The Quality of Service in Rural Settings: A Multifacet Challenge

### **Chapter 9**

## Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children Initiated and Managed on Therapy in Rural Primary Healthcare Clinics of South Africa

*Linneth Nkateko Mabila, Patrick Hulisani Demana and Tebogo Maria Mothiba*

### **Abstract**

HIV has affected the health and welfare of children and undermined the success of child survival in some countries. The introduction of antiretroviral therapy (ART) in managing HIV is one great public health success story. ART has commanded increased survival for people living with HIV (PLHIV). Barriers to achieving ART outcomes in children have been simplifying the prescribing process for non-paediatricians, such as medical doctors and nurses familiar with prescribing ART for adults but involved in treating children, particularly at the primary health care level. And the lack of appropriate antiretroviral formulations for children. The calculation of individualised doses for liquid oral ARVs for children at each clinic visit is considered complicated and time-consuming. ART failure among children seems to be an under-recognised issue, and adherence to treatment guidelines is reported to be a challenge among nurses caring for children and PLWHIV. Rational medicine use is essential to ensure the success of pharmacologic interventions. The attainment of ART goals depends on the effective use ARVs as recommended in guidelines. It is pivotal that nurses be empowered with strategies aimed at promoting the rational use of antiretrovirals.

**Keywords:** rational antiretroviral therapy use, children, nurses, rural primary healthcare clinics, antiretrovirals, South Africa

### **1. Introduction**

The concept of rational use of medicines is old. It dates to 300 BC when the physician Herophilus said that "*medicines are nothing in themselves but are the very hands* 

### **Figure 1.** *Medicine use cycle.*

*of God if employed with reason and prudence*" [1]. For many years, the rational use of medicines has been regarded as one of the critical principles of effective and quality health care [2, 3]. In 1985, the World Health Organisation (WHO) convened an expert meeting on the rational use of drugs, from which the rational use of drugs was defined as a contextual picture where "*Patients receive medications appropriate to their clinical needs, in doses that meet their requirements, for an adequate period, and at the lowest cost to them and their community*" [4]. The World Bank also defines the rational use of medical care as two fundamental principles, such as using medicines in accordance with scientific evidence for efficacy, safety, and compliance as well as the cost-effectiveness of the medicines in use within the constraints of a particular health system [4, 5].

Although the World Bank definition considers the financial capacity of medicine use in different countries, the WHO advocates using medicines at the lowest possible cost, regardless of the healthcare system [5]. The WHO and World Bank definitions are primarily based on therapeutic and medical perspectives. Reasonable use of drugs can also be seen from the consumer or patient's point of view. What is considered beneficial from a medical point of view may be regarded as unreasonable by the patient and vice versa [6]. From a medical point of view, improper use of drugs can begin in one of four major stages (**Figure 1**) of the medicines use cycle [2].

Even though half of the patients take almost half of their medicines correctly, half of all medicines are inappropriately used worldwide. The inappropriate use of medicines leads to resistance development, medication therapy problems, and increased medicine and treatment costs [7]. Therefore, both medical and patient perspectives need to be considered to gain a complete understanding of the rational use of drugs.

### **2. History of antiretroviral therapy in South Africa**

When the South African national Antiretroviral Therapy (ART) Program was launched in 2004. It was utterly dependent on the hospital's HIV clinic, where ART services were provided exclusively by medical doctors [8–10]. This means that ART and care at SA at the time were limited to several selected accredited health clinics due

### *Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children… DOI: http://dx.doi.org/10.5772/intechopen.110171*

to the presence of doctors in these clinics. Most public clinics were run and operated by nurses, so ART services were only seen in hospitals. The doctor then managed the ART program, performed a health examination, and initiated and prescribed treatment for the patient in need. Nurses were not allowed to treat HIV patients or prescribe or administer ART [10]. This practice resulted in the overcrowding of hospital facilities following an increasing demand for HIV care with limited personnel. Consequently, poor management of patients on ART necessitated the decentralisation of services to PHC clinics, rendering nurses essential to managing patients living with HIV [11–14].

Hence, managing the HIV/AIDS pandemic made SA struggle to reply to the troubling impact of HIV/AIDS in conjunction with upholding its democratic mandate to give equitable access to health services progressively. These challenges forced the government to rethink and reorganise its health resources and systems because of the reconsideration of the roles and responsibilities of nurses within the management and care of chronic and complicated diseases [15]. For example, in April 2010, ART was granted a presidential mission stipulating that ART is currently available in all 5500 South African public clinics. It required SA to revise the HIV treatment guidelines in 2010 and request nurses in primary care clinics to enrol for the Nurse-Initiated-and-Managed Antiretroviral Therapy (NIMART) training [16]. The mandate also meant that nurses should be trained to prescribe and treat patients with ART. NIMART has changed the role of HIV treatment and management.

The spread of HIV has led to innovations in the areas of nurse training, job shifts, retention, and practice. This expansion of HIV services was designed to meet the urgent needs of prevention, care, and treatment and embrace the vision of decentralised HIV services to PHCs [15]. Van Damme et al. [17] emphasise that the adoption of ART to reasonable levels, like primary health care, has increased ART access for PLHIV.

Following the implementation of task shifting, it was reported that a total of 2552 public clinics were involved in initiating and caring for patients on ART by April 2011. By March 2015, this number had reached 3591 public clinics [18]. As the numbers grew, training needed to be widened and improved since NIMART required nurses to assess, diagnose, and manage patients with HIV. Nurses, therefore, need to be equipped with skills such as history taking, physical assessment, interpretation of laboratory results, and knowledge about the pharmacological interaction of antiretroviral drugs [19]. The main reason for this integration approach was that in SA, PHC is an identified level of care that reaches most South Africans. Therefore, it is a relevant platform for the ART programme to reach all those in need [20].

Crowley and Stellenberg [21] cautioned that, even though HIV services are a decisive part of PHC, public clinics need to be sufficiently equipped for them to be able to provide quality HIV services to children on ART. This seems to be a global challenge in that Portillo et al. [22] highlight a San Francisco reality that the increasing demand for PHC services and the current healthcare personnel shortage is foreseen to cause compelling reductions in the number of healthcare professionals who are competent to provide HIV care. Moreover, Meyers et al. [23] had foreseen this situation and said that "*there has been a dramatic increase in ART access for HIV-infected children in SSA*". However, the availability of adequate care and treatment programs remains limited. Hence, it is essential to note that the decentralisation of services to rural PHC facilities without the provision of sufficient Human Resources (HR), as well as constant support, could compromise the quality of care provided to patients at this level with long-term repercussions for reaching the National strategic plan (NSP), strategic developmental and global health goals.

Meyers et al. [23] emphasised that essential HIV care, treatment services, and managerial support are vital components for ensuring quality services. Furthermore, they

highlight that the provision of ART at the PHC level should be supported with human resources and the implementation process of comprehensive models to decentralise HIV care effectively. In the era of Sustainable Development Goals (SDGs), the UNAIDS set countries the ambitious "90-90-90" target of eradicating global infection with HIV by 2030. This required that by 2020, 90% of people living with HIV would know their status, 90% of whom would be on ART, and 90% of the latter would be virally suppressed [24].

### **3. HIV care in children and the prevention- of -mother- to- childtransmission**

The SA programme for the prevention- of -mother- to- child- transmission (PMTCT) of HIV has, in recent years, achieved noteworthy successes in ensuring good outcomes for pregnant women living with HIV and reducing the risk of vertical HIV transmission to their children [25]. Despite having a persistently high antenatal HIV prevalence of around 30%, South Africa (SA) has made excessive developments in reducing the vertical transmission of HIV in children, especially in their first two months of life, from around 23% in 2003 to about 0.7% in 2019 [26]. Improving ART access during antenatal care has contributed significantly to this success. The integration of ART initiation into Antenatal Care (ANC) is associated with higher levels of ART initiation during pregnancy [27]. Still, it has led to an increase in the relative proportion of vertical transmissions due to breastfeeding in the first six months postdelivery [26].

### **4. Complexities in the management of children on antiretroviral therapy**

The introduction of the NIMART programme in rural clinics brought the emergence of new challenges regarding prescribing and dispensing ART by nurses [28]. The Millennium Development Goals (MDGs) era also confirmed that children living with HIV continue to have less access to HIV services than adults [24]. Issues of ARV tolerability and access to formulations appropriate for children also remain. For instance, the Lopinavir/ritonavir (LPV/r) formulation is very unpleasant to taste. Infants often tend to tolerate it when their taste buds are still undeveloped but spit or vomit it out as the taste buds develop and they grow older [29, 30]. In South Africa, only in 2020 did the LPV/r pellets become available in the state and private sectors. These pellets are developed to overcome challenges with administration and storage experienced with the previously available tablet and syrup formulations for paediatric HIV patients [30, 31].

### **5. The goal of antiretroviral therapy in children**

ART aims at reducing the rate of replication of HIV and breaking its progression into AIDS [32–36]. The use of ART is the basis of clinical interventions that can be used to prevent the transmission and progression of HIV infection in people living with HIV/AIDS. Even though ART does not destroy the virus and cannot cure HIV or AIDSrelated illnesses, it significantly reduces the viral load. It slows disease progression, thus increasing the life expectancy and quality of life of PLHIV [37]. Furthermore, when effectively used in children, ART has been shown to improve growth and virologic and immune responses [38–42]. Mortality due to HIV infection in children has meaningfully decreased in the era of effective ART [43, 44]. Quality of life is an essential ART outcome [45] in developing countries that have not been solved yet. The range of HIV/AIDS problems measured by the number of affected children is extensive [46].

### **6. Challenges with antiretroviral therapy**

A noted obstacle towards achieving widespread paediatric ART coverage has been the simplification of the prescribing process for non-paediatricians, including medical doctors and nurses who are more familiar with prescribing ART for adults but also involved in initiating and managing children on ART, particularly in rural primary care levels of South Africa [31]. The calculation of individualised doses for children, especially for liquid oral ARV formulations for infants or young children at each clinic visit using the current weight or body surface area, is also observed to be a complicated and time-consuming process for nurses in resource-limited settings [31, 47]. The development and updating of an integrated weight-based ARV dosing chart for children based on WHO guidelines and adapted for the ARV formulations available in South Africa has contributed to building confidence among prescribing clinicians and pharmacists and helped facilitate children's access to ART [31].

### **6.1 Adherence to ART in children**

The main goal of antiretroviral therapy is to reduce the viral load (VL) in the blood to undetectable levels. Over the decades of ART, various scientists have determined that adhering to this treatment is essential for patients to experience the full benefits of ART, which include the overall and permanent suppression of viral replication, reduced destruction of CD4 cells, the prevention of viral resistance, the promotion of immune reconstitution, and a decreased disease progression. ART improves the prognosis of people living with HIV and reduces HIV-related morbidity and mortality, as well as the development of other opportunistic infections [48–50]. DiMatteo [51] defines this as the extent to which a patient's drug-consuming behaviour aligns with the doctor's recommendations. Although essential, ART compliance is often challenging for people treating ART, especially children. Factors affecting a children's ART compliance include (i) the caregiver, (ii) the child himself, (iii) the prescribed medication or treatment, (iv) socio-economic status, and (v) the provision of services [51–55]. The degree to which patients are compliant with their treatment regimen is an essential determinant of clinical success [56, 57].

There is no generally accepted measure of ART compliance, and each method has various strengths and weaknesses, as well as cost, complexity, accuracy, accuracy, aggression, and bias. Therefore, developing real-time ART adherence monitoring tools can change the development of new preventive strategies to improve adherence. Ultimately, applying these strategies may prove to be the only cost-effective way to reduce morbidity and mortality in individuals and reduce the likelihood of HIV transmission and the emergence of resistance in the community [58].

