Prevalence and determinants of care needs among older people in Ghana.

INTRODUCTION: Given the longevity noticed among older people in Ghana, and the potential occurrence of functional disability in later years of life, it has become essential to understand their care needs. This study examined the care needs in daily tasks and associated factors in Ghana, following the World Health Organisation International Classification of Functioning, Disability and Health framework.
MATERIALS AND METHODS: A cross-sectional survey was conducted among a sample of 400 older people from Komfo Anokye Teaching Hospital in Southern Ghana. Care need was assessed by one question; "Do you regularly need help with daily tasks because of long-term illness, disability, or frailty?" Multivariate logistic regression was used to test the association between care need and independent variables based on the WHO-ICF conceptual framework.
RESULTS: Majority of the sample (81%), particularly women (54%) reported needing care in daily tasks. Per the WHO-ICF conceptual framework, functional disability-activity variable, (OR = 1.07 95%CI: 1.05-1.09, p<0.001), and absence of government support-an environmental factor, (OR = 3.96 95%CI: 1.90-8.25, p<0.001) were associated with care need.
CONCLUSIONS: The high prevalence of care needs among older people may offer an indication that majority of older people in Ghana could benefit from long-term care services. Functional disability and the absence of government support are the major issues that need to be prioritised in addressing the increased demand for care related to performing daily tasks among older people in Ghana.

Introduction

The population of people aged 60 years or older in Ghana is growing rapidly due to decreasing birth rates and delayed mortality [1]. The number of older people in Ghana increased more than seven-fold from 213,477 (4.5%) in 1960 to 1,643,381 (6.7%) in 2010 [2]. The percentage of older people in Ghana is further expected to increase to 9.8% by 2050 [2]. Although the percentage of older people in Ghana is lower than that of some developed countries, it is worthy to note that it is growing at an alarming rate [3]. Population ageing has an association with the increase in service need and thus, requires updated policies and programs to respond to the current and future health needs of older people in Ghana [4], particularly those who may be living with functional disabilities- i.e. limitation in performing life activities such as bathing.

Given the increase in longevity among older people in Ghana [1, 2], and the likely occurrence of functional disability in older people in later years [5], it is relevant to explore their care needs. Care needs can be identified as the need for assistance in essential life activities, including activities of daily living (ADL) and instrumental activities of daily living (IADL) [6, 7]. Independence in ADLs (defined as basic self-care tasks, such as bathing) and IADLs (secondary task to care for self, as well as home responsibilities) are essential to promote the health and social wellbeing of older people. What is unknown in Ghana is the prevalence of care needs and its associated factors among older people. Understanding the care needs related to daily living tasks among older people in Ghana is essential to provide data to assist policy and program developers to provide the appropriate health and social interventions. In Ghana, the declining traditional extended family support system for older people [8, 9] has heightened the need to understand the prevalence and associated factors of older people’s care needs [8, 10]. Nonetheless, adult children and other family relatives still assume all the roles as primary caregivers for older people who may need care [9, 11] since formal social care is yet to gain prominence in the Ghanaian context. Often, these caregivers offer care and support with high cost and burden [12], casting doubt on the continuity of their care.

Available international evidence on factors associated with high care needs are reported as personal, health and environmental factors [13-15]. For instance, Rosso, Auchincloss [16] study reported that transportation and mobility difficulties are associated with high care needs among older people. Similarly, other studies identified disability-unfriendly physical environment as a factor accounting for high care needs among older people [13, 14]. Personal factors, such as living in an urban area [17], being a woman [18], living closer to one’s children [19-21], advanced age and living alone marital status [15], and being divorced [22] are associated with high care needs. Furthermore, low level of education is associated with high care needs of older people [23]. Health-related factors associated with high care needs among older people are reporting health as bad and living with depression [13, 19, 24], as well as living with Alzheimer’s disease or related dementia [25]. However, studies on determinants of care needs of older people in Africa is scanty [26, 27], with none in Ghana. In this study, care needs will be considered as a body function and structural impairment, which may be determined by intrinsic and extrinsic factors surrounding older people. This current study contributes knowledge to supplement existing literature by exploring care needs in the context of the World Health Organisation International Classification of Functioning (WHO-ICF) components. This information will enhance our understanding of the holistic factors determining older people’s functioning level. We hypothesized that the higher the needs across the components of the WHO-ICF, the high care older people would need.

Analytical framework

According to the World Health Organisation, the WHO-ICF is a conceptual framework that is essential for describing and understanding a person’s health in terms of function and disability [28]. Function, in this framework, refers to all body functions, activities and participation without restrictions [28]. Disability refers to impairments, activity limitations, and participation restrictions [28]. The WHO-ICF acknowledges the interaction between determinants of health and disability, as well as personal and environmental factors [28, 29]. This framework perceives that the interactions of these entire components help in understanding the health needs of people, including older people. Accordingly, it is hypothesised in this study that factors determining the care needs of older people will encompass environmental, health status, community, and network factors, as well as their intrinsic capacities of older people. Using the WHO-ICF in examining care needs among older people, will reveal the various factors potentially influencing the current and future care needs of older people in Ghana.

