Nature and Impact of Family Care in the Life of Elderly People: A Study in Dhaka City

 Nature and Impact of Family Care in the Life of Elderly People: A Study in Dhaka City

 Dr. Anuradha Bardhan, Associate Professor

Institute of Social Welfare and Research, University of Dhaka, Bangladesh

DOI: https://dx.doi.org/10.47772/IJRISS.2024.801151

Received: 07 January 2024; Accepted: 15 January 2024; Published: 16 February 2024

ABSTRACT

Family care is an important issue that plays a significant role in the life of elderly people since the number of elderly people is increasing and the role of the families is also changing. The family structure reduces the number of caregivers in the family, and it has a crucial implication on the healthy life of older people. The objective of this study is to explore the nature and impact of family care in the life of elderly people in Dhaka city. This study is mainly qualitative in nature and the case study method was followed to understand the in-depth situation of family caregiving. Through a purposive sampling technique, 20 families were selected as cases from the Dhaka South City Corporation area. In-depth interviews were conducted to collect some qualitative data. The study findings indicated that the majority of elderly people get care from spouses and children to perform the basic activities necessary for daily life where women play a vital role. Family members provide both daily living and instrumental support to the elderly people. Moreover, this study found that lack of family attachment, busy urban life, professional stress, involvement of women in the labor market, migration of youth, individualism, limited formal and non-formal caregivers, lack of proper health and disease related information and knowledge, and apathetic attitude are the major challenges for getting adequate and effective elderly care. The findings suggest home-based and community-based care program is needed to support family caregivers and older people to stay in their homes and communities.

Keywords: Family care, Elderly people, Caregiving relationship.

INTRODUCTION

Population ageing is an irretrievable global phenomenon. Worldwide the number of people aged 65 years or older is projected to more than double, rising from 761 million in 2021 to 1.6 billion in 2050. The number of people who are 80 years or older is increasing more rapidly. The tendency towards longer love and smaller size of families is the predictable result of the demographic transition. In 2021, 1 in 10 people worldwide were aged 65 or above. In 2050, this age group is projected to account for 1 in 6 people globally. Over the next three decades, Northern Africa, Western Asia, and Sub-Saharan Africa will be expecting the fastest growth in the number of older people. Now Europe and Northern America combined have the highest share of older persons. By 2050, the world will have an estimated 459 million persons aged 80 or more, which is almost triple the number in 2021 at around 155 million (UN, 2023).

Due to the increasing number of elderly people, the need for the ageing population care and support for older people is growing. Changing living arrangements and multiple complex healthcare issues have created a crisis in the care setting. People all over the world are living more years than before but it does not indicate healthy ageing or a better quality of life. In fact, long life would add non-communicable diseases and disability which bring limited functional capacity of older people. All elderly people do not experience and enjoy good health due to poor health and unhealthy lifestyle. Moreover, despite the greater longevity of older women than men, they face prolonged widowhood and lack of potential support from their spouses. Older women are more vulnerable to frailty, and worse health, and need more long-term care services than older men. Care needs are changing due to the different health conditions of older people in terms of primary, acute, end of life care and support with activities of daily living. After considering the changing pattern of care needs, the major focusing area would be ageing in the right or preferred places. All over the world, most of the older men and women prefer to remain in their own homes. Besides, socio-cultural values and norms emphasize taking responsibility by family members towards the elderly care in the home environment (UN, 2023).

Bangladesh is also facing challenges in the road of elderly care. According to the Bangladesh Bureau of Statistics, from 2015 to 2019, sixty years and above people were over 13 million which is the country’s 8% total population. In 2050, the share of elderly people will be more than double which is around 21.9% with 36 million people aged over 60 years. It indicates that out of five Bangladeshis, one will be an older person. So, it is a great concern for policymakers and planners to prepare a long-term care system for the elderly community (HAI, 2020). The number of elderly people in Bangladesh is increasing proportionately in every division. Among the divisions, it is projected that the Dhaka division will be around twofold more than any other division in 2025. The projected elderly population of the Dhaka division would be 55.52 million in 2025 from 44.11 million in 2020 (BBS, 2015).