### **6.2 Medication errors**

Aronson has since 2009 defined medication errors as a failure in the treatment process that leads to or has the potential to harm the patient. Furthermore, he emphasises that medication errors can take place;


These errors can be categorised with the help of psychological classifications such as knowledge, rules, behaviour, and memory-based errors. Dosing mistakes can sometimes be serious, but often they are not trivial. However, system failures that lead to minor errors can later lead to fatal errors, so it is essential to identify them. Velo and Minuz [59] predicted that bug reporting should be encouraged by creating an impeccable, non-immunity environment. In addition, prescription mistakes are irrational, inappropriate, and ineffective. There are also recipe spelling mistakes, including the indecipherability of the written recipe. Avoid dosing mistakes in balanced prescribing, that is, the use of drugs adapted to the patient's condition and dosages that optimise the ratio of benefit to harm within the uncertainty associated with therapeutic decisions.

In clinical practice, the separation of prescribing and dispensing activities is considered a *"safety mechanism to ensure an additional independent assessment of the proposed therapy before the patient begins treatment"* [60]. In some settings, such as rural areas with limited health personnel [61], dispensing may be carried out by the prescriber, such as dispensing nurse(s). This is considered *"non-ideal and may promote irrational prescribing, especially if the prescriber stands to gain financially"* [62].

When the prescribing and dispensing functions are separated, proper therapeutic knowledge of the dispensing process is essential to check the prescribing gap and provide the prescriber with necessary recommendations or interventions. Therefore, contact between the prescriber and the patient is important because it can significantly impact the patient's medicine use practice. For example, compliance may improve only if the patient understands the importance of taking the medication, can follow the instructions appropriately, and is aware of the risk of non-compliance [63, 64].

On the other hand, the WHO advocates that *"the rational dispensing principle should be followed to ensure that patients receive adequate information regarding the use of dispensed medicines to achieve the desired benefits. For instance, if dispensing practices such as counting, packaging, and labelling is poorly executed; they are likely to impact the patient's confidence in the dispensed products, and subsequently compliance to therapy*" [65, 66].

*Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children… DOI: http://dx.doi.org/10.5772/intechopen.110171*

### **7. Healthcare professionals' compliance to treatment guidelines**

The appropriate use and monitoring of ARVs have resulted in the enhancement of patient's quality of life [67]. The implementation of task-shifting in South Africa and the decentralisation of ART [68] brought forth noticeable evidence of improved health outcomes, quality of care, and patient satisfaction for PLHIV [69, 70]. In South Africa HIV treatment guidelines, standard treatment guidelines and essential medicine lists are in place as a monitoring and support tool for healthcare professionals to ensure that they appropriately prescribe medicines and can provide good quality care to PLWHIV. There is also a recent (2019) South African National Guideline for the Prevention of Mother-to-Child- Transmission outlining three major strategies for programme improvement. These strategies aim at


Patient safety is a strategic goal and a central value in nursing practice. It is provided through an error-free medication administration which is essential towards achieving positive patient clinical outcomes for patients. In practice, there are therefore a set of guidelines that nurses are required to follow to ensure patient safety. Even though the nurses' adherence to treatment guidelines and factors associated with non-adherence to treatment guidelines among nurses remain under explored [71, 72]. Studies demonstrate a suboptimal adherence to guidelines by all prescribers, and a need for training on the use of these guidelines as well as improved monitoring of compliance at PHC level has been identified [71–73].

### **8. Strategies for addressing the irrational prescribing of medicines**

Generally, the irrational prescribing of medicines is considered a *"disease"* that is difficult to treat even though it is possibly preventable [74]. Therefore, there are several strategies that are aimed at changing patients and prescribing behaviour to encourage the rational prescribing of medicines. These strategies can generally be grouped into targeted or system-oriented approaches [2]. Targeted methods include educational, business, and system-oriented strategies include regulatory and economic interventions [2, 74, 75]. Educational interventions are often aimed at persuading or informative, including printed matter, seminars, or face-to-face contact [76].

Inappropriate medicine management occurs at all levels of the healthcare system, both in hospitals and primary health care. The factors influencing the irrational use of medicines are usually very complex. They are associated with the attitudes of prescribers who are often convinced of the effectiveness of a particular therapy without considering

### **Figure 2.**

*Rational ARV prescribing cycle (adapted from the WHO-6-step of rational prescribing a guide to good prescribing).*

other alternatives, too much staff responsibilities, patient's pressure on the use of a specific drug, lack of knowledge in the field of pharmacoeconomics, and others [77].

According to Wettermark et al. [78] educational interventions can affect the knowledge and awareness of prescribing physicians. Still, their effectiveness in behavioural change remains modest when not combined with other strategies. On the other hand, managerial techniques are specially aimed towards guiding practice. Such managerial interventions that can be hired consist of monitoring, supervision and feedback, the usage of a restrictive drug treatments list, drug utilisation reviews, or the usage of based prescription forms [75]. An example in this case is the *"Swedish Wiselist"*. This is the Essential Medicines List (EML), which adheres to only 200 medicines to increase physician familiarity with quality medicines and reduce costs, complemented by regular medical oversight to specialists [79]. Economic strategies, on the other hand, aim to promote positive financial incentives while eliminating the awkward incentives of prescribing physicians [80]. Embrey and Hogerzeil [2, 75] say that economic interventions could include introducing significant changes to the healthcare provider's reimbursement system or banning prescribing drug sales.

In South Africa, to meet the basic constitutional human rights to health care, the new government commissioned a committee that specifically looked at medicine issues, this gave rise to the National Drug Policy (NDP) of 1996. The aim of the NDP is to address deficiencies such as the irrational medicine use, inaccessibility to medicines and cost-ineffectiveness treatment, and inefficient procurement and logistic practices to "ensure an adequate and reliable supply of safe, cost-effective drugs of

*Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children… DOI: http://dx.doi.org/10.5772/intechopen.110171*

acceptable quality to all citizens of South Africa, thereby promoting the rational use of drugs by prescribers, dispensers, and consumers". The NDP allowed for the provision of the Provision of the EML guided guided by the Standard Treatment Guidelines (STGs) through the National Essential Drugs Programme [81].

For the intervention to be very effective, it should be targeted at the clinic or prescribers who have the utmost need for improvement, with a particular focus on the identified prescribing behaviours [2, 75]. In some cases, several interventions may often be required to make the necessary changes. Again, it is worth noting that the efforts to promote rational medical care and prescribing should be multifaceted, including the address of aspects of patient and community behaviour [82, 83]. The six steps method of pharmacotherapy education promoted by the WHO (see **Figure 2**) need to be executed in every medical and nursing curriculum "*as part of an integrated learning program which has positive effects on medical students' knowledge of basic and applied pharmacology, pharmacotherapy skills, and satisfaction and confidence in prescribing*." [84].

### **9. Strategies for promoting the rational use of antiretroviral therapy**

Failure of ART in children is an underestimated problem and is not adequately addressed by paediatrics and HIV treatment programs. The failure rate of paediatric ART in facilities with limited resources ranges from 19.3% to over 32%, so a comprehensive analysis of the causes of failure and an approach to addressing impaired adherence to treatment are urgently needed [85, 86].

Studies by Davies et al. [87] and Bunupuradah et al. [88] indicate that a high proportion of virological failures were observed in children in an established HIV primary care environment. These studies also found that the average age at which ART began in this cohort of primarily vertically infected children was 3.4 years, and the need to identify HIV-infected children early is latent. It suggests that you are missing out on the opportunity for a typical diagnosis. In addition, one-third of these children are said to have never achieved virological suppression since they were initiated on treatment. An inadequate system can explain this persistent viremia in the clinic to find a failed child or the lack of clinician knowledge or convenience to manage high viral loads. This is well reflected in the proportion of children (80%) who remained unchanged despite long-term antiretroviral therapy failures. One-fifth of patients aged 10–15 years were not fully disclosed at the start of the study, and this is a known risk factor for ART failure in children [87, 88].

These researchers also emphasise that VL testing in children on ART in resourceconstrained environments should be prioritised over monitoring CD4 cell counts to reduce the time it takes for treatment to fail. They also suggest that this facilitates the appropriate conversion of children to secondary ART therapy and minimises immunological disorders. In addition, clinicians need to understand that the most important factor in good paediatric HIV management is achieving reasonable compliance [89]. Furthermore, they point out that easier ways of supporting adherence are very important in frequently visited clinics. This has been shown to significantly improve the quality of patient support that children and their caregivers receive. It is crucial for the nurses to keep in mind that adherence support should not be initiated when a child has a high VL. Very often, proper basic counselling on adherence is not provided until the child fails treatment, so once the child reaches a developmental milestone, proper counselling should be initiated and reassessed at the beginning of ART. Regular and continuous counselling is essential for paediatric patients, as the psychosocial

situation of paediatric patients often changes and new barriers to adherence usually arise [90]. Providing paediatric antiretroviral care, particularly at PHC clinics, has distinct obstacles. One of these is a shortage of staff, which includes staff that is comfortable dealing with children [91]. Paediatric ART failure is an under-recognised issue that receives inadequate attention in the field of paediatrics and within HIV treatment programmes. With paediatric ART failure rates ranging from 19.3% to over 32% in resource-limited settings, a comprehensive evaluation of the causes of failure, along with approaches to address barriers to treatment adherence, is urgently needed [90].

In summary, one-third of children aged 0–19 in two HIV clinics with expanded primary care failed to achieve antiretroviral therapy, and 33% did not achieve virus suppression after the initiation of ART. Hence, by addressing the core deficiencies in paediatric HIV care, such as insufficient early diagnosis of HIV-infected children, lack of VL monitoring and clinician comfort in responding to high VLs, and the unstructured and inadequate adherence counselling, we will start to achieve durable VL suppression in children and control this silent epidemic [91]. This will help HIV/AIDS programmes to achieve long-lasting VL suppression within the paediatric HIV population and curb this silent epidemic. An effective response to the challenges of HIV treatment failure in LMICs must include reductions in the cost of second-line agents [92].

The strategies should be comprehensive, evidence-based, and focused on the rational long-term use of ART in children and adolescents [93–95]. Although early mortality and retention in care has been identified by different scholars as early as the year 2002 to be remaining as a significant challenge in HIV programmes, the majority of reports from low- and middle-income countries (LMICs) had in the past decade shown encouraging immunological, virological, and survival outcomes [96–103], with lower than expected reported rates of switching to second-line ART regimens [104, 105], and this was back then attributed to being in part due to actual rates of treatment success, but mainly because of the limited access to both virological monitoring and the unavailability of second-line antiretroviral drugs [105]. In a study by Orrell et al. [106], clinicians were found to be reluctant to switch treatments due to the cost of the regimen, the complexity of the regimen, the inconvenience, and the lack of subsequent treatment options. With the maturation and expansion of the cohort and increased access to virological monitoring and second-line treatment, an increased failure rate of diagnosed treatment and a switch to second-line treatment were expected [107]. This is because the cost of second-line treatment is higher than the cost of first-line treatment. These increases are due to the HIV treatment programs [108–110]. Elliott et al. [111] identified the need for rational ART use in LMICs, which relies heavily on accurately identifying medical malpractices and optimising the timing of the clinician's switch to alternative therapies. In addition, consider various factors such as availability, risk, and benefit substitution to assess the risk of HIV drug resistance and reduced therapeutic efficacy, immunological and clinical progression, and inappropriate early switching of patients. Rivera et al. [112] indicated that HIV resistance develops due to low ARV drug levels because of several factors and variations in drug absorption and metabolism and noncompliance owing to adverse effects or a poor understanding of the importance of the medication. The monitoring of VLs must guide effective treatment [113]. Hence, the recommendation is that the following two conditions are adhered to: Firstly, adequate plasma drug levels must be maintained as results may be inconclusive if adherence is not satisfactory or if the prescribed regimen has not been followed. In addition, the quality of drugs, bioavailability, and drug-drug interactions can affect the outcome. Secondly, the availability of alternative medicines must be assured [113].