Methods

Study design, setting and sample

A cross-sectional survey was conducted at Komfo Anokye Teaching hospital located in the southern part of Ghana. The study required a sample of 200 at a confidence level of 95% using Epi Info software (version 7.2.3). However, we increased this to 400 to compensate for any probable loss of response for questions included in this study. The participants were older people aged 60 years or over, admitted to the hospital due to any health problem or frailty, and who stayed a minimum of one night in any ward of the hospital, and who gave their permission to participate in the study. Older people who were seriously sick were excluded from the study. The study employed a consecutive sampling technique based on the hospital admission register to recruit participants.

Recruitment of participants was completed on randomly selected days (i.e., 4 days per week) over eight hours to increase the likelihood of older people who were admitted being offered the opportunity to participate. After nurses had determined the eligibility of older people, the primary researcher sought their consent and collected the survey data. Data were collected during participants’ hospitalisation in the time and day chosen by the participants.

Data collection

Data were collected between the months of April and August 2018. A survey questionnaire was used to collect data from all participants by the primary researcher (see Appendix A in S1 Appendix). A self-administered questionnaire was used to collect data from literate participants. The primary researcher read the questions to solicit responses from participants who could not read due to their low educational level. The questionnaire consists of the socio-demographic profile, information related to their hospital admission, care needs and functional ability level using the WHO global Study on AGEing and adult health questionnaire.

Measures

Dependent variable

Care needs

Care needs was assessed by one question; “Do you regularly need help with daily tasks because of long-term illness, disability or frailty (e.g., personal care, getting around, preparing meals, etc.?)” based on dichotomous responses “Yes” and “No”.

Independent variables

Based on the WHO-ICF, the six domains with their respective variables are discussed below:

Personal factors

According to the WHO-ICF, personal factors refers to the intrinsic nature of individuals [29]. Personal factors included age, marital status, education, religion, and employment status. In this study, it was hypothesised that advanced age, being a female, living as a widow, having no religious affiliation, having a low level of education, living in an urban area, living alone, and not working were associated with high care needs.

Age was measured as a continuous variable. Gender was measured on a categorical nominal variable “male” or “female”. Marital status was measured with “never married”, “married/cohabiting”, “separated/divorced”, and “widowed”. Marital status was categorised as “single”, “separated or divorced”, “married or cohabiting”, and “widowed” for chi-square analysis. In terms of education, the response categories were “no education”, “at most Junior High completed”, “Senior High completed” and “at least College/Pre-University completed”. This was further categorised as “no education”, “at most Junior High completed”, and “at Least Senior High School completed”. Religion was initially measured as “none”, “Christianity (including Roman-Catholics)”, “Islam”, and “Traditional religion”. However, for the analysis, the “none” and “Traditional religion” were combined as “none”, with “Christianity” and “Islam” treated as separate categories. In terms of living arrangements, the categories were “alone”, “as a couple”, “as a couple and with children”. Employment status was categorised as “currently working” and “currently not working”.

Body function and structure

Body function and structure refers to the level of impairment or function of individuals that can influence their overall health [29]. The body function and structure was assessed by one open-ended question “What physical impairment did the doctor/nurse diagnose you with ……….?”, was used to determine any impairment. The responses reflecting this component was mainly “visual impairment” and “injury”. These variables were coded as “1” meaning “Yes” and “0” meaning “No”.

Health condition

Health condition refers to any illness or chronic condition that can affect the overall functioning of older people [29]. In this study, health conditions were assessed by one open-ended question “What illness did the doctor/nurse diagnose you with…?” These conditions include chronic conditions, infectious diseases and alcoholism. The health conditions mainly reported by participants were diabetes, stroke, ulcers, cancer, hypertension, kidney disease, asthma, heart disease, and lung diseases. Other health conditions reported were hernia, malaria, chronic alcoholism, heart failure, jaundice, atrial fibrillation, ganglia, urosepsis, haemorrhage, gastroenteritis, uremic encephalopathy, anaemia, urinary tract infection, cardiomyopathy, goitre, chronic left external capsular infarct, appendicitis, liver disease, pneumonia, intestinal lung disease, cellulitis, gangrene, hepatitis, cataract, fall injury, kidney disease, blindness, fibroid, angina, prostate enlargement, and neurological problem. Each of these variables was categorized as “1” meaning “Yes” if the condition was present and “0” meaning “No” if the condition was not present. For the analysis, these conditions were transformed into multi-morbidity variables coded as “no condition”, “only one condition” and “two or more conditions”.