Bangladesh would face challenges due to the increase of the elderly population after 2040 in health care settings, family care settings, and social security programs. Fertility rates are decreasing and life expectancy is increasing due to advanced and modern health technology, so the dependency ratio would increase more than five times between 2011 and 2061. Now elderly people aged 60 years and above are supported by eight people, but this number is expected to decrease to 2.3 persons per older person in 2061 elderly (Khan et al., 2016). According to (WHO, 2017), low and middle-income countries face economic and structural challenges in elder care settings where formal care systems is almost absent. Family is an informal caregiving system providing care towards elderly people with unskilled and non-professional arrangements that threaten the quality of care. In the elderly care setting, we should establish a new area where families, government organizations and other voluntary and non-government organizations would come forward to act on a partnership basis. So that ageing in place can be established according to elderly people’s preferences (WHO, 2017).Family-based care is the main indicator of long-term care to the elderly because they suffer from chronic diseases with disability, which limits their functional capacity to perform their basic activities in daily life. To lead a normal and integrated healthy life the major aim of long-term care service is to assist older people in day-to-day life (Phillips et al., 2010).

Family provides various support besides help in activities of daily living like emotional support, social support, companionship, co-coordinating housing, care decisions, communicating and negotiating, and so on (Gitlin, 2019). Women take the major responsibility of caregiving tasks of their parents, children, husband, and grandchildren simultaneously, so middle-aged women are called sandwich generation (Bruhn, 2016). Women who were the major traditional caregivers within the family have entered into the labor force, so it is quite impossible for women to keep a balance between outside work and providing care in the family (Schulz, 2006). The role of women in the family as a primary caregiver has been changed, so it would create a great impact on informal care settings that are totally family-oriented. However, caregiving relationships between the elderly and adult children and spouses have a great impact on physical and psychological wellbeing of older people. Positive and supportive relationship make caregiving task easier and provide assurance of quality of care (ENA, 2021). Major caregiving research identified the need for primary and secondary caregivers, but elderly people mostly depend on spouse who falls under primary caregivers (Gaugler, 2015). According to Cantors Hierarchical Compensatory Model, the spouse is considered as the primary caregiver and the children as the secondary caregiver, which sequence of caregivers is associated based the personal relationship (Hill, 2015). The caregiving relationship is one of the bases of care tasks, through which we can understand intergenerational transactions, including the relationship between giver and receiver (Binstock et al., 2005). Friends, neighbors, and other non-relative persons come at the end for caregiving tasks (Bovenberg, 2010).The caregiving situation can be explained through the gender socialization framework, where gender roles and personality factors are connected to women. Women are more attached to caregiving tasks than men because traditionally they had fewer preferred roles to perform (Tajvar, 2015).

METHODOLOGY

The study followed a qualitative approach for obtaining in-depth information about the nature of family care and its impact on the lives of the elderly by considering different vulnerabilities, challenges, and expectations of elderly people. It includes the case study method which is one of the essential methods in a qualitative study. Case study as qualitative method was selected for this study to describe, understand, evaluate and compare different aspects of family care, which includes socio-demographic characteristics, living arrangements, caregiving relationships, opinions of the elderly, care expectations, and also challenges and suggestions of the family caregivers, considering different age groups (i.e., young-old, middle-old and old-old), sex, religion, educational background, present and past occupation, financial condition, etc. The Dhaka South City Corporation area was considered the study area in this study.  In this study, the purposive sampling technique, one of the vital types of non-probability sampling, was followed. In this study, 20 families were selected using the purposive sampling technique. Data were collected through interviews using a semi-structured interview schedule. Data were analyzed and presented using a thematic approach to provide in-depth insight into the study issue. In this study, the researcher tried to maintain some ethical issues, such as ensuring the voluntary participation of the respondents with their informed consent. This study strictly avoided biases, misinterpretation, and deception in the data collection and analysis stage.

Theme based Findings of the Study

The major objective of the present study is to explore the nature and impact of family care on the life of elderly people in Dhaka city. In this study, many areas have been explored related to elder care in families, which includes the types and impact of care, experience and opinions of elderly people and caregivers, and suggestions to improve the caregiving condition. The study found some key points from the responses of the respondents such as old age, spousal care, intergenerational support, financial support, reciprocity, respectful care, physical and mental well-being, caregiving burden, caregiving relationships, social and cultural environment, living arrangement, care expectations, family size and structure, ADL and IADL related support, ageing in place, co-residence with children, perception of caregivers and so on. The following themes have been generated in the study using those issues to know the nature and impact of family care on the lives of elderly people.