### **10. Adherence to HIV treatment guidelines**

The appropriate use and monitoring of ARVs have resulted in the enhancement of patient's quality of life. However, Elliott et al. [111] contend that the complexity of treatment regimens, over and above a multitude of factors such as drug intolerance, poverty, and the level of education of patients, directly influenced the lack of adherence. This also directly influences resistance and treatment failure. Hence, the rational use of ART in LMICs is critically dependent on clinicians' precise detection of treatment failure [111]. The proper use and monitoring of ARV has dramatically improved the patient's quality of life in recent years. However, the complex nature of these therapies, in addition to various factors such as drug resistance, socio-economic status, and the level of patient education, can reduce patient compliance and increase resistance and treatment failure potential. On the other hand, prescribing errors in ART management are said to be common in inpatients [114].

The rational use of ART in LMICs relies heavily on the accurate detection of TF and optimisation of the timing of switching to alternative therapies. Monitoring and switching strategies aim to balance the risk of HIV drug resistance with reduced efficacy of second-line treatment, immunological and clinical progression, and inappropriate early switching. Current and future status of alternative therapies and general medicine availability [111].

There is no well-established link between antiretroviral usage and the development of virological, treatment, and immunological failure, except that virologic failure is highly dependent on the patient's adherence to the prescribed antiretroviral treatment. To the researcher's knowledge, the inappropriate use of ARVs by prescribers is a topic that has never been explored, especially evaluating its impact on the clinical outcomes it might pose to children on ART. When looking at antibiotics as an almost similar class of drugs to ARVs, the literature highlights that the well-established link between antimicrobial usage and the development of resistance emphasises the importance of developing strategies to improve antimicrobial prescribing. It further highlights the possible reasons for inappropriate prescribing: lack of education, misinterpretation of results, prescribing etiquette, and medication errors. These contribute to the increase in morbidity and mortality, the development of antimicrobial resistance, and healthcare costs to such an extent that studies have proven the importance of antimicrobial prescribing [115–117].

Similar to antimicrobials, there is no established nor existing reference for measuring the appropriateness of ART use. [118] highlight that compliance with local, national, and international guidelines as the standard for appropriate therapy is increasingly utilised to reduce subjectivity. Moreover, evaluating compliance to treatment guidelines provides a reproducible method for large-scale evaluations across multiple facilities, especially when sharing similar treatment guidelines such as the consolidated national guidelines for managing HIV/AIDS [119].

The appropriateness of every antiretroviral prescribed can be assessed according to classic criteria established for antimicrobial evaluation by Kunin, Tupasi and Craig [120] (see **Table 1**). Even though this criterion seems outdated, it has since been used and relied upon by many established researchers in appropriate antimicrobial use; for example, researchers such as Dailey et al. [121], Bishara et al. [122] and van Bijnen et al. [123] have all conducted their studies following this criterion depicted in **Table 1**.


### **Table 1.**

*Criteria for categorising the appropriateness of ART use in children (adapted from Kunin et al. [120]).*

### **11. Good medical record-keeping in HIV/AIDS management**

Inaccuracy in prescription writing, poor legibility of handwriting, the use of abbreviations and incomplete prescriptions contribute to the poor keeping of medical records. For example, omitting the total volume of the prescribed syrup or solution or the duration of the prescribed medicine can lead to misinterpretation by healthcare personnel. This can result in medicine dispensing and administration errors [59]. Hence, good nursing practice requires detailed record-keeping that is comprehensive, timely, and accurate. Because, without complete recording, there is no evidence to prove that medical care was offered to the patient [124, 125].

This is supported by the saying in nursing practice that *'what is not recorded has not been done"* [51]. Medication errors are common in general practice and hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to

### *Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children… DOI: http://dx.doi.org/10.5772/intechopen.110171*

erroneous medical decisions can result in harm to patients. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. An unsafe working environment, complex or undefined procedures, and inadequate communication among healthcare personnel, particularly between doctors and nurses, have been identified as important underlying factors contributing to prescription errors and prescribing faults. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of online support. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically [51]. The inappropriate keeping of medical records can influence patient management and the endurance of medical care, leading to inadequate health care [126]. Therefore, the appropriate use of ARVs requires the nurses' understanding of good medical record-keeping and the importance of it in ART management. Patients' clinical records, clinic records, and administrative records are the necessary nursing practice records. Medical records explain all relevant patient details such as the history, clinical findings, diagnostic test results, pre and postoperative care, patient's progress, and pharmacological treatment. If written correctly, notes acquired in these records support a healthcare professional's correctness of treatment [127]. The appropriate keeping of records is important in nursing care in that it provides clear evidence of the care plan, the decisions made, the care delivered, and the information shared with the patient. It is a means of communication with multidisciplinary health team members [124–127].

### **12. Treatment support systems for the children on ART**

The nurses in rural clinics need to facilitate local support systems for the parents and caregivers of children receiving ART, as well as identify local community support groups to support, help, and motivate the parents and caregivers of children receiving ART. Nurses need to remember that children depend solely on caregivers for adherence, treatment administration, and presenting to the clinic for a collection of their antiretroviral treatment. Additionally, caregivers can be their primary parents, guardians, older siblings, aunts, uncles, or grandmothers. As clinicians, you can support the parents/caregivers as they suffer emotional strain in caring for children on ART. Give information about support groups in the community of your facility. The emotional well-being of a parent/caregiver plays a huge role towards the child's adherence to treatment [128–130].

### **13. Knowledge of the rational and irrational medicine use concept**

Promoting the rational use of ARVs will require effective policies and efficient collaboration between health professionals, patients, and the entire communities. An adequate understanding of the relevant aspects of ARV use among all stakeholders is essential to drive collaborative efforts to address irrational ARV use. The tackling of irrational ARV use should be prioritised to improve healthcare delivery towards ensuring patient safety and allowing for optimal utilisation of the ARVs. Irrational prescribing often derives from a wrong medical decision because of a lack of knowledge or inadequate training. Adverse clinical outcomes can be related to a lack of knowledge or skill. Even the simple act of transcribing previous medications and collecting information as part of the medication history requires knowledge of pharmacotherapy and adequate information about the patient's clinical condition. Equally, the choice of dose requires information about the patient's clinical status and immediate verification of the appropriateness of treatment. The provision of continuous in-service training and mentorship on the rational use of ARVs is pivotal for nurses in PHC settings. In addition, the hospital's Drug and Therapeutics Committee should regularly evaluate ARV usage patterns in these clinics [7].

### **14. Lessons learned from South African primary healthcare ART programmes**

In South Africa, initiating ART in primary care is the responsibility of NIMART-trained professional nurses. It is no doubt that the availability of NIMARTtrained nurses in PHC clinics has tremendously improved patients' access to HIV services [18, 72, 131]. Task-shifting has brought paediatric ART initiation and management into the practice of NIMART-trained nurses. Therefore, the nurses must be equipped with the knowledge and skills vital for this role. The country also introduced the clinical mentoring manual for integrated services through the Department of Health [132], targeted mentorship introduced for nurses in primary health care, and it was found to enhance clinical expertise. Doctors or nurses can become clinical mentors if they undergo mentoring training. In addition, supervisory and mentoring support is viewed necessary to help improve nurses' confidence in managing paediatric ART patients. Literature, however, reveals that the sustained success of this approach is dependent on factors such as adequate training and effective support systems [131]. Lessons learned from SA also revealed that training, mentorship, and clinical practice experience are associated with knowledge and confidence of NIMART-trained nurses regarding the provision of ART services to children. These studies therefore *recommended "the strengthening of the current training and mentoring and ensuring that NIMART-trained nurses are provided with regular updates and sufficient opportunities for clinical practice"* [71, 72, 131, 133–135]*.*

### **15. Conclusions**

The irrational use of medicines occurs at all levels of health care. This practice is also observed in hospital settings, and it contributes to a decrease in the patient's quality of treatment and often causes negative health consequences. For this reason, it is essential to consider the adoption of appropriate training, mentorship, and support methods as a strategy for promoting the rational use of ARVs. These can be introduced in rural PHC settings to increase the safety and effectiveness of antiretroviral use. This approach has been witnessed in practice to lead to increased quality of life, improved patient care and confidence, and professional development because *Strategies towards Empowering Nurses on the Rational Use of Antiretrovirals in Children… DOI: http://dx.doi.org/10.5772/intechopen.110171*

appropriately trained nurses have been observed to experience work satisfaction due to the difference they make in patients' lives.

Quality improvement strategies such as mentorship, clinic medical record audits, and automated prescribing systems where possible can be used to address knowledge gaps in practice.

### **Acknowledgements**

This project received funding from the University of Limpopo's Staff Capacity Development Programme (UCDP), as well as funding from the National Research Foundation Black Academics Advancement Programme (BAAP) (previously known as) National Research Foundation (NRF) - First Rand Foundation (FRF) Sabbatical Grant (Ref No: NFSG180605340566, Grant No: 116803).

### **Conflict of interest**

The authors in this study declare that there is no conflict of interest, financial or otherwise.

### **Notes/thanks/other declarations**

None.

### **Author details**

Linneth Nkateko Mabila1 \*, Patrick Hulisani Demana2 and Tebogo Maria Mothiba<sup>3</sup>

1 Department of Pharmacy, University of Limpopo, Polokwane, South Africa

2 School of Pharmacy, Sefako Makgatho Health Sciences University, South Africa

3 Faculty of Health Sciences, University of Limpopo, Polokwane, South Africa

\*Address all correspondence to: nkateko.mabila@ul.ac.za

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 10**

## An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana

*Marion Okoh-Owusu, George Kojo Owusu, Celia Brown and Frank Baiden*

### **Abstract**

Institutional maternal deaths in the Western Region of Ghana increased from 133 in 2011 to 150 deaths per 100,000 live births in 2014. We reviewed available audit reports on deaths that occurred in 2014 in order to identify priorities for improvement. We undertook a manual search for audit reports and used a structured questionnaire to extract information on the sociodemographic characteristics of patients and the circumstances of care and death. We entered and analyzed the data using EPI-INFO (v.7). Analysis was largely descriptive. Audit reports were available for 75% of the 93 deaths recorded in the region in 2014. The mean (SD) age of death was 28 (±8) yrs. The majority (80%) involved women who made at least three Antenatal Clinic (ANC) visits. Hypertensive diseases (35.8%), hemorrhage (31.3%) and sepsis (7.5%) were the leading causes of death. Most (82%) deaths occurred in hospitals, with almost 75% after 24 hours of arrival. Data completeness and consistency were the major limitations in the analysis. There is a need to improve institutional maternal health care in the region, with interventions designed to address the causes of maternal deaths and to improve the survival of mothers and babies ultimately.

**Keywords:** maternal deaths, audit, mortality, descriptive, evidence-informed

### **1. Introduction**

Globally 830 women die daily from preventable causes related to pregnancy and childbirth. Nearly all of these deaths occur in developing countries. Despite considerable efforts, maternal mortality in sub-Saharan Africa remains unacceptably high and falls short of the target set in Millennium Development Goals (MDGs) [1–3].

According to the Ghana Demographic and Health Surveys, maternal mortality in the country declined from 634 per 1000 live births in 1990 to 319 in 2015 [4, 5]. This represented an average annual rate of decline of 2.7%. Ghana has achieved this level of reduction in maternal mortality through the deployment of interventions that have improved access to maternal health services, including emergency obstetric care and skilled attendants at delivery. The most notable of the interventions was introduction of the fee-free delivery policy (FEP) in the country in 2005. This is reported to have

contributed to increased access to skilled attendants at delivery and reduced maternal deaths. Overall, however, Ghana failed to achieve the MDG target of attaining a maternal mortality ratio of 185 deaths per 100,000 live births by 2015 [6, 7].

