CEC Journal: Issue 3

Unmet Health Information Needs of the Elderly in IDP Camps

Unmet Health information needs and coping strategies of the elderly in Internally Displaced Persons (IDPs) camps in Nigeria
Over 2 million Nigerians are currently displaced and the elderly, although not usually brought into policy focus, are subjects of varied dimensions of deprivation and need. In the context of internal displacements (camps and centers), food insecurity; water sanitation and hygiene; health; shelter/non-food items; and security are core areas of identified needs among the elderly. Office for the Coordination of Humanitarian Affairs (OCHA) Nigeria (2016) established that about 6% of the IDPs in Nigeria are aged persons. Hence, the population significance of the aged population and care structure for the cohort comparatively evoke interest, especially in unstable social conditions. Albeit, Humanitarian Needs Overview (2016) report opined that before the humanitarian situation in the north-east zone of Nigeria (consisting of Gombe, Yobe, Adamawa, Borno States, and later Taraba State), health indicators have been lower than the national average. The report further revealed that the destruction and/damage of infrastructure; and lack of trained health care workers and medical supplies have created an urgent need for integrated primary health care for about 3.7 million IDPs and host community populations.

The rate and population size of displacement is newly attaining historical height in Nigeria, though extant literature regarding the health and health needs of the aged in IDP camps is scanty. However, the United Nations Commission for Humanitarian Response (UNCHR) (2015a) reports show that 9,309 households have vulnerable elderly, and of this population, about 70% are unable to care for themselves on a daily basis. Again, about 22% are single-elderly with no other support or have been neglected by caregivers, while elderly-headed households are about 20% of the population. Exactly 53% of vulnerable households are households with vulnerable elderly. There is very little information on intra-household distribution or how particularly vulnerable people access assistance within camps. According to UNCHR (2015b), cases were reported of single elderly with unmet dependency needs and without access to any means of livelihood. Most of the elderly are accompanied, either by relatives or neighbours, but some cases are unaccompanied. In host communities, the elderly often lack a care-giver, whereas in the camps single elderly are typically attached to community members, though it is difficult for non-family members to assume such responsibility. The vast majority of elderly individuals monitored are living with chronic health complaints.
Thus to bridge the gap in knowledge and to stir policy interest, the paper – focuses on identifying the category(ies) of health care services and health information that is available to the aged in IDP camps – establishes that care services and health information are suited to the health needs of the elderly; identifies areas for further intervention in terms of health systems strengthening; and documents the health care practices and decisions (health seeking behaviour) of the older persons in camps.

Hitherto, a review of the subsisting health care structure in Nigeria shows that the three levels of care (primary, secondary and tertiary) instructively provide care for the population. However, the WHO Global Health Observatory data repository (2016), reports that from the onset of the crises (2009) to 2014, government’s budgetary expenditure on health has not exceeded 8% of the national budget, while out-of-pocket expenditure on health as a percentage of total expenditure on health within the same period is an average of 69%; and external resources for health as a percentage of total expenditure on health is an average of 5.7%. In accounting for the health personnel, between 2008 and 2015, physicians were 4 to 100 persons; and nursing/midwifery personnel were 6 to 100 persons (Global Health Observatory Data Repository, 2016). In describing one of the indicators of Universal Health Coverage, Awosusi, Folaranmi and Yates (2015) commented that less than 5% of Nigerians have health insurance.