Activity limitations

Functional disability. According to the WHO-ICF, functional disability is an activity limitation which refers to difficulties experienced by people in carrying out life activities [29]. Functional disability was scored by a 24 items questionnaire, consisting of ADL, and IADL. Difficulties were assessed using ordinal response categories (none (0), mild (1), moderate (2), severe (3), extreme (4)) in response to the question “In the last 30 days, how much difficulty did you have with ………due to health problems, injuries, mental or emotional problems?” Internal consistency of response across the 24 items in this study was assessed and reliability was found to be high (Cronbach alpha = 0.96).

Environmental factors

According to the WHO-ICF, environmental factors refer to the physical, social and attitudinal aspects that influence individual function [29]. In this study, the social environment was assessed by two questions, (1) “How many children do you have? The response was categorised as “none”, “1–5”, and “6 or more”, and (2)” Do you receive support from neighbours or community? Do you receive support from the government? Do you receive support from religious members? Do you receive support from religious members? Do you receive support from non-governmental organisations? Each response was categorised as “yes” if the support was present and “no” if no support from that source. Emotional support was assessed by one question “How many times during the past week did you spend time with someone who does not live with you, that is, you went to see them, or they came to visit you, or you went out together?” based on eight points Likert Scale (0 to 7) (e.g. Frequency was assessed as 0 to 7 or more, but was categorised as “none”, “1–5 times” and “6 or more times” for analysis. Perceived social support was measured using nine questions based on three-point scales “hardly ever”, “some of the time”, and “most of the time”. For example, “Does it seem that your family and friends, people who are important to you understand you?

Participation

Participation refers to the level of engagement in social or community activities to increase functioning [29]. In this study, the participation in social or community activities was assessed by one question: “About how often did you go to meetings of clubs, religious meetings or other groups that you belong to in the past week?”, based on a scale from “none” to “seven or more”. These responses were categorized as “none”, and “at least once”.

Data analysis

Descriptive statistics were used to describe the demographic information of study participants. To compare relationships between categorical variables, a bivariate analysis was used. Bivariate and multivariable logistic regressions were performed to assess any significant relationship between variables under WHO-ICF components (independent variables) and care needs (dependent variable). Logistic regression was used to estimate crude and adjusted odds ratios and 95% confidence intervals to test for associations between the dependent and independent variables. Any variable with a p-value of 0.2 in the bivariate association was considered to include in the multivariate logistic regression analysis. A P-value of 0.05 was used to identify the determinants of care needs. Stata version 15 was used to manage the analysis.

Ethical consideration

We received ethics approval from the Kwame Nkrumah University of Science and Technology Ethics Committee (CHRPE/RC/033/18) before the commencement of this study per the Declaration of Helsinki. Anonymity and confidentiality of the study site and participants were also ensured.

Results

The demographic characteristics of the participants are presented in Table 1. Participants were mainly women (51%), and the average age was 72 years. Furthermore, 81% of participants reported a need for care in daily living tasks (See Table 1).

Table 1

Demographic characteristics of older people, and care needs.

Demographic Characteristics (N = 400)	N (%)
Age (mean, SD)	71.3±8.42
Sex
Male	196 (49.0
Female	204 (51.0)
Marital status
Single/separated/divorced	58 (14.5)
Currently married/cohabiting	212 (53.0)
Widowed	130 (32.5)
Education
No education	128 (32.0)
At maximum junior high completed	209 (52.3)
At least senior high completed	63 (15.8)
Religion
None	27 (6.75)
Christianity	331 (82.8)
Islam	42 (10.0)
Residence
Rural	227 (56.8)
Urban	173 (43.3)
Living arrangement
Alone	50 (12.5)
With couple	100 (25.0)
With couple and children	250 (62.5)
Employment status
Currently working	156 (39.0)
Currently not working	244 (61.0)
Do you need care?
Yes	322 (80.5)
No	78 (19.5)

Bivariate analysis of care needs with variables across WHO-ICF components

We included variables that had p<0.2 in the multivariate logistics regression for further analysis. From the bivariate analysis, marital status, religious belief, residence, living arrangement, visual impairment, injury, perceived support variables, religious group/member support, non-governmental organisation support, and several children were not significant with care needs. More than half (51%) of the participants who reported needing care lacked governmental support (see Table 2).

Table 2

Bivariate analysis of care needs across WHO-ICF components.