A problem that has persisted throughout the implementation of the fee-free delivery policy has been high number of avoidable maternal deaths within health facilities, that is, institutional deaths. Progress in reducing institutional maternal deaths has been slow, with reports of sustained high numbers of avoidable deaths in health facilities in the country [8–11]. A case in point is the increase in institutional maternal deaths in the Western Region of Ghana from 133 to 150 deaths per 100,000 live births between 2011 and 2014. Reducing institutional maternal deaths will be important if Ghana is to achieve the target set in the Sustainable Development Goals (SDGs) of 70 maternal deaths per 100,000 live births or less by 2030.

### **2. Maternal death audits**

An important intervention introduced in Ghana in the early 2000s is the conduct of audits on all maternal deaths in health facilities in the country [12]. Such audits must be conducted within four weeks of the death, and hard copies of reports must be shared with District and Regional Health Management Teams [10]. The audits aim to establish the circumstances of death and identify service delivery factors that must be improved to prevent future deaths. All deaths are simultaneous to be entered into the District Health Information Management System-2 (DHIMS-2), the backbone electronic data capture system of the Ghana Health Service (GHS).

While the information on all maternal health audits is expected to be shared at the regional and national levels, district and regional health management teams are also encouraged to periodically analyze the data that are made available to them to identify areas of generating generalizable knowledge and information to guide revisions to policies and guidelines. This paper is a descriptive analysis of data available in maternal death audit reports submitted to the Western Regional Health Directorate in Ghana in 2014.

### **3. Methods**

### **3.1 Study site**

The Western Region is one of the ten administrative regions of Ghana. The region covers a land area of 23,921 square kilometers and is the fourth-largest region in the country. It has a population of about two and half million people, 24% of whom are women of childbearing age. The entire western boundary of the region shares a border with La Cote D'Ivoire. The region experiences the highest level of rainfall in Ghana, and most parts of the region are forest that is traversed by very poor roads. The capital of the Western Region is Sekondi-Takoradi. The Effia Nkwanta Hospital in the Sekondi-Takoradi metropolis (STM) is the main referral health facility in the region. In addition, each of the 22 districts/municipalities in the region has a hospital or health center that offers comprehensive maternal health services. Consistent with the guidelines of the GHS, all maternal deaths in the region must be subjected to audit by facility management teams. Audits are required to cover the history of pregnancy,

### *An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana DOI: http://dx.doi.org/10.5772/intechopen.110632*

circumstances of death, and findings on the causes of death. The findings are to be reported on specially-designed maternal deaths audit forms. This information is expected to be entered into the District Health Information System Two (DHIMS-2) and transmitted to the regional and national levels. The DHIMS-2 is the electronic data capture system that serves as the backbone of institutional health service information management in Ghana. A copy of the report must also be sent to the regional level.

### **3.2 Data management, analysis, and limitations**

The findings of the audit are recorded on specially-designed audit forms. The information is copied and transmitted to the district and regional health administration for collation and analysis. In addition, periodically teams from the regional health administration travel to the various districts and sub-district health facilities to verify submitted audit reports and follow-up on actions taken on the basis of the findings.

For the purpose of the work presented here, data were extracted from all audit forms submitted to the Regional Health Administration in 2014. Where feasible, information was corroborated with data in the DHIMS-2. The data from the forms were entered into computer using a platform created in EPI-INFO version 7. Analysis was largely descriptive and included computation of mean age of death, maternal mortality ratio, and extent of data adequacy.

An important limitation to the extent of analysis is the extent of data completeness for different variables. The effect of this is the use of different denominators for some variables (reported in the "Results" section). The absence of comparator data from overall (all pregnant women) maternal services against which the findings could be compared and inferences drawn was yet another limitation.

### **4. Results**

A total of 93 maternal deaths occurred in 2014, and all the deaths were entered into the DHMIS-2 by December 2016. At least one maternal death was recorded in 15 out of the 22 districts in the region. However, at the Regional Health Directorate, audit reports were available for 67 (72%) of deaths, and all 67 were from 9 out of the 22 districts/municipalities (**Table 1**). The number of deaths recorded in the DHIMS and the number of deaths reported to have been audited as per the DHIMS were consistent with the number of actual reports available at the Regional Health Directorate in only 9 out of the 22 (41%) districts/municipalities. Among these nine district, seven had recorded no deaths (**Figure 1**).

The total number of audited maternal deaths for STM (60%) represents the highest number of deaths recorded in a district. It was followed by Ellembelle district, which also recorded 13 deaths in the DHIMS (DHIMS-2, 2017b) but reported 10 (15%) cases of audited maternal deaths. The highest maternal mortality ratios were recorded in the regional hospital in Sekondi-Takoradi (355/100,000 live births) and the districts hospitals Ellembelle (231) and Jomoro (146) (**Table 1**). Per population of women of childbearing age, however, the Ellembelle district recorded the highest of 45 deaths per 100,000 women, with the STM recording 25 deaths per 100,000 women.

The median and mean ages of women were 27 (range of 13–51 yrs) and 28 yrs., respectively. The age distribution was as follows: 10/67, 5% (less than 19 yrs); 45/67, 67% (20–35 yrs); and 12/67, 18% (above 36 years). In all the districts, deaths occurred among women who were regular Antenatal Clinic (ANC) attendants. Seven (18%)


*Maternal deaths and related factors in the Western region of Ghana in 2014*♠*.*

*An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana DOI: http://dx.doi.org/10.5772/intechopen.110632*

women in the cases in the Sekondi-Takoradi metropolis were non-ANC attendants. Overall, 80% of cases involved women who made at least three ANC visits.

The leading causes of death were hypertensive diseases (24 out of 67 cases, 36%), hemorrhage (31%), and sepsis (8%) (**Figure 2**). Nearly all (96%) of the cases of

**Figure 2.** *Causes of maternal deaths in the Western region of Ghana in 2014.*


*Rural Health – Investment, Research and Implications*

**Table 2.**

*Causes of maternal deaths per district in 2014 in the Western region of Ghana.*

*An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana DOI: http://dx.doi.org/10.5772/intechopen.110632*

### **Figure 3.**

*Recommended actions following audit of maternal deaths in the Western region of Ghana – 2014.*

hypertension-related deaths occurred in the Sekondi-Takoradi (18 cases, i.e., 78% of cases) and Ellembelle (4 cases, i.e., 17% of cases). In contrast, at least one hemorrhage-related death occurred in each district and municipality, with STM having the highest proportion of 43%, followed by 24% in Ellembelle (**Table 2**). All the cases of sepsis-related deaths occurred in the Sekondi-Takoradi municipality and Wiawso district. In 61% (34 out of 55) of cases, death occurred during the postpartum period. In 36 (54%) cases, deliveries resulted in live births.

The majority 82%, that is, 48 out of 59 cases of deaths, occurred in hospitals, with about a quarter (25%) occurring within 24 hours of arrival. Nearly an equal number of deaths during the day (29 out of 56 cases) occurred at night (27). The autopsy was conducted in only five (8%) cases in three districts or municipalities. The major interventions recommended by the audits were more timely intervention (38% of recommendations), improved staff competency through in-service training (25%), and improved logistics (11%) (**Figure 3**).

### **5. Discussion**

The paper is a descriptive analysis of the causes and factors of maternal deaths in the Western Region of Ghana in 2014. A major limitation of this effort has been the quality of data available at the regional level. Although maternal death audits are mandatory and audits reports are required to be submitted to the region, it was in only 67 out of the 93 (73.1%) cases that such audit reports were submitted more than a year after the deaths occurred. Nationwide, out of 941 maternal deaths in 2014, only 81% had been audited by the end of the year (DHIMS-2, 2016).

It is apparent that the disparity between data on maternal deaths captured in the DHIMS-2 and physical records of audits at the Regional Health Directorate was quite considerable and is likely to be a national problem. This could be attributed to the fact that most health information officers have access to the online DHIMS-2 platform

(DHIMS-2, 2017c) and tend to make that data entry more prompt at the district level. The fact is the lack of completeness in the details required for the audit review process at the regional level. The lack of records on maternal health audits and hence lack of completeness in maternal health records was similarly reported in a recent review of maternal deaths at the regional hospital in the Eastern Region in 2012. In that review, it was found that audit reports were not available for 24% of cases [13].

Another level of data inadequacy that undermined the validity of the analysis is the lack of completeness in the data presented in various audit reports. Many fields on the audit forms were not filled, and the number of events did not add up. It was evident that audit teams or officers who completed the audit forms placed emphasis on filling out the section on the cause of death (99% completeness) and were less concerned when completing portions of the form that describe the circumstances of death. Data incompleteness ranged from 64 to 88% for parameters such as parity, time, place, and period of death. Given the basic nature of such information, the lack of completeness in these instances is unlikely due to a lack of familiarity or staff's lack of knowledge on how to complete these forms. It is more likely due to negligence buoyed by a lack of oversight and review of forms prior to submission to the regional level. In a study done in the era when mandatory audits had not been institutionalized, maternal health data at a district hospital in rural northern Ghana were similarly found to be grossly incomplete, inaccurate, and inconsistent. The era of audit and the introduction of an electronic data platform does not appear to have had much effect in these regards.

The current procedure where maternal health audits are conducted by the health teams at the facility where the death occurred needs to be reviewed. The approach appears overly self-serving and unlikely to engender the desired level of scrutiny and accountability. Consideration should be given to establishing a system of audits that routinely involves external and independent experts [8, 10]. It is critical that every maternal death is properly accounted for as a matter of public health records and as part of quality assurance in health institutions in the country. The lack of completeness of data on maternal death events is a serious issue that the authorities in the Ghana Health Service need to address urgently. A regime of responsibility and sanctions needs to be instituted.

This study found that the three main causes of death accounted for about 75% of all deaths. This pattern is consistent with findings in other studies and suggests that a precipitous drop in maternal deaths could be achieved if interventions could be targeted at these causes. Hypertensive diseases in pregnancy are overtaking hemorrhage as the leading cause of maternal mortality in Ghana [14–16]. Substantial reduction in these maternal deaths could be made in Ghana through widespread hypertension and proteinuria screening and early delivery of women with severe diseases [17]. Hemorrhage and sepsis are amenable to improved blood transfusion services and early and appropriate use of antibiotics. The positive impact of these has been demonstrated in a quality improvement program piloted at the Greater Accra Regional Hospital [18].

For many years, programs to reduce Ghana's maternal mortality ratio have predominantly focused on interventions at the community level. It has often been implied that when women attend ANC, the risk factors for maternal deaths will be identified, and the instituted interventions will lead to safe delivery. In this study, however, we find that 80% of deaths occurred among women who attended ANC at least thrice during pregnancy. We also found that most deaths occurred among women who had been at the facility beyond 24 hours. These findings support those

### *An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana DOI: http://dx.doi.org/10.5772/intechopen.110632*

made in a 2009 review of maternal deaths in the Upper West Region of Ghana [10] and in other countries with a high burden of maternal deaths [19, 20]. They put to question the long-held preposition (often advanced by health workers) that most maternal deaths result from women reporting late at the health facility [10, 13]. The quality of institutional maternal care should not be taken to be assured, and unless the issue of quality of institutional maternal care is rigorously addressed by the health service, substantial gains made in increasing antenatal attendance and skilled attendance will be undermined.

### **6. Conclusion**

Hypertensive diseases in pregnancy, hemorrhage, and sepsis account for about 75% of institutional maternal deaths in the Western Region of Ghana. With most of the deaths occurring in women who were regular antenatal attendants and in women who were in health facilities for more than 24 hours, it is evident that most could have been prevented with appropriate and timely interventions at the various health facilities. Therefore, institutional maternal care strengthening should be a major priority in reducing maternal mortality in the Western Region of Ghana.