In addition to understanding the background of health, health care services, and health system function in the north-east zone, Nigeria Demographic Health Survey (NDHS) (2013) confirms that the geo-political zone records low educational attainment, with a median of only about 5 years (more than 60% of females are not educated, about 50% of males have no education). The region accounts for one of the highest fertility rates (6.3%) in Nigeria, and under-five mortality rate is an average of 160 deaths per 1,000 live births. There is a prevalence (79%) of ‘home-deliveries’ due to distance to health facility and poor antenatal care services; and the endemic nature of poverty (getting money for treatment)is identified as one of the problems associated with accessing health care in north-east Nigeria. In assessing the impact of the crises on the health infrastructure in the zone, the Borno State Health Sector Bulletin (2016) reports that 800 health facilities (21 of which are hospitals) have been damaged. This has a devastating impact on the health system with direct implication for accessibility to basic health services.
The burden of disease among the elderly in IDP Camps
In consonance with recent ontological and epistemological argument for Universal Health Coverage, the health literature presently tilts to the worst-off – vulnerable, and emphasis abound on the wellbeing of mothers and children with less attention to the health needs of the elderly. This can be described as an historic pattern, as policies and development agenda in the past have focused exclusively on the needs of children and women – pregnant women. This is visible in the focus and interests of UNICEF (United Nations International Children’s Emergency) and in fact the just concluded development agenda of the Millennium Development Goals (MDGs). Social care of old people is embedded in the principle of reciprocity and moral contract. Hence, the burden of elderly care rests on children and other kinship networks. The displacement and health discourse emphasizes the prevalence of diseases that are communicable; related to poor water, sanitation and hygiene practices; malnutrition; and malaria (Borno State Health Sector Bulletin, 2016). The epidemiological report from the 23 IDP camps shows malaria (44%) as the leading cause of morbidity, while acute respiratory infection, acute watery diarrhoea, bloody diarrhoea, severe acute malnutrition, measles, mental health and others also cause morbidity. Albeit, emphasis has been on the assessment of increasing mortality and morbidity in the absence of better PHC (Primary Health Care) coverage, due to the damage/destruction of health infrastructure, lack of trained health care workers, and shortage of medical supplies (Humanitarian Needs Overview, 2016).

In the case of older persons, UNCHR (2015) identifies them as sole caregivers for others. They also suffer from health problems, have difficulty adjusting to their new environment, and/or otherwise lack psychological, physical, economic, social or other support from family members or others. The health challenges of older persons are enormous and beyond the services available. An examination of the global burden of disease database shows that in-patient services and/or comprehensive health care facilities are necessary in resolving the burdens of high blood pressure, high body mass index, unsafe sex, household air pollution and alcohol use as they account for the various dimensions of morbidity, mortality and disability among persons over age 60 (Institute for Health Metrics and Evaluation, 2015).

Older persons in displaced camps have higher rates of coronary heart disease, diabetes, stroke, cancer, respiratory diseases and rheumatism (WHO, 2003). A study in China found that 74% of those over 80 years old had chronic diseases, 1.5% were physically disabled or handicapped, and 3.46% had Alzheimer disease (Jiang, 1998). In Iraq, more than half of 340 older people surveyed by Help Age International in 2006 had chronic joint and bone problems, hypertension, heart problems, diabetes and reduced eyesight and hearing. In West Darfur, Sudan, 34% of surveyed refugees aged 50 and over were disabled, 27% could not move without help and 19% had severe impaired vision; while 61% reported chronic diseases that required specialized treatment and/or medicines that were not available.

While older people vary greatly in their health status and ability to adapt, the risks to this population in emergencies remain significant. In the understanding of Evans and Williams (1992), ageing refers to a progressive loss of adaptability so that the individual becomes increasingly less capable of coping with life challenges. Among the top physical health problems the elderly at IDP camps experience are mobility problems, diabetes, digestive, including gallbladder, bowel, and hernia; heart disease problems, arthritis, sore joints and vision problems (Johns Hopkins Bloomberg School of Public Health (JHSPH) and the Institute for Policy Studies (IPS), 2014:26).

Based on emerging evidence from the World Health Organisation and Borno State Ministry of Health (2016c:5), in Nigeria, chronic diseases (heart disease, stroke, cancer, chronic respiratory diseases and diabetes) and upper respiratory tract infections were found among the elderly. Also, among the elderly IDPs in Nigeria, a situation report by UNICEF (2015) confirms that the elderly were experiencing the most mortality (51%) following the opening of a new IDP camp. It was established that chronic infection accounted for more than half of the causes of death among the elderly. In another instance, Khan (2014:89) identified disease conditions ranging from cardiac problems, vision loss, arthritis, conjunctivitis, and other mobility related illnesses among both male and female elderly persons in IDP camps. However, it should be noted that the elderly in these conditions, had travelled to the current destination, and the fact that they might be healthy or appear healthy at the point of departure or displacement does not preclude the possibility that they had disease conditions in their bodies. Albeit, Thomas and Thomas (2004:116) noted that among the elderly, there is an inevitable time lag in the accumulation of relevant factors for diseases after arriving at their destination.  Thus in Nigeria, although data on disease prevalence among IDPs are usually not disaggregated along the lines of gender and age, it is clear that the ageing process is associated with disease and illness conditions, bearing in mind that ageing is not a disease condition but only a process.