Demographic Characteristics (N = 400)	Total N (%)	care need		p-value
PERSONAL FACTORS		Yes N (%)	No N (%)
Age (mean, SD)	71.3±8.42	71.8±8.45	68.9±7.93	0.006
Sex				0.027
Male	196 (49.0)	149 (46.3)	47 (60.3)
Female	204 (51.0)	173 (53.7)	31 (39.7)
Marital status				0.623
Single/separated/divorced	58 (14.5)	45 (14.0)	13 (16.7)
Currently married/cohabiting	212 (53.0)	169 (52.5)	43 (55.1)
Widowed	130 (32.5)	108 (33.5)	22 (28.2)
Education				0.006
No education	128 (32.0)	110 (34.2)	18 (23.1)
At least junior high completed	209 (52.3)	170 (52.8)	39 (50.0)
At least senior high completed	63 (15.8)	42 (13.0)	21 (26.9)
Religion				0.933
None	27 (6.75)	21 (6.52)	6 (7.69)
Christianity	331 (82.7)	267 (82.9)	64 (82.1)
Islam	42 (10.5)	34 (10.6)	8 (10.3)
Residence				0.659
Rural	227 (56.8)	181 (56.2)	46 (59.0)
Urban	173 (43.3)	141 (43.8)	32 (41.0)
Living arrangement				0.842
Alone	50 (12.5)	41 (12.7)	9 (11.5)
With couple	100 (25.0)	82 (25.5)	18 (23.1)
With couple and children	250 (62.5)	199 (61.8)	51 (65.4)
Employment status				0.006
Currently working	156 (39.0)	115 (35.7)	41 (52.6)
Currently not working	244 (61.0)	207 (64.3)	37 (47.4)
BODY FUNCTION AND STRUCTURE
Visual impairment				0.268
Yes	5 (1.25)	5 (1.55)	0 (0.00)
No	395 (98.8)	317 (98.5)	78 (100)
Injury				0.212
Yes	265 (66.3)	218 (67.7)	47 (60.3)
No	135 (33.8)	104 (32.3)	31 (39.7)
CHRONIC HEALTH CONDITION
Multi-morbidity				0.138
At most 1 condition	308 (77.0)	243 (75.5)	65 (83.3)
Any 2 or more conditions	92 (23.0)	79 (24.5)	13 (16.7)
ACTIVITY LIMITATION
Disability score (mean, SD)	54.6±21.2	60.1±16.9	31.9±21.9	<0.001
ENVIRONMENTAL FACTORS
Perceived Support
Family and friend understand you				0.809
Hardly ever	74 (19.0)	62 (19.6)	12 (16.4)
Some of the time	162 (41.7)	130 (41.1)	32 (43.8)
Most of the time	153 (39.3)	124 (39.2)	29 (39.7)
Feel useful to family and friends				0.742
Hardly ever	83 (20.8)	68 (21.1)	15 (19.2)
Some of the time	173 (43.3)	141 (43.8)	32 (41.0)
Most of the time	144 (36.0)	113 (35.1)	31 (39.7)
Awareness of matters concerning family and friends				0.381
Hardly ever	179 (44.8)	142 (44.1)	37 (47.4)
Some of the time	112 (28.0)	95 (29.5)	17 (21.8)
Most of the time	109 (27.3)	85 (26.4)	24 (30.8)
Share deepest problems with some family and friends				0.387
Hardly ever	83 (20.8)	67 (20.8)	16 (20.5)
Some of the time	173 (43)	144 (44.7)	29 (37.2)
Most of the time	144 (36.0)	11 (34.5)	33 (42.1)
Emotional support
Often time you spoke with someone via telephone (past week)				<0.001
None	173 (43.3)	154 (47.8)	19 (24.4)
1–5 times	161 (40.3)	123 (38.2)	38 (48.7)
6 or more times	66 (16.5)	45 (14.0)	21 (26.9)
Spent time with someone who does not live with you (past week)				0.034
None	54 (13.5)	47 (14.6)	7 (8.97)
1–5 times	196 (49.0)	164 (50.9)	32 (41.0)
6 or more times	150 (37.5)	111 (34.5)	39 (50.0)
Neighbours/community support				0.110
Yes	222 (55.5)	185 (57.5)	37 (47.4)
No	178 (44.5)	137 (42.6)	41 (52.6)
Government support				<0.001
Yes	174 (43.5)	158 (49.1)	16 (20.5)
No	226 (56.5)	164 (50.9)	62 (79.5)
Religious group/members support				0.216
Yes	235 (58.8)	194 (60.3)	41 (52.6)
No	165 (41.3)	128 (39.8)	37 (47.4)
Non-government organisation support				0.443
Yes	10 (2.50)	9 (2.80)	1 (1.28)
No	390 (97.5)	313 (97.2)	77 (98.7)
Number of children				0.554
At most one child	40 (10.0)	31 (9.63)	9 (11.5)
2–4	128 (32.0)	100 (31.1)	28 (35.9)
5 or more	232 (58.0)	191 (59.3)	41 (52.6)
PARTICIPATION
Often times you attend meetings (past week)				0.006
None	313 (78.3)	261 (81.1)	52 (66.7)
At least once	87 (21.8)	61 (18.9)	6 (33.3)

Determinants of care needs among older people based on the WHO-ICF

In the unadjusted logistic regression, age, gender, education, employment status, multi-morbidity, disability score, participation restriction status, speaking with someone via the phone, spending time with someone whom older people do not live with, and government support were statistically significantly associated with older people’ need for care (see Table 3).