### **Acknowledgements**

The authors dedicate this paper to the memory of all the women who died through childbirth in the Western Region in 2014 and to all the health workers who, under trying conditions, persevere to save maternal lives. The authors thank Mr. Lukeman Bamengzut, Ms. Georgina Ayepah, Mr. Pter Ntibeh, and Ms. Grace Afranie Toku for completing the data entries. We also thank the Public Health Unit and the Regional Health Directorate, who supported with access to the data.

### **Conflict of interest**

The authors have no conflicts of interest.

### **Contribution of authors**

Marion Okoh-Owusu MBChB MPH: Contribution: principal investigator, team leader, data collection, data entry and analyses, writing of manuscript.

George Kojo Owusu, MBCHB: Contribution: co-investigator, data collection, writing of manuscript, review of manuscript.

Celia Taylor BSoc Sc, PHD: Contribution: writing and critical review of manuscript.

Frank Baiden MBChB PhD: Contribution: project supervisor, data analyses, writing and critical review of manuscript.

### **Author details**

Marion Okoh-Owusu1 \*, George Kojo Owusu2 , Celia Brown3 and Frank Baiden4

1 Ellembelle District Directorate of Health, Ghana Health Service, Western Region, Ghana

2 Effia Nkwanta Regional Hospital, Sekondi, Western Region, Ghana

3 The University of Warwick, Coventry, United Kingdom

4 Ensign College of Public Health, Eastern Region, Ghana

\*Address all correspondence to: drokohowusu@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*An Analysis of Institutional Maternal Death Audit Reports in the Western Region of Ghana DOI: http://dx.doi.org/10.5772/intechopen.110632*

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[2] Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: A systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;**387**(10017):462-474

[3] Lieberman A. Challenges for maternal health efforts. Lancet. 2016;**388**(10050):1146-1147

[4] Amoakoh HB, Klipstein-Grobusch K, Amoakoh-Coleman M, Agyepong IA, Kayode GA, Sarpong C, et al. The effect of a clinical decision-making mHealth support system on maternal and neonatal mortality and morbidity in Ghana: Study protocol for a cluster randomized controlled trial. Trials. 2017;**18**(1):157

[5] Amu H, Nyarko SH. Preparedness of health care professionals in preventing maternal mortality at a public health facility in Ghana: A qualitative study. BMC Health Services Research. 2016;**16**:252

[6] Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Millennium development goal 5: Progress and challenges in reducing maternal deaths in Ghana. BMC Pregnancy and Childbirth. 2016;**16**:51

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Section 4

## Essential Social Services as Health Enablers

### **Chapter 11**

Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months in Rural Areas of South Kivu, Case of the Health Zone of Minova, Eastern DRC

*Emery Likaka, Espérant Kiangana and Gaylord Ngaboyeka*

### **Abstract**

Already knowing enough about the determinants of malnutrition, this study set itself the objective of verifying the influence of access to arable land on the nutritional status of children aged 6 to 59 months in a rural Health Zone of the DRC in South Kivu (Minova) with very high prevalence of malnutrition (62% CM and 7.1% AM). A crosssectional quantitative study conducted on a representative sample of 424 children aged 6 to 59 months selected using the Lynch formula by probabilistic stratum sampling; using a structured questionnaire. Malnutrition (acute and chronic) assessed on the basis of WHO growth standards served as the dependent variable and access to arable land considered according to the FAO definition was the main independent variable. Chi-square or Ficher tests were used to compare proportions and logistic regressions were used to determine the factors associated with malnutrition; the significance threshold set at 5%. The frequency of less than 3 meals per day and the low socio-economic level of households were associated with chronic malnutrition (pvalue 0.046 and 0.007). Exclusive breastfeeding and unimproved source of drinking water were associated with acute malnutrition. Finally, no statistically significant association was found between access to arable land and the nutritional status of children aged 6 to 59 months. How land production and household incomes are allocated for other needs would also be part of the problem.

**Keywords:** arable land, chronic malnutrition, acute malnutrition, Minova, Sud-Kivu, DR Congo

### **1. Introduction**

Globally, nearly two billion people, or about 30% of the population, suffer from invisible hunger, that is, deficiencies in micronutrients and other macronutrients [1]. Efforts to achieve food security for all in order to combat malnutrition are hampered by emerging issues that threaten the food system [2]. Undernutrition is the single most important risk factor for mortality and morbidity in developing countries [3].

One in three children (200 million worldwide) does not realize their full physical, cognitive, psychological, and/or socio-emotional potential due to poverty, poor nutrition, poor health, insufficient care, and stimulation associated with other risk factors for early childhood development [4–6]. Scientific studies carried out on maternal and child health have revealed that 45% of cases of death of children under five are directly or indirectly due to malnutrition [4]; The cost of prematurely developed diseases and deaths directly caused by hunger in the world is estimated at 30 billion per year according to the FAO.

In Africa, there was a time when land seemed almost inexhaustible, but population growth and market development are creating increased competition for land resources, especially near villages and towns and in rural areas. High-value productive areas. According to the FAO, about 65 percent of agricultural land in Africa is degraded, costing the continent nearly \$68 million each year and affecting 180 million people, mainly poor rural populations already struggling to meet their needs. With demographic pressure on natural resources such as access to land and water, to which are added the indirect effects of the Covid-19 pandemic and climate change, deforestation, recurrent armed conflicts and the rate of high unemployment favoring the rural exodus; the number of people suffering from malnutrition in Africa and the DRC is likely to double or even triple over the next few years. A profound change in the global food and agriculture system is, therefore, necessary to hope to feed millions of people who suffer from malnutrition hunger today and the 2 billion additional people that the world will have by 2050 [7], Asia and Africa are the most affected.

In the Democratic Republic of Congo, evidence from nutritional surveys of major DHS and MICS studies report alarming prevalence of deficiency malnutrition in chronic and acute forms, while paradoxically the country has about 80 million hectares of arable land, including Barely 10% developed and occupies the second place in the world in terms of cultivable arable land after Brazil and an unprecedented hydrographic network [8].

Despite some progress recorded in the prevention and fight against malnutrition, the DRC is to date deviating in order of severity, the first country in the world with such a high number of people affected by food insecurity.

The incidence of poverty for the whole country is very high (71.34%) if we compare it to that of the other countries of Central Africa [9]. Deficiency malnutrition in all its forms remains a worrying public health problem [10] with 43% chronic malnutrition and the prevalence of GAM ranging from 6.5 to 15% in the provinces and an average of 2% acute malnutrition strict; ranking the DRC as 1 of 10 countries that account for 60% of the global burden of wasting in children under 5.

In South Kivu, about 9% of children aged 6–59 months only have access to a minimum acceptable diet and 14.9% for the Minova Health Zone [11] and the 2018 MICS survey revealed 48% chronic malnutrition (about one in two children), a proportion far above the national average (43%).

Still in South Kivu, in the territory of Kalehe, the prevalence of stunting in children under five in the ZS of Minova was estimated at 62.1% in 2018 against 51% in 2020 according to the results of the surveys conducted by the NGO Graines and the National Nutrition Program as well as global acute malnutrition at 7%.

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

Recurrent armed conflicts force people to move outside their natural living environment (rural exodus) in search of peace and employment to urban centers that are poorly prepared for rapid urbanization and demographic explosion.

It should also be noted that the large land concessions in South Kivu and Minova in the territory of Kalehe are strongly solicited by personalities and businessmen who want to invest in land. This seems to constitute a kind of heaviness for the rural population who rely only on agricultural life for their survival, yet without financial means to compete with purchases or limit sales.

A study carried out in 2008 by the INGO ACF in the territory of Kalehe revealed that access to land for women and other inhabitants of Minova is very limited and constitutes one of the major sources of conflict between herders and farmers. According to this study, the total cultivated areas vary between 0.02 and 12.7 Ha, with an average of 1.5 Ha for the ZS of Kalehe and 1.7 Ha for the ZS of Minova per agricultural practitioner [12].

The survey conducted by the National Nutrition Program in South Kivu with the support of UNICEF, WFP and FAO found that the average cultivated area per inhabitant in the Minova Health Zone varies between 13.1 and 30 ares.

Having found no studies focused on in-depth research into the causes of the persistence of malnutrition in this area despite the joint interventions carried out by Humanitarian Organizations; we estimated that there would be a problem of household access to arable land, which would influence these high prevalence of malnutrition alongside other underlying factors. Thus, this justified our study to explore the association between access to land and the nutritional status of young children in rural areas, given that for the low-income peasant population; it has been affirmed by certain literature that agriculture represents an important part of the food ration of families [13, 14] while other authors think that the simple fact of having access to arable land does not guarantee advances a good nutritional status.

In view of the above, our study mainly addressed the following research question: "Is there an association between having or not having access to arable land and the nutritional status of children aged 6–59 months in rural areas, the case of the Minova Health Zone given the high prevalence of stunting and acute malnutrition?" If not, what are the other factors associated with this malnutrition in the Zone?

Generally, this study aims to verify the influence of rural households' access to arable land on the nutritional status of children aged 6–59 months in order to better guide control strategies and actions to improve their health.

Specifically, this involves identifying the proportion of households without access to arable land in this health zone; assess/determine the level of exposure of households without arable land to acute and chronic malnutrition in children under 6–59 months; determine the prevalence of chronic and acute malnutrition among the target population of Minova Health Zone and other associated factors.

Three hypotheses have thus been formulated to verify these objectives: the proportion of households in the Minova Zone that do not have access to arable land will be close to 50%; the prevalence of chronic and acute malnutrition will be significantly higher in households without access to land compared to those with access; then the large size of households and closely spaced births will be one of the main factors associated with acute and chronic malnutrition in children aged 6–59 months in this area considering the low purchasing power of the population.

### **2. Methodological framework**

### **2.1 Materials and method**

This cross-sectional quantitative study was conducted in 11 Health Areas randomly selected out of the 21 in the Minova Health Zone (Bobandana, Bulenga, Cheya Chebumba, Kalungu, Karango, Kishinji, Minova, Muchibwe, Numbi and Ruhunde) in the province of Sud Kivu (Eastern DRC) during the period from June to November 2021.

The study population is made up of children aged 6–59 months residing in the households of the chosen Health Areas; the size of our sample was 375 children but we added 15% or 426 children in total surveyed to prevent the risk of non-response and possible incomplete data when cleaning the database.

Inclusion criteria: to be a resident child aged 6–59 months in the survey household whose father or mother has given consent for anthropometric measurements and is willing to answer the questionnaire. The mother of each selected child was also concerned by the measurement of the Brachial Circumference.

Was excluded from the study, the child from 6 to 59 months concerned whose parent did not give the consent for his participation or residing less than 6 months in the household.

### **2.2 Sample and sampling technique**

Systematic and proportional stratified sampling was used at several stages in strict compliance with statistical standards (Health area at 1st stage, Village at 2nd stage).

In the village, households with children aged 6–59 months were identified with the help of parcel surveys from Community Relays then the choice of children was made by the technique of systematic random drawing with reference to the table of proportion of Health Areas.

The sampling interval was equal to the number of children aged 6–59 months in the village divided by the number of children to be surveyed in this village.

The sample size was calculated with the following Lynch formula:

$$\begin{aligned} n &= \frac{NZa^2 \bullet P \bullet (1 - P)}{N \bullet a^2 + Za^2(1 - P)} \\ &= \frac{211163 \bullet 1.96^2 \bullet 0.43(1 - 0.62)}{211163 \bullet 0.05^2 + 1.96^2(1 - 0.62)} \\ &= \frac{211163 \bullet 3.8416 \bullet 0.43 \bullet 0.38}{211163 \bullet 0.0025 + 3.8416 \bullet 0.38} \\ n &= 375 \\ n &= 375 \text{Respondents} \end{aligned} \tag{1}$$

where *N* = total population of the 11 health care; *n* = sample; Z alpha = constant = 1.96 (for 95% CI); a = the margin of error; P = the prevalence of malnutrition in the health zone; P = 62% of Chronic Malnutrition [15].