Matching health infrastructure with health information on the camps/in centres
Although the IOM (International Organization for Migration) (2014) reports that 60% of the IDPs had access to medicines, 50% accessed health facilities/services within 3km distance, and health referral was available to about 50% of dwellers, between May 2014 and February 2015, the north-east zone had witnessed an increase in violence leading to wide spread displacement and a surge in the population of displaced persons up to 1.2 million. Thus, in comparison with the rates of early 2014, the struggle for survival in IDP camps also expanded and not much could be delivered to support the health and wellbeing of residents.

As a background, although the report about the displaced population is not stable, it is estimated that not than 2 million people had been displaced by the conflicts in north-east Nigeria. According to the FHI 360’s (2015) report of May 2015, about 3.3 million people constituted the IDP population, but an assessment of the health facilities reflects that none of the camps were providing HIV/AIDS awareness campaign, ARV refills, continuous HIV counseling and testing and the identification of new clients. Also, referrals for HIV/AIDS services have been very weak with poor documentation. In November 2016, WHO (2016c) asserts that Health Resources Availability Monitoring Scheme (HeRAMS) has been set up to provide key information that includes the health service’s functionality status, accessibility, health infrastructure, human resources, availability of health services, equipment and medicines at primary and secondary levels of care. The WHO supports were medical supplies in form of interagency emergency health kits, malaria and post-exposure prophylaxis kits (WHO, 2016b). In some cases, private support organizations provided one-off health services in terms of dental care, eye care, health promotion and welfare services (Nsofor, 2015). Empowerment programmes by the Federal and State Ministries of Health, and National Primary Healthcare Development Agency (SPHCDA) in partnership with WHO focused on maternal and child survival techniques. Community Resource Persons (CORPs) were trained to provide medicines and supplies for treating pneumonia (Amoxicillin), diarrhea (Low Osmolar ORS and Zinc) and rapid diagnostic test (RDT) for identifying those with malaria and artemisinin combination therapy (ACT) for treating the ailment. They were also given mid upper arm circumference (MUAC) stripes for identifying different degrees of malnutrition. The participants were also taught when to refer and how to identify a sick young infant (less than 2 months) immediately. The 100 CORPs were also trained to promote family and community practices (WHO, 2016a).

When the scale of insurgence and displacement surged, OCHA (2014) established that in one of the camps, a 6-bed clinic was set up (with one medical doctor and about 2 support staff per shift). The drugs provided were largely anti-malaria, antibiotic, pain killers and antihelmintics. Although a referral service was instituted, the question of ‘who pays for the care?’ emerged. In comparison with the most recent conditions, a 2016 report (Ireogbu, 2016) also ascertains that medical personnel are not enough in the camps notwithstanding a Memorandum of Understanding that exists between the National Emergency Management (NEMA) and government’s tertiary and secondary hospitals for referral cases. Therefore, by the last quarter of 2016, Borno Health Sector Bulletin (2016) asserts that health services were stretched in the camps because of the overwhelming number of IDPs. An examination of the National Disaster Response Plan (2011) locates NEMA’s responsibilities to provide ambulance services, mobile clinics, immediate needs (search, rescue and relocating resources); and support the Federal Ministry of Health (FMoH), in the emergency transport of personnel, medical supplies and other lifesaving resources. The FMoH is primarily the provider of health and medical services during emergency.

The health services in the camps were not sufficient but tentative, first-aid services. Thus, for the elderly who experienced disease or illness that were hitherto transferred from their origin or developed in the camps, care was to be sought at secondary/tertiary health facilities where the burden of care is higher and the cost of treatment has to be sorted by the elderly. This is because the population of the elderly without some form of social network around them was higher. Hence, the expenditure on health has to be covered or the elderly will be subjected to unconventional patterns of treatment, since they have been disconnected from livelihood sources and/or social support structures that can care for them and pay their health bills. Therefore, the challenge that displacement poses to the elderly is enormous. First, there is a disconnection from social support services; second, they are left to grapple with the challenges of health seeking and/or paying for such.