Table 3

Determinants of care needs among older people in Ghana.

Variables based on ICF component	Unadjusted OR; 95% CI	Adjusted OR, 95% CI
PERSONAL FACTORS
Age	1.05 (1.01, 1.08)**	1.01 (0.97, 1.06)
Gender
Female (vs male)	1.76 (1.06, 2.91) *	0.99 (0.48, 2.10)
Education
No education (vs At least senior high completed)	3.06 (1.48, 6.30)**	1.83 (0.66, 5.04)
at most junior high completed (vs At least senior high completed)	2.18 (1.16, 4.09)*	1.43 (0.60, 3.37)
Employment status
Currently not working (vs Currently working))	2.00 (1.21, 3.29)**	1.61 (0.80, 3.22)
HEALTH CONDITION
Multi-morbidity
Any 2 or more conditions (vs at most one condition)	1.63 (0.85, 3.11)
ACTIVITY LIMITATION
Disability score	1.07 (1.05, 1.08)***	1.07 (1.05, 1.09)***
PARTICIPATION RESTRICTION
Often times you attend meetings (past week)
None (vs at least once)	2.14 (1.24, 3.70)**	0.76 (0.32, 1.79)
ENVIRONMENTAL FACTORS
Emotional support
Spent time with someone who does not live with you (past week)
None (vs6 or more times)	2.36 (0.99, 5.65)	1.84 (0.62, 5.44)
1–5 times (vs 6 or more times)	1.80 (1.06, 3.05)*	1.68 (0.83, 3.40)
Often time you spoke with someone via telephone (past week)
None (vs 6 or more times)	3.78 (1.87, 7.65)***	1.78 (0.70, 4.50)
1–5 times (vs 6 or more times)	1.51 (0.80, 2.85)	2.33 (0.99, 5.46)
Neighbours/community support
No (vs Yes)	0.67 (0.41, 1.10)
Government support
No (vs Yes)	3.73 (2.07, 6.74)***	3.96 (1.90, 8.25)***

Significant at

*p-value < 0.05

**p-value < 0.01

***p-value<0.001.

However, adjusting for all these statistically significant variables, disability score and government support were independently statistically significantly associated with the care needs of older people.

Regarding the disability score, a 1-unit increase in disability score increases the older people’s need for care by 7%. Older people who lack government support was 3.96% more likely to report a need for care.

Discussion

To the best of our knowledge, this is the first study to select variables based on the WHO-ICF framework to study care needs among older people in Ghana. Overall, the findings revealed that care needs are related to environmental and activity limitation components of the WHO-ICF framework. The study revealed a high prevalence of care needs among older people, particularly in women. Functional disability and absence of government support to older people were associated with high care needs among older people.

The prevalence of care needs was high among older people, and this implies that the majority of older people in Ghana may need care, especially assistance in fulfilling daily activities. This finding echoes the reasons why most older people report needing caregivers [30] and it justifies why they often express concerns about caregiver availability in developing countries [31]. This finding is a stepping-stone to inform policymakers, social welfare program developers and health care professionals in Ghana to develop innovative ideas or approaches to meet the long-term care needs of older people. These interventions should take into consideration the gender variation in care needs as older women required more care compared to men [32]. Population ageing in Ghana is a new phenomenon, and so knowing the prevalence of care needs is essential to developing programs and services to meet the care needs of older people.

The findings that one additional increase in disability score is associated to a 7% increase in care needs reveal how health-related factors can decrease the quality of life of older people in Ghana. This finding is consistent with previous studies conducted globally [13, 14]. Older people living with a functional disability might experience restrictions in participating in everyday activities they may cherish [33]. Activities needed to improve older people’ health, such as visiting friends and attending social gatherings may be impacted [33], thus, increasing the need for care. Reliable health insurance programs should be established by mandated state institutions to increase the accessibility of healthcare among older people in Ghana. Additionally, there should be a promotion of national interest in the health needs of older people to enhance older people’s independence and wellbeing.

In this study, it was further revealed that government support is significantly associated with older people’s need for care. By implication, the absence of government support of any kind, be it health, financial, emotional, or physical will mean older people will have a high need for care. This is understandable in Ghana because the traditional extended family that was providing care and support for older people in times of disability is gradually depleting [8, 9], drawing attention to the need for state to provide support for older people. The absence of government support or care may be catastrophic for older people in the future because they will be left alone to care for themselves. This finding demonstrates how health and social welfare programs should be strengthened to attend to the diverse needs of older people in Ghana.