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

### **2.3 Malnutrition in its chronic and acute forms was the dependent variable of our study**

After exclusion of outliers, the two forms of malnutrition were defined according to WHO growth standards.

Regarding the Independent Variables, we considered: Access to arable land:

Defined according to the FAO as the set of processes by which citizens, individually or collectively, acquire the rights and opportunities allowing them to occupy and use land (for production and for economic and social purposes), whether on a temporary or permanent basis [16, 17].

These processes include participation in formal and informal markets, access to land through family or social networks, including transmission of land rights by in heritance and within families, and allocation of land by the state and other authorities, with control over them.

According to the Provincial Inspection of Agriculture of South Kivu (direction of production and protection of plants), an agricultural household must have on average an area of 50 ares (1/2 hectare) for the cultivation of cassava and at least 30 ares for other speculations such as (legumes, cereals, vegetables, potatoes) in order to consider that he has access to arable land to meet his most basic needs.

Conveniently, to express the area of arable land owned by a household during this study; the head of the household of the child surveyed presented the land purchase document, or he expressed it according to locally recognized conventional measures (kamba moya = one hectare of land, nusu ya kamba =1/2 hectare; kipandé = between 30 and less than 50 ares).

The other independent variables were evaluated taking into account their standard values (birth weight in Kg, child's age in months, male or female sex, arm circumference in millimeters, exclusive Breastfeeding in 6 months, the daily frequency of meals greater than or equal to 3, their composition of at least four essential food groups, the level of education attained by the head of the household, and his profession, the size of the household, the marital status of the parent of the child, religion, birth interval, child vaccination status, source of drinking water, socio-economic status or constituted wealth index.

### **2.4 Data collection**

The subjects of study were randomly identified by a systematic technique of drawing from households after having constituted a sampling base as indicated above. The biological mothers (or father of the child) served directly as respondents to the questions asked.

To identify the survey households, the interviewers used the home visit notebooks and local count notebooks from the Village Community Relays. Data was collected electronically on Android tablets using Open Data Kit (ODK) and stored remotely on the server. This collection in the field was facilitated by qualified staff, with medical and non-medical profiles (two nutritionists, a public health graduate, a primary school teacher and two agricultural engineers) making up three paired teams; all supervised by the Principal Investigator. A refresher course preceded the collection to strengthen the investigators' understanding of the mastery of the tools and the technique, followed by a pre-survey.

High-precision anthropometric equipment provided by UNICEF, including SECA electronic scales, Shakir measuring rods and strips, was used to take various measurements (weight, height, MUAC) in addition to the search for nutritional edema.

In terms of ethical consideration, the request for consent was read and requested from each respondent before completing the questionnaire and taking measurements. No act contrary to the ethics and methodology of the research was practiced. Parents of children suspected of malnutrition were advised to take them to the Health Centers of their choice for confirmation and appropriate action.

### **2.5 Data analysis**

The data collected from a structured and digitized questionnaire with the Kobo toolbox platform were analyzed with Stata version 14.

Descriptive statistics (medians and interquartile ranges (IQR) for continuous variables, and frequencies with percentages for variables categorical) were used to describe the study sample according to the shape of the distribution and then the chisquare test was used for comparison.

To determine the associated factors, we constructed logistic regression models (univaried and multi-varied) and to introduce the variables into the multi-varied analysis, the step-by-step selection method with a forced entry of plausible factors was used.

The measures of association were reported by the unadjusted odds ratios (ORna) and the adjusted odds ratios (ORa) with their 95% confidence intervals, ie the significance level set at 5%.

### **3. Results of the study**

The majority of people in the Minova Health Zone (86.60%) is self-employed and live in self-employed activities (agriculture, livestock, petty trade, etc.). 39.10% of households include more than 7 people and the majority of houses are built of boards (44.12%). Mostly monogamous (74.19%), almost a third of the population has no level of education (34.82%) and the Protestant religion is dominant, followed by Catholics.

The median age of our respondents was 26 years and for children under five, this was 24 months, dominated by the 24–59 month age group (**Table 1**).

The results of the analyses show in the histogram in **Figure 1** that 52.6% of households in Minova do not have access to arable land. There was also a high prevalence of acute malnutrition in households without access to land (9.1%) compared to those with access (5.1%) but this difference was not statistically significant.

Regarding the mode of acquisition of arable land by households, sharecropping and inheritance are the most dominant means of acquisition found in Minova with 39.49 and 26.15%, respectively. With regard to the crops cultivated, 44.30% of farmers practice mono-cropping. With regard to provisions, only 8% of households have food stocks in their homes. 29% practice livestock farming, dominated by backyard animals and 84.63% of households spend an average of between two and twenty thousand Congolese francs, or \$1 to \$10 per week, to supplement market needs, which indicates a kind of precariousness in living conditions (**Table 2**).

**Table 3** shows that the prevalence of global acute malnutrition in the Minova Health Zone is 7.92% based on the weight/height ratio associated with other measures taken among children aged 6-59 months, and that chronic malnutrition (stunting) affects at least one out of every two children in the area, i.e. 50.38%. In addition,

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*



### **Table 1.**

*Sociodemographic characteristics of households surveyed in the Minova health zone.*

### **Figure 1.**

*Distribution of malnourished children according to access to land in the Zone (*p *value GAM = 0.269 and* p *value CM = 0.337).*


*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*


**Table 2.**

*Agricultural practices of surveyed households in the Minova Health Zone.*

7.91% of children were born with a low birth weight according to the WHO reference and more than half of children (65.48%) were exclusively breastfed for six months. Only 5.45% of households have access to a diversified diet (4-star foods) that can meet their essential nutrient intake needs. A significant proportion of households (40.63%) consume their livestock products occasionally.

The results of the univariate analysis presented in the following **Table 4** show that the factors associated with acute malnutrition in children aged 6-59 months are low birth weight, household socioeconomic status, daily meal frequency, exclusive breastfeeding, and immunization status.


*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*


### **Table 3.**

*Nutritional status of children under 5 years of age in households surveyed in the Minova Health Zone.*

After adjustment by multivariate analysis (**Table 5**), only the variables exclusive breastfeeding, low birth weight and source of drinking water remained associated with acute malnutrition.

With respect to chronic malnutrition, the results of the bivariate analysis (**Table 6(a)** and (**b**)) reveal that meal frequency and household socioeconomic status are significantly associated with chronic malnutrition in children aged 6–59 months in the study area (p < 0.05 with 95% CI).



**Table 4.**

*Factors associated with acute malnutrition (AM) in children 6–59 months of age in the Minova health zone (simple logistic regression).*


**Table 5.**

*Multivariate analysis: factors associated with acute malnutrition (am) in children 6–59 months of age in the Minova health zone.*

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

In **Table 7**, it is found that even after adjustment for all factors by multiple regressions, daily meal frequency and low household socioeconomic status remained statistically associated with chronic malnutrition as found in the bivariate analyses.

Children from households that consumed less than three meals per day were twice as likely to be chronically malnourished compared to other children and those from households with low socioeconomic status were 3.97 times more likely to be



### **Table 6.**

*Factors associated with chronic malnutrition in children aged 6–59 months in the Minova HZ: simple logistic regression.*


### **Table 7.**

*Multivariate analysis: Factors associated with chronic malnutrition in children 6–59 months of age in the Minova health zone.*

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

chronically malnourished compared to children from households with high socioeconomic status.

### **4. Discussions from results**

### **4.1 Access to arable land**

This study shows that more than half of households, or 54%, live without access to arable land, while agriculture in rural areas is an important source of income for the population, as stated by Coulibaly B. and Berkhout ED. in their studies carried out in Mali and in certain countries of Sub-Saharan Africa [18, 19].

The international NGO ACF in its study conducted in the Minova Health Zone in 2008 confirms that of all the main constraints linked to agriculture in this zone; limited access to arable land alone occupies 22% and the practice of sharecropping comes first as a mode of accession, followed by inheritance. According to studies by the National Nutrition Program of South Kivu and the UNICEF-WFP-FAO agencies, at least 45% of the households surveyed have no means of accessing land and that the purchase of food constitutes up to 75% of object of family expenses. This reality, which is not, however, unique to Minova alone, remains a major concern for the population, especially when it is necessary to take into account the speed of population growth experienced by the country.

### **4.2 Malnutrition and access to land**

With a prevalence of chronic malnutrition of 50.38% in Minova, that is, one in two children, against GAM at 7.7%; malnutrition remains one of the worrying factors in the health of children in terms of the risk of morbidity and mortality. These results are not far from those found in the MISC 2018 surveys (48% chronic malnutrition for South Kivu against 43% for the whole of the DRC), EDS 2014 (MC 53% and MAG 6.5%) and the survey the most recent (2021) from Pronanut the three UN Agencies which found that the prevalence of GAM in Minova in children under five increased from 7.5% in 2018 to 5.8% in 2021, 95% CI (4.1–8.1) and that of MC decreased from 67.6 in 2018 to 51.0 (30.1–34.4) as a result of ongoing joint response interventions in the Area.

Several factors discussed below justify this high prevalence and further require a holistic response to continue to reverse the trends.. Even though some of the articles read claim that food security and hunger presented strong evidence of qualitative and quantitative links between land tenure, household food security and nutritional status [11, 13, 20] and that the reduction or a loss of access to land in an agrarian society leads directly to a reduction in income; access to food and impact on the nutritional status of populations [11, 13, 18, 20–22]; we found that there is no statistically significant association between having access to arable land and improved nutritional status.

Our results also diverge from the findings of the study carried out by Eide WB and Nahalomo on the situation of adequate food and the nutritional status of people evicted from the land in 2018 in Uganda, which found that out of 187 children followed 1 child in 2 of mothers evicted from arable land had developed wasting. The results of the similar study conducted by Tefft and Kelly had however also found the results close to those of Eide and Nahalomo.

By comparing the nutritional status of children in the rice-growing areas with that of children in the cotton-growing areas Tefft and Kelly 2002 [23] in Mali, Tefft and Kelly found a lower prevalence of wasting and stunting (*p*-value less than 0.05) among children from households in the irrigated rice-growing areas of Macina and Niono (19–25%) compared to children in the cotton-growing area (35–48%), which signified a positive influence of the access to arable land.

Andrew D Jones in the study on agricultural biodiversity, dietary diversity and nutritional status in low and middle income countries concurred with the findings that, agricultural biodiversity (as a result of access to arable land) was consistently positively associated with improved height-for-age (HAZ) Z-score of preschool children. He says, "A one-unit increase in the number of cultured species was associated with a 0.03 and 0.05 increase in HAZ, respectively, in children aged 24–59 months. He also found that land evictions become a public health problem because limited or nonexistent land ownership is linked to about 80% of cases of hunger and under nutrition among people living in rural areas." The same is true for Azka Rehman et al. in Pakistan who in turn stated that women's land ownership has a significant positive effect on children's height/age z-score (HAZ score): if a woman owns land, the heightage score of her child may be 0.94 points higher than that of landless women [24].

Despite this continuation of previous results, our study found rather high proportions of malnutrition among children from households without access to arable land (52.6% of MC and 9.1% of MAG) compared to those with access but this without any association statistically significant.

For us, this difference due to an effect of chance in the two categories of households can be explained on the one hand by the way in which the production of the land and the incomes of the households are affected there for other needs and other apart from the heterogeneity of predictors of malnutrition such as socioeconomic status, breastfeeding and infant feeding practices, which have shown statistically significant as sociations in other studies.

Gamuchirai Chakona and Charlie M. Shackleton also confirm this thinking when they state that intra-household food allocation is one of the important factors affecting the nutritional status of children in South Africa.