Age of Elderly Influences Pattern of Caregiving

Age is a vital factor to define the condition of older people in old age. The study analyzed the condition of three groups of elderly people those were considered such as young old, middle old, and oldest old in this study. These three groups require different types of care because of the age difference. Young old might have some functional capacity to perform some daily activities without anyone’s help, but middle-old and oldest-old might not have that capacity to perform any task without support. One of the caregivers expressed her experience,

“My mother is now sixty-five years old…As I observe she is still young to perform her all personal daily life activities…but a domestic maid helps her with cooking, shopping, cleaning houses, and laundry…due to age sometimes she becomes tired doing all household tasks…she takes care of me and my father but she also needs assistance.”

Another caregiver pointed out his experience,

“My father is now eighty-five years and now he is fully dependent on family support….he has diabetes, high blood pressure, and urine problem with kidney disease… he cannot perform daily personal tasks like bathing, dressing, and eating properly…he needs twenty-four hours support…even he cannot clean himself properly after toileting…when he has a serious illness, he falls in bed.”

The present study indicated that chronic diseases and functional disability lead to the need for elderly care. Young-old people need less support for Activities of Daily Living (ADL) and Instrumental ADLs (IADL) functioning from their caregivers. Still, middle-old and oldest-old people need more direct help and assistance for performing ADL and IADL functioning. Chronic and long-term diseases like diabetes, high blood pressure, heart and kidney diseases, and sensory impairment indicate the degree of service to elderly people.

Spousal Caregiving Affects Elderly Care

Although it was noticed that spouse, daughter, son, daughter-in-law, helping hand, neighbors participate in giving care to the older persons directly or indirectly, but spouse plays the most significant role. Daughter, son, and daughter-in-law may sometimes loosen their support, but spouse stands beside their partner till death. The degree of care received from the spouse is non-comparable with the care received from others. Different respondents highlighted this fact with their statements. According to one of the respondents,

“After the marriage of my two daughters, we, the two elderly couple are living in this house…we both are dependent on each other for daily life activities….my wife takes all the responsibility for all household tasks and she also takes care of me by providing food, medicine on time…provide emotional support…I also do shopping, laundry, money management tasks…in the absence of my daughters…I believe in the absence of her, it will be uncertain for me to live.”

On the other hand, older persons sometimes need to face an opposite scenario when they lose their spouse in life. The nature and degree of care they received from their spouse become missing from their lives and becomes very tough to lead their remaining lives. One respondent provided light in this regard,

“We have been living in this flat with my wife and son for thirty years…my wife is no more….my wife took care of me and my family….after death of my wife it was difficult to manage all of the issues…..my son is busy with study….one domestic maid helps us…but missed my golden memories with my wife.”

It was found from the study of (Pradhan, 2017) that the majority of the respondents in urban areas identified firstly their spouses as caregivers, secondly son and daughter-in-law, and lastly daughter or son-in-law during illness. According to Cantor’s Hierarchical Model of Caregiving, spouses are the first preference as primary caregivers in old age. Spousal caregivers provide a wide range of support by minimizing complex situations and handling problems. Based on Exchange Theory, spouses help their partners to reciprocate past support based on love or affection. Societal context and gender roles explain caregiving tasks for wives as an obligation and feelings of more choices for husbands (Hill, 2015).

Reasons for Accepting Caregiving Responsibility by Caregivers

Although many respondents or caregivers consider caregiving as their responsibility, few caregivers think they don’t have other choices without caring for their old persons. Many respondents are single children, or another sibling has not provided care to the elderly. For this very reason, they are bound to perform these duties for a long time, affecting their physical and psychological life. One of the respondents stated that,

“I am the only child of my parents……my parents both are older people….as a child of I have the responsibility to take care of my parents and support them in old age…they did a lot for me from my birth to now…it’s my turn to pay back and to keep them happy.”

One of the caregivers expressed her opinion that because of poor financial condition of her siblings, they are unwilling to take caregiving responsibility which forced me to take this responsibility.

“Society expects that children would take care of parents in old age and from the religious view point it is a sacred duty… My parents have two sons and one daughter….my brothers live in the villages and their financial condition is not better …so my parents are staying with me in the city.”

Another caregiver expressed his experience of taking responsibility due to gratification,

“From my birth till now, parents did a lot of sacrifices for me….they never thought of their sufferings and provided the best support and facilities to me….I saw satisfaction in their eyes when they did something for me…now I am mature and financially solvent …I feel satisfied and pleased to take care of them…I want to be a blessed child for them.”