Most of the services in the camps were ancillary provisions and were insufficient in meeting the needs of the elderly. The Borno Health Sector Bulletin (2016), documents the range of services at the camps as routine immunization, surveillance, malaria, out-patient services, health education and family planning, essential medicines, integrated primary health, maternal health, TB/HIV, laboratory services, in-patient services, psychosocial support, mental health. In clear terms, the National Policy on IDPs in Nigeria (2012) asserts that most humanitarian efforts do not favour the displaced elderly persons as their needs are largely unmet. Although the policy document emphasizes various forms of support including official information, nothing in the policy document refers to health information, as well as the challenges that non-communicable diseases and ill-health pose to the elderly. Again, it is silent on referral services and raises no issue regarding health care financing among the aged. Although the policy document recognizes the socially disadvantaged position of older persons, there is no reference to medical care for the aged, except for mental and psycho-social health.

The activities of the Federal and State Ministries of Health are supported by the efforts of the United Nations agencies – WHO, UNICEF, UNFPA and UNCHR. Also, the WHO HeRAMS (2016) reports identified 18 other partners. However, the 2015 FHI 360’s assessment of health facilities at the camps in Borno State (having the second largest rate of displacement), identified eight organizations providing varied services in at least one of the camps. They include – the Red Cross (ICRC) which provides first aid services in all the 15 camps; the MSF that provides basic medical and obstetric care in three out of the entire camps; the WHO has immunization and disease surveillance on ground in all the camps; the Action Against Hunger which provides water , sanitation and hygiene (WASH) interventions with stations in three camps; Save the Children group provided services related to education, trauma services, WASH, and food security in four camps; the UNICEF provides antenatal care, primary health care services; the National Center for Disease Control provides some form of technical support in only two camps, while the UNFPA makes condoms available in only one camp. Also, apart from the efforts of international partners like Alima, ACF, Premiere, Urgence Internationale, Medecins du Monde, FHI 360, International Medical Corps, and the Nigerian Armed Forces, the Borno State Health Sector Bulletin (2015) identified the role of the International Organization for Malaria which provides mental health and psychological support to persons affected; the International Rescue Committee (IRC) that scales up health and nutrition services. It is clear that the agencies of government, the United Nations and private partners did not float specific agenda for the elderly. According to the WHO (2016d), about 6 million people are in need of health care assistance, when only 49 temporary health facilities (emergency clinics) set up by the FMoH and its partners directly support camps for the displaced persons.

Based on the foregoing and in relation to health infrastructure and partnerships in the provision of health care to IDPs, it is evident that the category of health care services available are not suitable for addressing chronic, longer term and degenerative conditions like cancer, arthritis, blindness and other health challenges that the elderly experience in IDP camps. It is agreeable that available health care determines the health information that will be provided. Therefore, literature establishes the availability of information related to sanitation and health behaviour channeled towards the prevention, reporting and control of communicable diseases (UNICEF, 2016). This is in consonance with the available health care services. This will not be a misplaced priority, as malaria, typhoid, cholera, measles, maternal and child health, vaccinations among other necessities are endemic challenges, having effect on children and younger adults. This is largely because children, women and the disabled people have historically been at the core of disease management and control in situations of distress and vulnerability. The International Organization for Migration (IOM) (2017) report established that radio is the main source of obtaining information in the camps, and information on security is the most sought after among the IDPs. Through an engagement of literature on IDPs and health communication, there were general information – even health information, but the existence of specific channels that address the health information needs of the elderly (especially on chronic conditions) has not been identified. In continuation, Thomas and Thomas (2004:123) substantiated that as diseases (chronic and infectious) are prevalent among displaced populations, there is a lack of basic health knowledge, education and/or promotion among the IDPs. Hence, health promotion and health education are vital, although many countries still lack the appropriate resources to address these health needs.
Health Care Services inadequacy, coping strategies and action areas
In humanitarian crises, it is clear that the health needs of the elderly are usually crowded out by other population groups. However, health care services established in various camps, right from mobile clinic to referral health care, do not address the health needs of the elderly who are vulnerable. It becomes worst in Nigeria where no absolute health care services are available for the elderly population (Salami, 2014:220). However, because of the established inadequacies of the health systems and their perceived inability to explain or resolve the occurrence of certain health conditions, medical syncretism is an emerging theme in the IDPs health literature. Evidence from Uganda suggests that ‘spiritual consultations’ manifests among older persons seeking to understand, and/or treat the ‘root cause’ of illness/disease conditions – especially mental conditions. As observed by Roberts, Odong, Brown, Ocaka, Geissler and Sondrop (2009), the practice of medical syncretism is an individual rather than community form of support. Thus, the elderly in IDP camps actively seek solutions to their health challenges individually.