### **4.3 Factors associated with malnutrition**

Low birth weight (LBW), non-practice of exclusive breastfeeding and water consumption from undeveloped sources were significantly associated with the occurrence of acute malnutrition in children aged 6–59 months in the ZS of Minova even after adjusting for any confounding factors by multiple logistic regression.

This observation has already been made by several other researchers such as Mbalenhle Mkhize and M. Sibanda in South Africa in their study examining the factors associated with the nutritional status of children under five who found that low Birth weight contributed 25.92% to the occurrence of both acute and chronic malnutrition in children and similar observations were found in numerous articles used [3, 5, 6, 25, 26]. On the other hand, F. Diawara in Mali found in his study conducted in 2006 that only the age of the child, the parity of the mother and the family meal were associated with wasting in children aged 6–59 months with a value *p* < 0.05.

For our part, we are of the opinion that the low birth weight being a reflection of intrauterine growth retardation due to the prolonged under nutrition of the pregnant woman, the child born of this household is not spared to develop sooner or later, other *Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

forms of deficiency malnutrition such as emaciation, especially if other factors coexist such as diarrhea often caused in children by the ingestion of unclean water and early feeding.

Regarding the benefit of exclusive breastfeeding, several studies conducted by Experts have argued that early breastfeeding of the child at the hour following birth, exclusive breastfeeding before the first 6 months after birth and the continuity of breast-feeding until more or less 24 months constitutes a powerful line of defense against any form of infant malnutrition, including cachexia and obesity in adulthood.

In our study, we found in the bivariate analyzes that the further a child moved away from the age of breastfeeding, the more he had the chance of being affected by chronic malnutrition (less than 12 months: 20.59%, between 12 and 24 months: 44.30% and over 24 months: 57.50% with *p*-value <0.001) which further supports the thesis that breast milk effectively protects young children against different forms of malnutrition [27–31].

In relation to chronic malnutrition, the results analyzed after adjustment show that in households where children consume less than 3 meals a day, they were 2.46 times more likely to be affected by chronic malnutrition compared to those who have a frequency superior.

This result meets the opinion of several Experts in Nutrition (chrono nutrition) who affirm that the more a diet is adequate (quality, quantity, frequency); the more the child is protected from the risk of under nutrition although this is divergent from the results found by Stephen Kofi et al. in Ghana [19, 32].

This we, this is true by the fact that the more the child consumes meals during the day, the more it increases the chance to vary the foods that can bring together the different nutrients that the body needs for its growth. Our study also revealed that in households with low socio-economic status, children were 3.97 times more likely to have chronic malnutrition before age five ORa 3.97, 95% CI (1.12–12.34), *p* value = 0.007.

Our results thus join those found by D.Karageorgou who cites among the main factors of change in chronic malnutrition, the wealth index with 4% [33].

Célestin Bucekuderhwa and S. Mapatano also demonstrate in their study on understanding the dynamics of food vulnerability in South Kivu that the capacity to take charge is the ability to mobilize human, economic and institutional resources for the benefit of the household; and this ability therefore depends on education, knowledge, culture, time and control over resources, including socio-economic status or income [22].

### **5. Conclusions**

Considering the very high prevalence of multiple forms of deficiency malnutrition in the Provinces of the DRC despite its potential, this study examined the influence of access to arable land on the nutritional status of a sample of children. From 6 to 59 months in the HZ of Minova (South Kivu) with specific reference to cases of chronic malnutrition and acute malnutrition. Malnutrition (chronic and acute) which constituted our outcome was discussed in relation to access to arable land as the main explanatory variable associated with other factors sensitive to nutrition including breastfeeding and feeding practices. Infant and young child feeding, mother's age, household socio-economic status, level of education of mothers and household heads, water-hygiene-sanitation, vaccination, agricultural practices.

After analyzing the data, it was found that:


Compared to research perspectives and recommendations, we did not carry out the study on soil fertility in our study to assess the influence that this could have on production per sown area and the content of nutrients in food; this could be an important confounding factor.

We thus suggest to future researchers or organizations to be able to carry out studies on the physicochemical and biological analysis of the soil of the ZS of Minova in order to determine its level of fertility and better orientate on the consequent actions (types of appropriate speculations, bio fortification possibly, etc.).

Thus, we recommend:

	- To structure and ensure the strict application of the structure of food prices throughout the national territory in order to guarantee the minimum of food security to households and contribute to the fight against undernutrition considering that the latter do not have sufficient access to arable land and obtain their supplies from markets.
	- To put in place adequate strategies to improve farmers' access to arable land and their protection against land misuse (Ministries of Agriculture and that of Land Affairs).
	- Initiate a general grassroots development program alongside the determinants of health already known (improvement of drinking water supply, access to quality health care for all, job creation for young people and facilitation of access). More investment should be made in improving the food system to achieve better nutrition.
	- "No panis nec pax", no peace, no bread too: having to ensure the safety of people and their property throughout the national territory is one of the prerequisites for the nutrition and health of the population.

*Access of Households to Arable Land and Nutritional Status of Children Aged 6–59 Months… DOI: http://dx.doi.org/10.5772/intechopen.110188*

• To the community of the Health Zone of Minova:

To understand that despite the efforts made to redress chronic and acute malnutrition, much remains to be done. With or without access to land, we can fight malnutrition in our households.

The fight is essentially based on prevention. Our life practices and the way our household incomes are distributed (their use) greatly depend on it. Let us learn to consume in quantity and quality what we produce locally.

### **Author details**

Emery Likaka<sup>1</sup> \*, Espérant Kiangana<sup>2</sup> and Gaylord Ngaboyeka<sup>2</sup>

1 UNIKIS-ERSP-UCB, Bukavu, Democratic Republic of the Congo

2 ERSP-UCB, Bukavu, Democratic Republic of the Congo

\*Address all correspondence to: lokitaemery@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 12**

## Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults for Co-Residential Family Care Arrangements

*Kidus Yenealem Mefteh*

### **Abstract**

Using a phenomenological study design, this study attempts to investigate the factors that lead rural older adults to seek out co-residential family care arrangements. Twelve older adults from rural areas were interviewed in-depth; the data were then inductively categorized and organized into themes. The circumstances that lead older adults to give up their independent life and move in with their offspring in the research area include physical limits and health issues, separation and divorce, the loss of a spouse, economic troubles, neglect, inheritance disputes, and inaccessible places. The result recommends decision-makers and other interested parties that measures must be focused on preserving a favorable living environment for elderly people living in rural areas and addressing issues that are crucial in co-residential family care settings developing senior/adult care facilities and expanding access to health care.

**Keywords:** co-residential care, rural ethiopia, older adults, qualitative study, family caregivers

### **1. Introduction**

An increasing number of older adults are living and receiving support and care from diverse sources. Older adults can organize their living arrangements in official institutions, with other people, or by themselves, according to Li [1]. However, compared to those living alone or in institutions, the majority of older adults live with their family members [1–4]. In Ethiopia, there are 3,568,810 million persons over the age of 60 or 4.8% of the country's total population [5]. In 2022, the number is anticipated to reach 5,325,652 million. Among them, 78% of them would reside in rural areas, while 22% will do so in cities (CSA as given in Ministry of Labor and Social Affairs, [6]). In Ethiopia, the majority of senior citizens reside in their own or family houses and are supported by their families [7–10]. In rural Ethiopia, older people

primarily get care and support from their extended family network, which cannot be properly replaced by any other body [9].

The traditional system of care through familial ties is essential for the well-being of older adults in underdeveloped nations like Ethiopia where the system of public transfer for supporting older adults is inadequately established. However, studies frequently concentrate on older adults in residential care institutions with little attention to older adults living with their relatives [11], particularly to those who are dependent and in a co-residential living arrangement with their kin. This is despite the fact that the majority of older adults in Ethiopia receive care and support through their kinship ties [7, 8, 12]. When an elderly person can no longer handle necessary daily tasks on their own, care is required. Health, environmental, and economic changes spur support within families [13]. Many elderly people see an increase in family support as their sickness progresses [14]. Additionally, older adults may need care due to physical issues and psychological difficulties [15]. According to the vast majority of studies, physical limitations, especially those that affect ADL, increase the need for family care and the chance that older adults will live with family members [1, 16, 17]. Likewise, emotional closeness or bonding, as well as reciprocity of care [18–20], play important roles in co-residential family care [21, 22].

Widowed, divorced, and never married older people are more likely to live with and rely on their offspring than married older people [2, 16, 23, 24]. When elderly people lack the funds to cover their basic necessities and medical care, they must rely on their families [25]. On the other hand, older adults with great physical and mental health and the ability to give back appear to be prerequisites for care and support. According to a study conducted in Ethiopia, older adults who are financially independent, physically fit, and in good health are more likely to receive assistance [10].

Studies have also highlighted the socioeconomic, psychological, and spiritual requirements of older people in rural areas. Older adults deal with a variety of physical and psychological issues [26], such as joint discomfort and dependency-inducing sight impairment [27]. The context of caregiving in a co-residential care setting is determined by a variety of characteristics, including the caregiver's relationship to the care receiver, gender, age, and socioeconomic status [28]. Older adults with little financial resources are more likely to be marginalized and have low social status [29], which can lead to isolation (neglect) and eventual loneliness. In addition, rural older adults have socioeconomic difficulty, low income, and a lack of land ownership [30–32].

Care choices for older adults are influenced by factors such as the number of children, educational level, residential area, availability of health infrastructure and care facilities, and filial piety-related values [33]. In Ethiopia, facilities offer older people essential services, health care, and recreational activities [34, 35]. Studies on the effects of institutional care and the requirements of senior citizens living in residential care facilities have also been done by Alemnesh and Adamek [36], Eskedar [37], Tigist [38], and Bruck [39]. Older adults benefit from the fundamental healthcare services offered in institutions, although they are insufficient [36, 37].

In Ethiopia, older adults receiving institutional care are more likely to experience depression, isolation from friends and relatives, a lack of daily activities, and a lack of social engagement [36–39]. Getachew [40] and Aynshet [41] each conducted a study on the conditions of elderly persons who are homeless and older adults who are beggars. The research concluded that factors contributing to bad living conditions included poverty, death, separation from immediate family, and a lack of social support.

In her investigation of the care provided to Italo-Ethiopian war veterans (1935–1941), Hosseana [42] discovered that both formal and informal care providers offer financial,

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

material, transportation, health, and informational support. The research on older adults in rural locations in Ethiopia received little attention from Abraham [43], Noguchi [44], Fantahun et al. [45], and Kifle [8]. However, elderly people in rural areas and those who live in communities remain a population group in Ethiopia that has received little attention [8, 11, 43].

In sub-Saharan Africa, where the majority of older adults live and receive support from their informal networks, families are strong and familial ties are still present despite the strain [46]. In Ethiopia, it is a widespread family system custom to look after older parents, especially in rural areas [7–9, 12]. In addition to this, the majority of the scholarly literature focuses on urban older adults who reside in institutions. Society has the propensity to view elderly people as helpless and dependent, which opens the door to abuse such as exploitation and neglect.

Older people make up 9.1% (11,103) of Bassona Warana Woreda's total population, according to CSA [5]. According to the Woreda Finance and Economic Development Office report from 2021, the proportion of older people aged 60 and over in the total population is predicted to be 9.5%, which is significantly higher than the national share of older people (4.8%) in the total population of the nation as measured by the 2007 Census. This project will significantly advance knowledge, practice, and policy in the field of geriatrics in general and geriatric social work in particular given the paucity of literature on family care and support for older adults in Ethiopia. It will address the knowledge gap regarding aging rural Ethiopians receiving family care, which currently exists in the literature. The study's baseline data on geriatrics and family care was what the researcher hoped would spark more research on informal care. This study aims to explore study participants' experiences with the conditions that lead them to co-residential family care and is motivated by the paucity of studies on elder adults living in family care arrangements in rural areas.