The study of (Pradhan, 2017) also mentioned that adult children provide care to elderly people because they believe that it is one of the prime responsibilities of their life. Also, their parents had a lot of contributions to their upbringing. Exchange Theory suggests that children may expect to receive some reward in the future as an inheritance from their elderly parents, or they may want to reciprocate their parents for spending years caring for or upbringing them (Hill, 2015).

Caregiving Responsibilities Affect Mental Soundness of Caregivers

There is no doubt that providing care is both physically and mentally stressful for caregivers, especially for those caregivers who have been providing care for an extended period. Caregiving experience for caregivers depends on the nature of illness of older persons, duration of caregiving in a day, availability of other support, and inter-relationship between caregivers and care-receivers. Although many caregivers consider caregiving a responsibility, it reduces mental well-being. One respondent opined that,

“I am taking responsibility of my mother for five years….now I am fifty-five years old with multiple health complexities….my mother needs twenty-four hours hand to hand support…sometimes she forgets and accuses me for little things…I know it’s not her fault…due to ageing…But it increases my strain and tension.”

Another respondent opined in the same direction,

“Caring responsibility brings satisfaction in life…but when it is overloaded, then it feels like burden…I cannot go outside leaving my husband alone in house…who would take care of him…I cannot attend any program of relatives or spending time…sometimes it feels burden for me.”

However, most of the respondents agreed that despite having the responsibility of providing care, at some point in time, caregiving reduces their mental peace to some extent. Respondents who were directly engaged in providing elderly care mentioned some of the suggestions such as developing the ageing social infrastructure for the elderly where they can get entertainment, developing priority banking services for the elderly so that they don’t get troubled when taking any banking services, arranging for free ambulance services, increasing the range of large scale social security programs like a pension fund, providing an allowance to needy elderly, health insurance facility, developing senior citizen card, training facility from where caregiver will learn how to provide care to the elderly, formatting volunteering group, creating an elderly-friendly society with the help of different media including social media, and creating less stressful job opportunities for those elderly who are physically capable. According to the study, it can be uttered that implementing the above suggestions can significantly change the elderly care system. Different studies pointed out that caregivers are likely to experience a higher level of distress when care recipients exhibit more problem behavior and show greater dependency when caregivers spend long hours helping with ADLs or IADLs or when they do not receive reciprocal help or positive feedback from care recipients (Begum, 2019), (Lin et el., 2012).

Caregiving Relationship Determines the Extent of Caregiving

The relationship between caregivers and care receivers defines how the caregivers will treat the elderly people. A sound and healthy relationship makes it easy for the caregivers to give elderly support willingly. Independent and dependent reciprocity, obligation, intergeneration Exchange, filial piety, responsibilities, mutual care and support, supportive family environment are various conceptual perspectives in this area that can help us understand the relationship in a family. Intergenerational transfers of love, affection, material and social support are at the heart of the family relationship. In this research, most caregivers and care receivers positively explored their relationship. One of the respondents stated that,

“I have a good relationship with my parents from my childhood…They always share their feelings, sorrows, and happiness with me… I always try to look after them and make them happy… On the other hand, they also provide me with emotional support and essential advices when I need it.”

However, a different situation is also possible if the caregivers and care receivers don’t have a good relationship. One of the respondents expressed some expectations from his son in the future,

“I have already lost my spouse… Now I live with my younger son… I cannot share my emotions with my son. He is very busy with his job… I have contributed a lot to his life from his childhood to now. Now it’s time to get back… I want a loving and sharing interaction with my son.”

The quality and quantity of caregiving relationships influence the physical and psychological well-being of the elderly people in the family. A mutually supportive and caring relationship is an excellent source of support, whereas a conflicting and unkind relationship reduces the quality and excellence of care. However, it was observed in the study that elderly people tend to report fewer problems in caregiving relationships.

Life is the addition of some positive and negative experiences with relationships in the world. The caregiving process and quality of care are affected by the quality of relationships between caregiver and care receiver. A poor relationship in spousal caregiving creates the risk of physical and mental abuse and violence with low quality of care. Social networks and support from friends, relatives, and neighbors make caregiving tasks easier for spouses or children which also affects caregiving relationships.