Also, in the context of individual patterns of survival and coping with the problems of health, borrowing has also been identified as a behavioural pathway for resolving health related issues. As documented in the Humanitarian Needs Overview report of (2015), households accounting for about 66% borrow to meet their food needs and this also can be translated to the need to seek health and well-being. Hence, borrowing to access care is a major challenge in the IDP camps

Based on health-seeking challenges that older persons encounter, the Nigerian Federal and State Ministries of Health, supported by WHO and UNICEF led sector agencies in health and nutrition, concluded an operational planning workshop to identify key priorities for the year 2017 and identified immediate needs for an urgent intervention. As a result, Federal funding is allocated to address the leading causes of morbidity; including malaria, diarrheal diseases, measles and malnutrition. This is based on the present experience and peculiar needs in the IDPs camps. However, other important related issues are further discussed to capture holistic international best practices in IDPs camp.

Recently, UNHCR (2017) maintained that the need of the vulnerable group will be prioritized during emergency displacement. The vulnerable groups include unaccompanied boys and girls who are principal applicants; pregnant and lactating women; elderly men and women over 60 years old; and all categories of people with disability. Robinson (2012) and other scholars maintain that mental health support for crisis-affected populations is often considered a priority in the short-term aftermath of a traumatic event. However, during a protracted humanitarian crisis, immediate needs can transform into long-term psychosocial issues requiring sustained attention and mental health care. Therefore, mental health and psychosocial support (Robinson, et al, 2012); a functional referral system; and environmental health should be in place with emphasis on ensuring access for the most vulnerable groups. These cannot be efficiently effective, until health information system and EWARN (Early Warning and Alert Response Network) earn support and standard practice of health information system is strengthened.

Funding to implement lifesaving interventions in crisis affected North East region states is urgently needed. The latest funding overview of the Humanitarian Response plan reports that the health sector is currently 13% funded well below the level required to conduct the scale up required to address unmet health needs amongst internally displaced populations and affected host communities (WHO & Borno State Ministry of Health, 2016b).  There is a need to strengthen services to absorb increase in referrals as well as accommodate welfare services to cater for the health related expenses of sick elderly persons.

Ensuring Health Information Literacy for the Elderly in IDP camps
The omission of the health information needs of elderly in IDP camps in both national and international internal displacement policies greatly reduces the prospects of achieving healthy living for elderly in camps. Displacements affect the elderly in a more unique way, which leaves them more vulnerable to mental and physical health challenges. For instance, displaced elderly men, having experienced disruption of kinship networks where they had high status and authority, become more withdrawn from their environment (Mosneaga and Vanore, 2016:25), and may also suffer psychological ill health. The elderly therefore require specifically designed health communication systems to improve their capacity to obtain, process and understand basic health information and services, in order to make appropriate health decisions while living in IDP camps. Limited access to health information among the elderly, which is more prevalent among those with lower socioeconomic status, is closely associated with poor access to health care services, which also increases the risk of worse health outcomes for the elderly (Sudore,  Mehta, Simonsick, Harris, Newman et. al., 2006:774).

In IDP camps within Nigeria, where there is high level of poverty (The Authority, 2017), and expectedly lower access to new media, there is a need to create and utilize more local, indigenous and traditional media of communicating relevant health information to the elderly. The radio is recognized as the most accessible means of information in Nigeria (Salami and Onuegbu, 2016:18; BBG Research Series, 2016) and a companion of the elderly (Ijiekhuamhen, Edewor, Emeka-Ukwu and Egreajena, 2016), mostly due to its cheapness and easy mobility. Well-packaged health information and health communication programmes (in form of speeches, drama and jingles), specifically designed for the elderly, should be disseminated through the radio. This increases the chances of keeping the elderly in IDP camps in Nigeria informed about their health and wellbeing. More so, musical and other entertainment programmes on radio is a source of relaxation for the elderly, which also improves their psychological wellbeing (Laukka, 2006:216). Thus, provision of radio sets and creation of health communication programmes targeted towards the elderly, has the potential to improve complete health outcomes of Internally Displaced elders living in IDP camps. This can be ensured collaborative efforts by the Nigerian Governments, NGOs (both local and international) and other concerned agencies. 

