute of Social Defence (NISD), Ministry of Social Justice and Empowerment, Government of India. This edited volume of the book, published as the outcome of the conference, contains empirical papers, case studies and conceptual papers. These are included in five different domains namely Ageing: Issues and Challenges, Ill Health and Well Being of Elderly, Aging in Institutions, Social Policies and Programmes for Elderly, and Positive Ageing: Outlook and Approaches. The book will help to identify the emerging areas of key concern in elderly care and protection. It has high relevance to government departments, policy planners, educationists, researchers, social workers, parents, children and especially for those elderly who fight for their rights and privileges.

Ageing Research Foundation of India

Ilango Ponnuswami

Dhaulagiri Journal of Sociology and Anthropology

Pradeep Acharya

During the study information about the existing state of the seven elderly homes around Kathmandu, Bhaktapur and Kavrepalanchowk district was collected during October-November, 2007 on behalf of Geront World Nepal, Kathmandu. An attempt has been made to come across physical, economic status of different homes, their problems and challenges as well as the personal feelings of senior citizens living in there. The survey has tried to clarify the problems and challenges of elderly homes and the elders. Effort has been provided to see whether the elderly homes are helpful in providing proper care and support for the senior citizens. An analysis of four data sets (interview of 61 senior citizens out of total 122 in 7 homes, interview of all seven home&#39;s authorized persons, published/unpublished profile of the homes, and interview of key informants) as well as field observation shows significant positive effects of homes on the life of senior citizen. The survey results indicate that i...

yogesh mahor

Human development has remained one of the major concerns for social planners and policy makers over time. While improvements in human development aspects like health, decline in fertility, and an increase in longevity are desirable, the projected increase of the elderly population over the next few decades is emerging as serious development concern that warrants priority. The Paper is a first-of-its-kind attempt by Poverty Monitoring and Policy Support Unit (PMPSU) of Madhya Pradesh State Planning Commission to outline the situation analysis and major Issues that affect the elderly and review of existing gapsin policy and practice. This Paper is a compilation of various reviews, factsheets and research articles to highlight the contrast of the happy picture of increased longevity, and the prospect of long years of hopelessness, bereft of family andsociety. Finally, it provides suggestive measures so that the 'golden age' does not become synonymous with 'destitution' for about two-thirds of the elderly population in the country.

Publisher ijmra.us UGC Approved

This article helps students to evaluate their own attitudes oward people over 65. It begins with the students taking an pinion survey on the characteristics of older people and oncludes with the opportunity for students to learn the ctual statistics and summarize the "Fundamental Hurdels f ld Senior Citizens Of India"

Hom Nath Chalise

Sanevata Devi

Aging is an inevitable part of life and brings its own set of problems and challenges which may not be unique to the senior citizens but affect their life the most. In the Indian society, the family members used to be responsible for taking care of the senior citizens of the family and to help them get over the wide range of problems that they may face, ranging from psychological to physical ailments. But today’s changing family structure and the prevalence of nuclear families have exposed the elderly members of the family to physical, psychological and financial insecurity. Subsequently many laws have also been enacted and rights have been provided in order to protect the senior citizens from any possible harm that may be inflicted on them by their family members or otherwise. This study paper provides insights into the problems faced by senior citizens and their rights

Journal of Geriatric Care and Research (JGCR)