In this study, personal factors, such as advanced age, lower level of education being divorced or living alone were not statistically significant in the adjusted model. This finding is contrary to other studies that revealed a significant relationship between these variables and higher care needs in older people [15, 22, 23]. The difference in the relationship between age and care needs may be because participants were recruited from a hospital and were all aged 60 years or older. So, their care needs may not be significantly influenced by their age but rather their functional difficulty.

The current study connotes several implications for future research. First, the study’s findings present evidence for researchers to explore the government’s interest in addressing the long-term care needs of older people through the provision of health and social services. It also implies that more longitudinal research needs to be conducted on functional disabilities among older people in Ghana. Qualitative studies exploring the narratives of older people concerning their functional disabilities and need for care are essential, and offer stakeholders the urgent need to intervene in the welfare of older people in Ghana.

The study has some strengths and limitations that need to be acknowledged. In terms of strength, this is the first study to explore the prevalence of care needs and associated factors using a conceptual framework such as WHO-ICF. The limitation is that the participants were a small, hospitalised sample, and the findings may not apply to the general population of older people in Ghana. Moreover, this study did not model the interaction across the domains of the WHO-ICF. However, this was necessary because the aim was to use the WHO-ICF as a conceptual guide for variable selections. This study did not include the physical environment that may also determine the level of care needs in older people. More research to model the various components of the WHO-ICF is essential to understand the overall impact on care needs.

Conclusion

A high prevalence of care needs exists among older people particularly women in Ghana. Employing the WHO-ICF, enabled us to identify the environmental and health-related predictors associated with care needs among older people in Ghana. Interventions to improve the functional abilities of older people and increase the national interest in the care needs of older people is needed in Ghana. These findings have drawn attention to the multi-sectorial interest in the health and social care needs of older people in Ghana. Therefore, mandated institutions should make a conscious effort to make available formal social care programmes to assist older people to meet their care needs.

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3 Sep 2021

PONE-D-21-10419

Prevalence and determinants of care needs among older people in Ghana

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: Review of plos one manuscript

introduction

1. What is the difference between instrumental ADL and ADL. Readers need to understand these terms in the introduction.

2. There is a lot mentioned about functional disability among the aged in introduction. If this is the main factor explored, then it must be mentioned in title and abstract in like manner. See highlighted portions. I see authors used a framework WHO-ICF in conducting the study. If there were specific factors such as functional disability, ADL etc in this framework that were explored, this should be made clearer in the introduction. Probably this work was about exploring those factors within the WHO-ICF framework.

3. In paragraph 3, authors stated that there is paucity of knowledge about……..this should come at the end of introduction, and then this can set the tone for the objectives of this study.

4. In paragraph 4, the authors bring in history of how Ghanaians lived in the past. This does seem to fit in here. I believe the authors want to make the point about the breakdown of family support systems for older Ghanaians in contemporary Ghana. This point can be made in a concise manner.

5. Again I do not see the point about care givers reporting poor health and psychological instability etc………..in paragraph 4. May be authors should concentrate on older people themselves and what the evidence is, about their challenges.

6. In paragraph 5, the authors state ‘globally, there are a number of studies…..’ the introduction has to be rearranged. This global piece was brought in after issues in Ghana were earlier introduced. Typically, the global aspects will be introduced then narrowed down to Africa and Ghana. This will make reading of manuscript better.

7. Again authors bring in WHO-ICF framework closer to the end of introduction. This does not quite fit in here. This should be bought up earlier and discussed in a way that shows the reasons for its usage.

Methods

1. The authors state that the minimum sample size required in this study was 200. Readers are unable to tell how this was arrived at. Which sample calculation method was used? The sampling techniques used are unclear. In one aspect, authors state consecutive sampling using hospital register and later states random selection of patients based on days they visited the hospital. This part should be clarified in methods.

2. Data collection. It will help if authors can add questionnaire as an appendix.

Plagiarism check.

This work has a 52% similarity with other works (checked with ithenticate). Authors should kindly modify to reduce the percentage of similarity with other published works.

Ethical considerations

I am unable to find statement on ethics in this work.