Women Act as a Pillar of Elderly Care

Women play the most significant role in providing care to older persons. Women such as spouse, daughter, and daughter-in-law come first to provide care in general. More love and affection in the heart of women, the traditional culture of society, and more male involvement in employment are reasons why female take primary responsibility for providing care to the elderly. Many respondents highlighted this fact from their personal experience. Long term care for elderly people in informal and formal institutions has been a new global gender priority. As people grow older, they tend to be dependent on family-based long-term care to get multiple care and assistance in activities of daily life. In low and middle-income countries, long-term care is provided by family members on an unpaid basis due to insufficient and lack of community and home-based services. Older women are more affected than older men because they are traditional care providers to their older spouses under inadequate support conditions and do not get proper care. Women in the forms of wife, daughter, and daughter-in-law take responsibility of long-term care which is unpaid across the world. Though they are considered as the unseen backbone of all long-term care systems, they are facing challenges while providing care to older person with advanced Parkinson’s or Alzheimer’s diseases. One of the respondents opined that,

“I live in an extended family with my wife, son, daughter-in-law, grandchild, and wife. Both of us are older persons, and my wife is seriously sick with some physical complexities…so my daughter-in-law and her daughter-in-law provide support in our daily activities of life…sometimes, a temporary maid (girl) also helps us.”

One of the elderly people expressed that,

“I am residing with my son and daughter-in-law….my daughter-in-law helps me carry out my everyday tasks and activities… she takes the primary responsibility of household tasks in the home.”

The Elderly People Prefers Ageing in Desired Place

It was found from the elderly people and their caregivers that elderly people prefer to determine where they want to spend their old age period and this choice significantly leads to better older life. In wealthy or middle-class families, children value their parent’s decisions about their living place especially if older people have financial solvency. However, in low-income families, elderly people get no chance to share their preference of living. Many respondents of this study described that staying in desired place leads to mental soundness of elderly people. One of the older women mentioned her views that,

“I have been living in this flat almost for twenty years.  My husband has bought this flat, and this is our permanent residence… I have two daughters, and they are married now. They stay with their family in this city in different areas… I have wished to remain here until death if there are no other problems in my life.”

One of the older women mentioned that she would like to stay indifferent to children’s houses because she does not want to stay in a permanent place for a long time. She opined that,

“I stay in different houses of my children… my husband is dead, and we did not buy any land or flat due to the limited income of my husband, so now I do not have any permanent house or residential place…all of my children stay in the same city in various areas…I stay in their homes, including my son and daughter’s houses interchangeably…and I have told them nobody should be worried about this issue…Because I prefer to live like this.”

This study found one older women who live alone in a rented flat, and opined her views in this way,

“Once I lived in this flat with my husband, but he is no more now…I have only one daughter living in the USA who tells me to go there…but I do not feel comfortable living with my daughter and son-in-law’s family…actually, I do not want to be a burden on my daughter…I can do all my daily activities with the help of a temporary maid…I do not know what will happen tomorrow.”

This study found in the case of illness or other physical complexities of oldest-old persons, children decide on behalf of their parents, considering their physical and mental well-being and the availability of caregivers. Some elderly people mentioned their views about the living places that they choose their housing by themselves, and their children did not interfere in this issue. In the study of (Begum, 2019), most elderly respondents expressed that they want to lead their old age period in the family, not in any nursing home or care institutions.

Caring Responsibility towards Parents as a Daughter

It was found from the present study that daughters playa valuable role in caregiving settings for older adults. According to society’s cultural and social norms, the son takes care of his parents in later life. But interestingly, it was found that daughters sometimes take the significant responsibility of their parents due to the absence of an elder brother or share roles with other family members. Daughters take responsibility due to emotional attachment and provide emotional and financial support towards their parents. One of the daughters, as caregiver of her mother, whose age was about seventy-five years old, commented that,

“My parents had three sons and two daughters…now, all of my brothers are no more…grandchildren of my mother do not show any interest in taking responsibility of their grandmother…furthermore, my elder sister is very sick. She does not have any household maid…so I have to take care of my mother…she has been staying with me for a long time …sometimes I have to sleep with her when she becomes very sick or cannot manage her toileting by herself.”

