The aging population is a global phenomenon, with significant implications for developing countries, especially in Africa. While the world's population over 65 is projected to reach 1.5 billion by 2050, Africa faces unique challenges due to existing poverty and inequalities.
Even by 2050, Africa’s older population is projected to remain less than 1 in 10 (9.3%). The trajectory of the growth of Africa’s older adults is even more noteworthy. Three population pyramids illustrate the impact of high fertility or low fertility on a country’s age-sex structure.
Representative of many sub-Saharan African countries with high fertility levels, Uganda in Eastern Africa has an age and sex distribution that shows a perfect traditional pyramid shape, indicating an extremely young age. Its median age is a very low 15.7. In contrast, Tunisia in Northern Africa has experienced fertility declines.
The Need for Culturally Sensitive Care
As the population of African American (AA) elders increases, there is a need to focus on delivery of culturally congruent care. In 2010, there were 38.9 million AA elders, and by the year 2050, AA older adults are projected to account for more than 21.5% of the US population, an increase from 10% in 1990s.
Yet, according to the Agency for Healthcare Research and Quality Health Disparities Report, AA elders are less likely than Whites to receive the right amount of support during the time of serious illness. Disparities in seriously ill AA elder care exist because of gaps in knowledge around culturally sensitive physiological, psychological, social, and spiritual palliative care practices.
Read also: Experience Fad's Fine African Cuisine
To facilitate psychological, social, and spiritual healing for the seriously ill AA elder, palliative care practices must be informed by the perspectives of the seriously ill AA elder. Defined for this study, palliative care’s role is “to anticipate, prevent and relieve suffering; to support the best possible quality of life for patients and their families, regardless of the stage of the disease”, not just care provided at end-of-life.
Serious illness is defined conceptually as “a persistent or recurring condition that adversely affects one’s daily functioning or will predictably reduce life expectancy”. A review of the current research into psychological, social, and spiritual experiences of seriously ill AA elders can provide insight into creating culturally sensitive approaches for improving quality of life and overall satisfaction with the healthcare received.
Through a culturally congruent framework, the integration of psychological, social, and spiritual experiences provides holistic, patient-centered care that “identif[ies], respects and address[es] differences in patient values, preferences and expressed needs”.
Research on African American Elders' Experiences
The purpose of this culturally focused integrative literature review is to summarize the current research examining AA elders’ psychological, social, and spiritual experiences during serious illness. The following questions guided this review:
- What cultural experiences contributed to psychological, social, and spiritual healing for AA elders living with serious illness?
- What cultural experiences contributed to psychological, social, and spiritual suffering for AA elders living with serious illness?
For this review, the following definitions were used to conceptualize the following terms: sociocultural, serious illness, healing, and suffering. Sociocultural was broadly defined: “the interaction between people and the culture in which they live”.
Read also: The Story Behind Cachapas
Serious illness was limited and operationalized in this review to the top four leading causes of death in African Americans: heart disease, cancer, stroke, and diabetes mellitus. Healing was defined as generating a “sense of wholeness as a person” despite one’s illness.
For this review, healing in the setting of serious illness was defined as a “life transforming, positive, subjective change”-psychological, social, and spiritual healing-that occurs when one experiences a serious illness.
Methodology of the Literature Review
Using Whittemore’s method for integrative literature review, an organized and rigorous approach to the literature review process was followed via five steps: problem identification, literature search, data evaluation, data analysis, and presentation of findings.
A computer assisted literature search was conducted during July 2013-September 2013. The following electronic databases were searched: PubMed, CINAHL, EBSCO, and Web of Science. Many different combinations of search terms were used.
The broader terms searched were: healing, psychological healing, social healing, spiritual healing, spirituality, faith, wisdom, meaning-focused coping, coping, recovery, subjective well-being, thriving, resilience, and optimism. Each of these terms was joined with the term “African American”.
Read also: Techniques of African Jewellery
These searches were delimited by the following: samples that included an average age of the sample of their participants age 60 or older; discussed psychological, social and/or spirituality dimensions of AA elders; serious illnesses of cancer, heart disease, stroke or diabetes mellitus; published within the last twenty years; and peer-reviewed primary research reports.
The initial multiple searches, using the above search terms, identified 316 publications. The primary author screened the titles, abstracts, and key words of these 316 publications. Due to duplicates and/or not meeting inclusion/exclusion criteria, 151 articles were removed, leaving 165 publications.
From the final 108 publications, the research design, aim/purpose, sample and main findings were extracted into a data matrix.
The sample consisted of 60 quantitative, 42 qualitative, and 6 mixed methods studies. The samples of the quantitative studies ranged from n=17 to n=98,528. Of these, 53 were survey research. The remaining 7 of the 60 quantitative studies incorporated several types of methods.
Of the 42 qualitative studies, the sample size ranged from n=6 to n=167. Of these, 4 used focus groups and the remaining used interviews for data collection. There were a variety of methodological designs, yet not all of them explicitly stated a design.
Of the 6 mixed methods studies, the sample size ranged from n=30 to n=200. These articles used surveys and interviews.
In the quantitative articles, 13 samples were made up of only African Americans, whereas, 47 included multiple ethnicities. As with the quantitative studies, some of the qualitative studies did not use exclusively AA samples (n=22). However, 20 of the qualitative studies exclusively sampled only AA elders.