Furthermore, there is a need to improve communication between health care providers and the elderly in IDP camps in Nigeria, through the face to face techniques. These include: Town hall meetings, Moonlight gatherings and Community assembly, which create the platform to access and understand the perceptions of the elderly towards health related issues, and also educate on relevant issues. Doctors, who are a major source of health information for the elderly (Leyer, Schlecht, Hampshire, Hackett, Lybert, et. al., 2010:136) and other health workers also need to pay attention to cultural characteristics of the elderly, in order to better understand their perceptions and orientations, and also to be able to communicate with them in a culturally-acceptable manner. This also has the potential to improve the information-seeking behaviour of the elderly in IDP camps in Nigeria.

It is also important to create and maintain an up-to-date health information management system for elderly in IDP camp in Nigeria. This implies a complete and automated documentation of the demographic data, previous health records, referral forms and other relevant health information for each elderly person living in IDP camps. This is necessary for easy and prompt decision making and proper assessment of the health and wellbeing of the elderly (Sadoughi, Shahi, Ahmadi and Davaridolatabadi, 2016).

The health needs of displaced persons unarguably vary and health maintenance is vital among the IDPs. However, helping the elderly within the context of their unique social and health status requires further policy and action-oriented engagement. To improve the provision and access to relevant health information among the elderly, health promotion requires a critical engagement of key stakeholders. It is clear that although health facilities exist in IDP camps, they are not strong enough to address the chronic disease conditions common among the aged. It was also inferred that since facilities do not exist, health information is not likely to exist.

Throughout literature, health education and information programmes relating to infectious/communicable diseases, sanitation and disease prevention are existent. However, no information, communication, education or campaign relating to chronic conditions that are prevalent among the elderly has been identified in literature. For the elderly to cope with the health conditions that accompany ageing, medical syncretism and borrowing to finance health and wellbeing are espoused as major directions of coping strategies among the elderly in IDP camps.

Therefore, in the context of these conditions a holistic engagement of the beliefs, concept of health and diseases; disease prevalence (morbidity and mortality); and needs of displaced persons should be established. This, as well as the different stages of displacement should be taken into consideration, such that the health services provided will not be in conflict with the existing health needs. This will help in increasing the functionality and effectiveness of health systems which are hitherto also capable of reducing conflicts – in terms of health seeking practices, and physical security (Salami and Adedeji, 2015:267). Basically, national policies on displacement should be careful to address the needs of older persons, first within the provisions of the policy so that other social and political protection efforts will find the right footing; and that vulnerability of the elderly in such conditions can be reduced. As the elderly course through the pre-flight, flight and post-flight stages of displacement, it is a policy imperative to understand and provide commensurate health care services that will ensure resilience in societies. Specifically, Robinson (2012) recommends that local and community-based organizations should establish a network for groups working with older adults, which would include older adult representation, and could promote such things as – developing health communication media and efforts directed towards older adults and their specific needs; connecting or building networks across IDP communities (Nigeria Humanitarian Response Plan, 2017). Also, it is imperative to organize discussions with government agencies, community health workers, NGOs, and local communities. This strategy will help health providers in IDP camps to synthesize health care services; local infrastructure; and local involvement (including local skills and knowledge) in order to reflexively provide health information that will touch on critical health challenges across all age groups. Again, this will increase availability and access to age-specific health information within the context of socio-cultural issues that influence health seeking behaviour and coping strategies in specific communities. The need for community engagement remains a vital process for identifying the varied underpinnings for advocacy, and promoting health education among the elderly. In this regard, the beliefs and concepts of health and disease among the elderly will be fully understood, become actionable and facilitate ease of health information/education dissemination; and promote individual responsibility in terms of health among the elderly displace from their homes.

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