Most of the respondents of this study, whether caregivers or care receivers, considered daughters and daughters-in-law as the best primary caregivers which is the same finding in the study of (Watt et al., 2014).The findings suggest that primarily after spouses, care preferences for the elderly go to children without considering gender. Specifically, sons take financial responsibility, and daughters take functional care. So, it has been assumed that the gendered division of filial responsibility exists in society (Phillips et al., 2010). Daughters feel more caregiving costs than sons, but they also experience caregiving rewards and gratification. Costs are like limitations of doing something, lack of freedom to go outside, lack of quality time for her family, doing more beyond capacity and incentive in terms of feeling satisfied, etc.

Positive Perception of Elderly People towards Family Support

Mental peace or satisfaction largely depends on how we perceive one particular thing. The same incident or situation or matter-one person can consider it positively; others can view it negatively. It was found from the study that some elderly people were conscious of the present world, and they had changed their mentality with time. As a result, they accepted the reality without expectations or little expectations from their children or other family members. One respondent expressed his thinking about older life and how his perception keeps him happy in life,

“Am I mentally prepared?…People should have mental preparation for their later life…If I think there is a problem in my life, then it is a problem…otherwise, not a problem…Human being has unlimited needs…In later life, people tend to look for others’ faults…If family members ensure a compromising mood, and accept each other’s issues…then there is no problem…How we perceive the vital life to be happy in later life…So if the family doesn’t care or look after you… you don’t need to feel bad or any mental stress…Physical well-being is not possible because the mental condition doesn’t remain well.”

Another respondent who believes in accepting positive things from their surrounding viewed his perception in the following way,

“Nowadays, electronic media such as television plays an essential support for me…proper food at the appropriate time, religious prayers, chatting with others, watching television…these are enough to live well…we can learn many essential things on YouTube…accept the positive things from social media…Facebook, WhatsApp…believe in God…He will take care of us”

Another respondent presented a new dimension. He believes that if both caregiver and care receiver understand each other’s situation and adjust accordingly, leading life is not difficult. He expressed that,

“I think society, as well as older persons, should change their mentality…If I expect care from my son who reaches home bypassing two or three hours on the road with extreme traffic jams every day after nine hours duty…then it would not be fair for him…So I understand his present situation…The elderly should also realize their children’s problems and sufferings…accept what they receive from their family…should be satisfied even with little.”

It was observed that despite having physical problems, most elderly people positively view their lives. Even the elderly people, who live alone or with only a spouse, don’t mention dissatisfaction in an extended way. The oldest-old people become happy when spending time with their children and grandchildren. When they were asked about their mental status, it was observed that they were less interested in exploring their mental state negatively. When describing their mental condition, they linked their past life experiences with family and social structure. They mentioned that society’s values, norms, beliefs, or cultures are changing rapidly due to available modern facilities, and they accepted this fact without any expectation.

Impact of Living Arrangement on Care

The study found different living arrangements of the elderly, such as a few elderly people living alone, some living with spouse only, and most of them living with children. The nature and source of assistance or support depend on the household living arrangement of the elderly people. It was observed that when elderly are living in empty nest households, that means without spouse or children or living with spouse only, they stay in those houses or communities or areas where their relatives or friends are available to give support. One of the young elderly couples living without children expressed that,

“Our two daughters are married, and they stay in another area of the city…my husband is an elderly involved in a family business…As I am staying home, I can do every daily activity with the support of our temporary helping hand…my husband takes the responsibility of shopping, visiting doctors, buying medicine, going to the bank with me, seeing my daughter’s house, neighbor’s house, and religious institutions or programs.”

Another elderly couple living with their son and daughter-in-law expressed that,

“Actually our living arrangements is decided with the discussion of our children….we both are sick and cannot provide care for others…so we have to depend on our son and daughter-in-law….our sons are sharing this responsibility…We do not stay in the house of a specific son… we do not have any requirement…but when my wife becomes sick and need twenty-four hours support, then we go to the elder sons house because they have enough space available with helping hand at home…so we feel comfortable and secured during illness with them… Our sons and daughters-in-law provide ADL or IADL support according to their capacity…we are satisfied with them.”

Another middle-aged, elderly couple who are living in the same area where their daughter is also living, expressed views about the impact of their living arrangements on care in this way,

“We have two daughters…one is living in USA and other is living in Dhaka…After retirement we both decided to live near our elder daughter….so we are living in the same apartments but different flats… we are now feel secured and satisfied…. If any emergency happens …we can get help.”