Reviewer #2: i. In the abstract, kindly indicate the research gap calling for the study.

ii. Under the data analysis section, the authors indicate that “ any variable with a p-value of 0.2 in the bi-variate association was considered for inclusion in the multivariate analysis” Is there any basis or theoretical justification for this? This should be discussed in the manuscript.

iii. In the methods, I did not see how the authors did measure validity and reliability of the data collection tool/ tool

iv. In the discussion, this is how the authors should discuss the results on the prevalence of care needs.

a. The authors should tell readers whether the prevalence of care needs reported in this study is higher than what has been reported elsewhere and then assign reasons for the differences. The authors should tell readers whether the prevalence of care needs reported in this study is the same as what has been reported elsewhere.

b. The authors should tell readers whether the prevalence of care needs reported in this study is lower than what has been reported elsewhere and then assign reasons for the differences.

v. A paragraph of the discussion should be devoted for the specific contribution of the study to literature.

vi. The authors should also discussed the strengths of the study.

vii. The authors should further discuss how the limitations of the study did not affect the findings of the study.

viii. In the conclusion section, the authors did indicate that the prevalence of care needs is high among hospitalized older people. Is there any theoretical or conceptual basis for determining the prevalence at which care needs are high?

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Comments plos one manuscript.docx

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Submitted filename: Reviewer #1 annotated manuscript.pdf

Click here for additional data file.

29 Oct 2021

Reviewer #1:

1. What is the difference between instrumental ADL and ADL? Readers need to understand these terms in the introduction.

Response

Authors have clarified the differences between ADL and IADLs. The sentence now reads as: “Independence in ADLs (defined as basic self-care, tasks such as bathing) and IADLs (secondary task to care of self and home household responsibilities) are essential to promote the health and social wellbeing of older people.”

2. There is a lot mentioned about functional disability among the aged in introduction. If this is the main factor explored, then it must be mentioned in title and abstract in like manner. See highlighted portions. I see authors used a framework WHO-ICF in conducting the study. If there were specific factors such as functional disability, ADL etc in this framework that were explored, this should be made clearer in the introduction. Probably this work was about exploring those factors within the WHO-ICF framework.

In this study, the authors alluded to functional disability as helping to understand the care needs of older adults and supported this with relevant literature from the western countries. It was then studied as an independent variable that was potentially associating with care needs. The WHO-ICF framework was used in the categorisation of the independent variables. The According to the framework, the functional disability variable falls under the “activity limitation” domain.

3. In paragraph 3, authors stated that there is paucity of knowledge about……..this should come at the end of introduction, and then this can set the tone for the objectives of this study.

This section has been removed and sent to the conclusion of the introduction.

4. In paragraph 4, the authors bring in history of how Ghanaians lived in the past. This does seem to fit in here. I believe the authors want to make the point about the breakdown of family support systems for older Ghanaians in contemporary Ghana. This point can be made in a concise manner.

Thanks for this comment. Authors have deleted those fine details that are not relevant.

5. Again I do not see the point about care givers reporting poor health and psychological instability etc………..in paragraph 4. May be authors should concentrate on older people themselves and what the evidence is, about their challenges.

We decided to leave the caregivers information because that offer some understanding on the current state of care needs of older adults. For instance, will caregivers avail themselves to care for older adults? Are caregivers going through circumstance that will be challenging for them to care for their ageing care recipients?

6. In paragraph 5, the authors state ‘globally, there are a number of studies…..’ the introduction has to be rearranged. This global piece was brought in after issues in Ghana were earlier introduced. Typically, the global aspects will be introduced then narrowed down to Africa and Ghana. This will make reading of manuscript better.

Thanks for this comment. We have updated the entire introduction.

7. Again authors bring in WHO-ICF framework closer to the end of introduction. This does not quite fit in here. This should be bought up earlier and discussed in a way that shows the reasons for its usage.

Authors have separated this under analytical framework as the aim was to help in the categorisation of the variables under all components.

Methods

1. The authors state that the minimum sample size required in this study was 200. Readers are unable to tell how this was arrived at. Which sample calculation method was used? The sampling techniques used are unclear. In one aspect, authors state consecutive sampling using hospital register and later states random selection of patients based on days they visited the hospital. This part should be clarified in methods.

Thank you for your insight. Please we have addressed these comments. We have specified how the sample size was calculated. It now reads “The minimum sample size required in this study was 200 at a confidence level of 95% using Epi Info software (version 7.2.3). However, we increased this to 400 to compensate for any loss of participants.”

Moreover, we used two sampling techniques in this study. First, we used random sampling to select the days for data collection and after that consecutive sampling technique was used to select the participants based on the days they visited the hospital. We have clarified this sentence in the methods.

2. Data collection. It will help if authors can add questionnaire as an appendix.

Thanks much. We have added the specific questions we used for this paper.

3. This work has a 52% similarity with other works (checked with ithenticate). Authors should kindly modify to reduce the percentage of similarity with other published works.

Thanks for this comment. Authors have taken drastic measure to reduce the similarity percentage. Thanks

4. Ethical considerations: I am unable to find statement on ethics in this work.

I have included a separate section on ethical consideration.

Reviewer #2:

i. In the abstract, kindly indicate the research gap calling for the study.