Only 23 of the 108 publications specifically reported a conceptual framework, necessary for providing conceptual clarity. For example, the spiritual domain was defined in a variety of ways: spirituality, religiosity, and/or religion practice.
Large numbers of the survey articles were cross-sectional, and longitudinal studies were frequently recommended by the authors to capture the multi-dimensional psychological, social, and spiritual experiences of serious illness. Within the survey research, the authors discussed the difficulty of collecting the wide variety of cultural dimensions of AAs elders’ psychological, social, and spiritual aspects due to difficulty using instruments that were not developed within the AA culture.
For the mixed methods studies, the authors reported choosing this approach to triangulate the findings of the survey and interviews. Finally, many studies only used one geographical location or one healthcare institution, decreasing the ability to collect broader findings across different settings.
Africa Ageing Futures: Challenges, Prospects and Ambiguities
Psychological Experiences
Individual psychological experiences found in these studies included depression, fear, anxiety, worry, psychological distress/stress, and sadness. Despite the multitude of negative experiences found, some positive psychological experiences were noted when cognitive reframing of illness occurred.
This reframing was described by terms such as optimism, wishful thinking, positive reappraisals, outlook and coping, resilience, and well-adjusted adaptations to one’s illness. The review findings do indicate that positive psychological outcomes do occur for seriously ill AA elders if negative experiences are decreased.
When negative experiences decrease, perhaps opportunities emerge for psychological, social, and spiritual healing for the seriously ill AA elder.
Social Support and Experiences
Social support was shown to impact seriously ill AA’s experiences. Despite research that has shown the benefits of social support, not all AA elders reported a positive role of social support. Negative experiences occurred for some, such as social isolation, decreased intimacy with others; negative social support from family, friends or healthcare providers, concerns about burdening others, and low socioeconomic resources or limited access to care.
AA elders’ social experiences may be negatively impacted by healthcare system discrimination caused by lack of culturally sensitive care, socioeconomic factors, and limited access to care. Even in the presence of negative social interactions, some individuals developed strength despite their suffering.
Spirituality and Healing
Significant differences were found among definitions of spirituality, religion, and religious practices among publications due to the complex nature of the term spirituality. The incorporation of a broad view of spirituality was important to fully describe healing/suffering for the seriously ill AA elder.
For purposes of this integrative review, the source articles defined spiritual healing in the following ways: existential and/or religious practices, psychological and/or sociocultural constructs of spirituality, and with the following terms: spirituality, religion, religiosity or religious practices.
Quality of Life Index of Older People (QoLIOP)
The study’s primary contribution is to construct a multidimensional QoL index that includes domains of an economic and non-economic nature and objective and subjective indicators focusing specifically on older adults living in Africa. This index id called the Quality of Life Index of Older People (QoLIOP).
In 2020, 9.2% (5.51 million) of the population was 60 years or older. Furthermore, the country is unique as it is the most unequal country globally (Gini coefficient of 65 in 2015), and it has an unstable socioeconomic and political situation with an official unemployment rate of 32.6%.
Using SA’s NIDS panel dataset, the QoLIOP will allow us to empirically determine the current QoL level among older people. Additionally, we will establish which dimensions in the QoLIOP explain the most variance signalling areas for policy intervention.
The results show that the newly developed composite multidimensional index is robust and reflects the well-being of older people in an African country. For our empirical application case study, South Africa, we find that the dimensions of household services, economic status and safety explained the most variance in QoLIOP.
We find that the QoL of older adults increased over time as they aged due to the improvements made in the household services, economic status and mental health dimensions. The dimensions that showed a decrease are safety and health. We find that white South Africans have the highest QoL among demographic groups, followed by coloureds and Africans.
The older adults that live in rural (traditional) areas have the lowest QoL scores, especially females residing in farming households.
When investigating which dimensions influence the QoL of older adults, Kelley-Gillespie (2009) proposed it should be viewed from the perspective of general systems theory. This theory emphasises the significance of people’s interactions with various systems that impact their behaviour, circumstances and QoL. Researchers agree that despite the variety in methods used to measure QoL, the components are quite similar.
A synthesis of the existing literature shows that the QoL of older adults has the following overlapping domains: i) social; ii) physical; iii) psychological; iv) cognitive; v) spiritual, and vi) environmental.
Health and Economic Inequities
After a lifetime of racial and health inequities, Black seniors are at risk of spending their last years with declining health, little income and virtually no savings. Numerous studies have noted that Black Americans have worse health than their white counterparts, including chronic diseases and disabilities leading to shorter and sicker lives than white Americans.
Black families generally have lower incomes than white families, which makes it more difficult to save for retirement. In the Federal Reserve 2019 Survey of Consumer Finances, white families had median and mean family wealth of $188,200 and $983,400, respectively. The median and mean wealth of Black families is less than 15 percent that of white families, at $24,100 and $142,500, respectively.
| Demographic | Median Family Wealth | Mean Family Wealth |
|---|---|---|
| White Families | $188,200 | $983,400 |
| Black Families | $24,100 | $142,500 |
Black Americans often don't participate in employer-sponsored retirement accounts and thus don't get the advantage of stock market growth. Only 44 percent of Black Americans have retirement savings accounts, with a typical balance of around $20,000, compared to 65 percent of white Americans, who have an average balance of $50,000, according to the Federal Reserve.
Unfortunately, too many Black Americans have a huge dependency on Social Security. But his biggest worry is the debt that will have to be paid back after moratoriums on rent, mortgages, and other loans are lifted.