A similar experience was also found from the rich and poor class family that, though elderly people live with their son’s family, due to their busy lives, they do not provide any physical, emotional support to them, and the elderly were not satisfied in this life. One of the elderly opined that,

“We are living with our younger son and daughter-in-law…both are working in private farm…they go in the morning and back in late night…only we can spend quality time with them on weekends…though we are living with them, but they cannot help us in daily life…my wife and a maid do all the household task.”

Living arrangements play a vital role in influencing the physical and psycho-social condition of elderly people. The study found that most young-old people can perform their daily tasks without the help of others. In contrast, middle-old and old-old were dependent on family for performing their daily activities. The study found that the family members expect better home-based care with specialized health treatment at home and in the community. Elderly people desired to live with families with dignity and respect. It was explored from the study of (Ugargol, 2018) that living arrangements have a direct relationship with the health and functional status of the elderly. A proper living arrangement positively affects the health condition of the elderly and vice-versa (Bailey, 2016). The living arrangements of elderly people replicate choices made by elderly people and their families based on individual preferences and available resources considering the social, economic, and health constraints of the elderly (Kamiya, 2020). The United Nations have focused on the importance of the living arrangement of elderly people because it has become an increasingly important policy issue, especially in countries with advanced stages of population ageing. Living arrangements of elderly people are essential determinants of their well-being (UN, 2019).

RECOMMENDATIONS

Family provides a wide variety of assistance and support to all the members from the childhood to death which includes elderly care within framework of caregiving relationships among family members. In this study, the nature and impact of the care on elderly people have been explored, where some recommendations have been highlighted based on the experience and outlook of the elderly people and their caregivers. The study recommends to develop community-based home care to support caregivers at home, improve daycare or respite care centers to release caregiver stress, increasing intergenerational relationships among generations using social or electronic media, ensure the availability of trained and skilled nurse/therapist/professional caregivers to assist oldest old elderly at home, and develop age-friendly community support to lead healthy ageing in later life. As the functional capacity and needs of all dependent elderly people are not the same and sometimes do not require formal institutional care, so integrated and gender responsive long-term care systems should be established to promote the self-esteem and rights of older people. The range of long-term care policies should consider these issues- intensive institutional care (long-term hospitalization, nursing homes), less intensive institutional care (residential home, respite care, sheltered housing), community services (day care centers, nurses, and professional career visits), home-based services (home help, cash benefit for caregivers, support group for careers) for providing support to family caregivers and investing in the paid care workforce.

Policy Implications based on the Findings

This study mentioned some essential issues based on observation of various policies and programs of the Asia Pacific region, such as promoting the concept of active and healthy ageing in health policy, identifying the health problems in the elderly, providing appropriate health interventions in the community with a strong referral backup support, initiating community-based primary health care approach including domiciliary visits by a trained health care worker, allowing tax relief for those whose parents live with them, allowing rebates for medical expenses and giving preferences in the allotment of house along with various social services including long term care for elderly, ensuring home-based help services for homeless; living alone or those who need help. It has been mentioned in the 8^th Five-Year Plan of Bangladesh that health service delivery system of Bangladesh would be reoriented due to an increase in elderly people. It would include an awareness-raising program, the establishment of palliative care units, introducing up-to-date medicine, introducing unique senior citizen cards, and enhancing the capacity of the health workers for the well-being of the elderly people. The key findings of this study will help the policymakers to have some in-depth knowledge about how to develop the life of elderly people. To reduce the stress and providing relief to family caregivers, policy interventions may include providing incentives to family members, getting support from NGOs volunteers, ensuring adult day care centers where elderly people may spend leisure time, reduce loneliness, and get treatment facilities, and arranging living facilities in each community for poor people.

CONCLUSION

Family based care is a customary practice which is directly linked with the wellbeing of older person in later life. Though the structure of family is changing and size is declining due to urbanization, modernization and globalization, family still now engaged in providing caregiving task. Traditionally family members like spouse, children, relatives, friends and neighbors are providing support in old age. The present study explored the types of support, caregiving relationships, feelings and effect of caregiving on caregiver and care receiver through in-depth interview of family. The study revealed that, women have been providing majority of personal tasks for a long time period. Based on age and functional capacity, older people need different types of support. Oldest old people aged eighty years and above need twenty-four hours of care which makes the caregiving task more stressful. Spouses and children provide care due to love, affection, filial responsibility, and reciprocity which is acknowledged by the Exchange Theory. The majority of the older people expressed positive and satisfying caregiving experiences based on intergenerational relationships between children and older persons.

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