Thanks for this comment. We have provided the research gap in the abstracts. It now reads as “Given the longevity noticed among older people in Ghana, and the potential occurrence of functional disability in later years of lives, it has become essential to understand their care needs.”

ii. Under the data analysis section, the authors indicate that “ any variable with a p-value of 0.2 in the bi-variate association was considered for inclusion in the multivariate analysis” Is there any basis or theoretical justification for this? This should be discussed in the manuscript.

In public health discipline selecting a p-value of 0.2 is a common practice (Awuviry-Newton, Tavener, Wales, & Byles, 2020).

iii. In the methods, I did not see how the authors did measure validity and reliability of the data collection tool/ tool.

International consistency for the group variable (functional disability) was assessed and it was found reliable and valid. Please see under “Activity limitations”.

iv. In the discussion, this is how the authors should discuss the results on the prevalence of care needs.

a. The authors should tell readers whether the prevalence of care needs reported in this study is higher than what has been reported elsewhere and then assign reasons for the differences. The authors should tell readers whether the prevalence of care needs reported in this study is the same as what has been reported elsewhere.

Thanks for this suggestion. Authors have addressed these comments in the discussion. We could not get results on prevalence of care needs per say. However, we had some evidence to extend the discussion.

b. The authors should tell readers whether the prevalence of care needs reported in this study is lower than what has been reported elsewhere and then assign reasons for the differences.

We have addressed this comment.

v. A paragraph of the discussion should be devoted for the specific contribution of the study to literature.

This suggestion has been addressed.

vi. The authors should also discuss the strengths of the study.

Thank you. We have addressed this comment.

vii. The authors should further discuss how the limitations of the study did not affect the findings of the study.

Thanks. We have addressed this comment.

viii. In the conclusion section, the authors did indicate that the prevalence of care needs is high among hospitalized older people. Is there any theoretical or conceptual basis for determining the prevalence at which care needs are high?

Thank you for this comment. This was the overall conclusion, which is thoroughly discussed in the discussion session. Thanks

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

17 Dec 2021

21 Jan 2022

Response to reviewer’s comment

Dear editor,

Author’s of this manuscript offers their utmost gratitude for taking the time to given in-depth comments to improve the paper. We acknowledge that we have addressed all reviewer’s comments thoroughly and this have substantially improved the manuscript.

Reviewer #1:

The manuscript has been significantly improved and reads better. However, there are some concerns.

1. Some editing is needed for example where authors mention ‘….a primary care giver’ this should be primary care givers.

Response: Thanks for this, we have subjected the manuscript to English language editing.

2. ‘Often, these caregivers offer care and support with higher cost and burden, casting doubt on the continuity of their care’. This sentence should be clarified as I do not see how cost of care cast doubt on care.

Response: This sentence has been retained because, however, we made few change in this. Please note that the opportunity cost of caring for older adults is enormous.

3. ‘… will assist in the development of an intervention to assist older people and relieve.’ This seems to be repetition as authors already stated this earlier …’ to provide data to assist policy and program developers to provide the appropriate health and social interventions ‘a

Response: thanks to the reviewer. We have modified this expression to read better.

4. ‘However, none of these studies were conducted in an African country, particularly in Ghana’. This statement may be misleading as there are number studies on care needs of people in Africa and Ghana. Authors could take a look at some these studies and show how their method is an improvement on previous methods.

Response:

Thanks much we have addressed these comments.

5. I am also concerned with how much space is given to the framework in this manuscript. Manuscripts for publication in this case can discuss findings without dwelling so much on framework.

Response: thanks for your suggestion, however, authors intended to discuss the framework to inform the selection of the variable. We therefore think that it is ok to be in the manuscript.

6. ‘However, we increased this to 400 to compensate for any loss of participants’ I do not see how increasing participants to 400 justify potential lost of participants. What did authors do at the recruitment stage that resulted in more sample. Probably that will explain this part better

Response: this sentence was constructed in error. We have now updated the sentence and it as “However, we increased this to 400 to compensate for any probable loss of response for questions included in this study.”

Reviewer #2: Thank you for the opportunity to re-review the Manuscript Number PONE-D-21-10419R1. This is to inform you that the authors have successfully addressed all my previous comments and I have no further comments to raise. I am of the view that the manuscript is now ready for publication.

Response:

Thanks much for your in-depth review. We acknowledge that your comments have substantially improved the manuscript.

2 Feb 2022

Prevalence and determinants of care needs among older people in Ghana

PONE-D-21-10419R2

Dear Dr. Awuviry-Newton,

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Reviewers' comments:

7 Feb 2022

PONE-D-21-10419R2

Prevalence and determinants of care needs among older people in Ghana

Dear Dr. Awuviry-Newton:

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on behalf of

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