### **2. Objective of the study**

The main goal of this study is to examine and explain older adults' lived experiences in rural areas in relation to the circumstances that led them to seek family care in a co-residential family care setting. This study specifically attempts to describe the socioeconomic and health-related factors that lead rural older adults to co-residential family care arrangements.

### **2.1 Research questions**


### **2.2 Scope of the study**

Only older adults who were receiving co-residential family care at the time the study was done are included in the study. The study also specifically focused on the conditions that lead older people in rural areas to require co-residential family care in order to represent the lived experience of older adults.

### **3. Methods**

### **3.1 Study area**

Although the meticulous number of older adults in Gudoberet Kebele (the smallest administrative unit in Ethiopia) is unknown, it is estimated that 438 (46,089.5%) older adults live there based on estimates from the Bassona Werrana Wereda (the third-level administrative division of Ethiopia—after zones and regional states). The choice of Gudoberet Kebele to conduct the study is influenced by the practicality of the Kebele in terms of time and expense as well as the researcher's familiarity with the area. The population is agrarians who depend on agriculture for their living, according to the manager of the kebele. Residents who belong to the Amhara ethnic group and are Ethiopian Orthodox Christians make up more than 99% of the population.

### **3.2 Study design**

In-depth interviews with rural older study participants were conducted by the researcher to get the data. The lived experience of older adults in rural areas was investigated and described using a descriptive phenomenology approach, with an emphasis on the factors that lead to co-residential family care. According to Sloan and Bowe [47], the researcher selected this approach to examine and explain older adults' experiences as they actually were. In a phenomenological study, it is typical to put away thinking and prior interpretation and place more attention on the lived experiences of older adults because these experiences make more sense to those who are living them. The study's intrinsic structural experience belongs to older adults because of their lived experiences with it (Husserl, n.d. as cited in [48]). In addition, descriptive phenomenology employs bracketing or separating the researcher's perspective, values, and comprehension of older adults' experiences in co-residential family care [49]. So, the researcher used language to convey their personal experience that mimics how rural older adults' facial emotions become psychological expressions [50]. Additionally, bracketing was used for the study's analysis and interview. The study has received approval from the Mizan-Tepi institutional review board, and informed consent and confidentiality were properly acknowledged when interview data was being gathered.

### **3.3 The sample**

The researcher has taken into consideration several phenomenologically recommended concerns when determining sample size. As Dukes [48] pointed out, the researcher placed a lot of emphasis on avoiding making assumptions about what they wanted to observe and paying attention to what was actually visible. Furthermore, samplings were also taken into account based on the research topics [51]. These factors guided the interviewing of 12 rural older adults receiving co-residence care who were available during the data collection.

Older adults who live with their families in a rural Kebele of Gudoberet and receive care from them are the study's participants. The inclusion criteria for choosing participants older adults are developed in accordance with the study's goal. The criteria utilized to identify participants are (1) older adults aged 60 and above based on the UN definition, (2) older adults who are co-residing with their family carers receiving care, and (3) older adults who are willing and capable of supplying information with consent.

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

### **3.4 Data collection procedure**

This study employed in-depth interviews to get data from rural older adults by creating an interview guide. After the interviewer establishes a casual, engaging relationship with rural older adults, the phenomenology design calls for a lengthy interview in which data are gathered through open-ended questions [52]. The Mizan-Tepi University Institutional Review Board granted the study's ethical approval (IRB). Additionally, the researcher adhered to [53] Ethical and Safety Recommendations when investigating delicate subjects. In addition, this study followed the Declaration of Helsinki's guidelines. The older adults in rural areas were scheduled for interviews at a time that worked best for them. They were made aware of their ability to decline to take part in or not reply to particular interview questions.

Likewise, older adults were made aware of their right to privacy and secrecy, and they were advised that neither their names nor the information they provided would be utilized in any other way. About 40–75 minutes were allotted for the interviews. The participants' native language of Amharic was used for all of the interviews. With the elder people's permission, the interviews were audio recorded.

### **3.5 Data analysis**

The first step in the data analysis method was arranging the older adult interview data and phenomenologically transcribing the audio recordings. The researcher has horizonalized the interview data by assuming that each statement is pertinent to the study. Listing the meaning or meaning units was done after the horizonalized sentences. After that, meanings were grouped into common themes (a group of related data arranged in the same location) and categories, resulting in a meaningful "essence" that permeates the data. This was accomplished by eliminating overlapping and repeating statements [54]. The textural descriptions of rural older adults in a co-residential family care setting were then developed using these grouped themes and categories. Construction of the circumstances for co-residential family care is based on the textural descriptions, structural descriptions, and integration of textures and structures into the meanings and essences of rural older adults' lived experiences [52]. This study's goal is not to theorize using previous interpretation, as was discussed in the study design. So, information gathered from older people in rural areas is inductively coded.

The researcher has carefully listened to the audio recordings of all of the participants older adults in order to improve the quality of the data. Peer debriefing involved disclosing part of the data and analysis to coworkers in order to solicit their helpful feedback. In order to confirm that the analysis accurately reflects the lived experiences of the study's rural older adult participants, the researcher also presented the analysis to them.

### **4. Findings**

The study participants who are older adults move out of their own homes or locations and into co-residential family care. For a variety of reasons, they moved away from their initial residence, and they spent between about 2 months to 23 years living in the houses of their offspring. The older adult participants' socio-demographic characteristics (**Table 1**) are listed below for a better understanding of their background. Additionally, the studies use pseudonyms to characterize the experiences of older adults.


**Table 1.**

*Socio-demographic characteristics of older adult participants.*

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

### **4.1 Physical limitations and health problems**

The functional limitations of older adults to carry out tasks is one of the justifications for shared living. Among the participants, *Bogale*, *Haile*, *Mekonen*, *Desta*, and *Yeshemebet* claimed that their choice to live with their adult children was motivated by a physical inability to manage daily tasks on their own. Their primary means of subsistence is agriculture, which involves hard physical labor. However, when they grew older, they found it difficult to handle the demands of agricultural labor. They, therefore, made the decision to leave all of their assets, including their land, to their children who lived close by in the hope that they would manage them and take good care of them.

*I started to lose my strength as I grew older. I was unable to tend to the animals while also cultivating the stony farmlands. I then made the decision to sell the cattle and give one of my daughters the farmland in exchange. I also let my two girls use the empty space in my compound. They built their own home and share residence with us. (Desta, 13 April 2021)*

Nevertheless, due to temporary and bedridden health issues, some older adults are unable to maintain their independent living. Even though they were physically fit when it started, their condition forces them to depend on their children. Before they begin to cohabit with their children, *Emebet*, *Abebe*, *Bogale*, and *Yeshemebet* each give a brief description of their health.

*I plunged into a little gorge twelve years ago. Then my hand and one part of my leg went numb. My kids drove me to the hospital and got me some holy water. I am unable to regain my health, though, because nothing is possible apart from God's approval. I therefore stay here and sleep in the midst of my kids as I wait for God to either heal me or take my life. (Emebet, 24 March 2021).*

*Due to an eye condition that made it difficult for me to cook, fetch water, and perform other household tasks, I was unable to work. Consequently, two months before to the date of this interview, I made the decision to move in with my married daughter. I do not have a female child living with me who helps with household duties. (Yeshemebet, 18 April, 2021)*

According to interview data from older adults in the study area, their physical health and strength are decreasing, forcing them to look for co-residential family care.

### **4.2 Inaccessible location**

The decision of older adults to relocate their living arrangements to their offspring, who are located in a relatively accessible location, is influenced by the location of their home or neighborhood being inaccessible. Their inability to access the institutions they deemed essential for the old age period is a result of the remoteness of their former location as well as their physical deterioration. Some older adults find it difficult to complete their old age activity because of the distance to a church and the rough terrain.

*The environment made it difficult for me to move into the location I wanted when I was at home. I find it challenging to consistently travel to church due to the slick roads. When I get older, that's when I need to connect with God. I therefore require a convenient place* 

*where I may locate a church close by. Because it's convenient for me to attend church and is closer to town, this is where I've chosen to live. (Bogale, 29 March 2021)*

*Gete* also notes the terrain and how to get to the church, but she also stresses out how the weather and lack of medical facilities have an impact on her health and force her to change her living situation.

*I formerly resided in a warm, sunny lowland area. I struggle with hypertension. Additionally, there isn't a clinic where people can get examinations and medical care. My children warned me that the warm, sunny weather might make my condition worse. I made the decision to come here because it is a highland location and is close to health centers. (Gete, 15 April 2021)*

As a result, the necessity for co-residential family care in rural older adults is influenced by external circumstances. Regardless of the quality of family caregiving, older adults are encouraged to live with their families in co-residence by the neighborhood's generally favorable physical environment, which allows them access to religious and medical institutions.

### **4.3 Separation and divorce**

One of the circumstances that lead to co-residential family care is conflict with a spouse that results in legal separation or divorce. Some of their reasons for divorcing their spouse and choosing a new living situation for their children include behavioral issues with their spouse, complications with their husband and adoptee, and disputes over children born outside of marriage.

*We shared a home for 35 years. We are currently residing in different locations due to our inconsistent behavior. I moved to Addis Abeba and stayed there for eighteen years as a result of her behavior. I built a house once I got home. I imagined that we would cohabitate. But she walked away from me. I became sick because I was upset. Then, when I arrived here, my sister assisted me in obtaining medication and recovering from my sickness. She warned me not to go back to my house again, so I made this my home. (Gizachewu, 12 April 2021)*

Due to tension between her husband and the adoptee, *Almaz*, 89, and her husband split 23 years ago. Her husband planned to give the adopted child ownership of their farmland.

*We had one adopted child and my spouse had been sterile. My husband wished to give the adoptee the farmland. He intended to take the farmland, according to my adoptee. I informed him that since he is not a member of my blood family, he cannot take my land. Our argument became very heated. He gave me some little barley. I instructed him to consume the barley. I divorced at that point. I eventually got to my biological child. (Almaz, 23 March 2021)*

*Asegedech* also says that she made the decision to live with her child because her spouse had an extramarital child. She was angry and made the decision to move in with her married daughter.

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

### **4.4 Death of spouse**

*Emebet*, *Yeshemebet*, *Gete*, *Bogale*, *Mekonen*, and *Haile* are among the older participants who are widowed. All of them, with the exception of *Emebet*, lost their spouses when they turned 60. If their spouses were still alive, some of the participants who switched to co-residential family care said they would prefer to live alone. They must relocate their living situation with their children due to the loss of their partner, their ensuing isolation, and the difficulties they face at work.

*Upon the death of my wife, I encountered difficulties in living because there is no one with me to cook and do other domestic work. Then, I decided to live with my child after the 7th year of my wife's death. (Bogale, 25 April, 2021)*

After turning 80, *Mekonen* and *Haile* lost their wife. They could not support themselves on their own. They made the decision to welcome their married son and daughter into their own house as a result. When their spouse passed away, they moved in with their children.

### **4.5 Economic problem**

Because they lack the resources to live alone, some older adults must rely on and live with their children in order to be healthy. They have no other option for living but sharing a home with their children, especially if they lack farmland. *Abebe*, *Mulu*, and *Asegedech* spoke about a financial issue that led to co-residence with their children.

*During the Derg regime, the local administration took my farm. After that, I got a job renting land from nearby farms. However, when my physical fitness declined, I was unable to continue, and the cost of renting land increased such that I could no longer compete with other farmers. These made me dependent on my son, then I had to switch to my daughter. (Abebe, 20 May, 2021)*

*The main cause of my daughter's dependence on me is the financial situation. I have no source of income and have instead spent the majority of my life working for others. I moved in with my daughter because I was having financial trouble. (Mulu, 26 April, 2021)*

*Asegedech* further notes that her reliance on her daughter is a result of the financial difficulties she encountered following her divorce from her husband.

*I didn't receive a portion of the land or any other property when my spouse and I got divorced. After that, I ran into financial problems. My daughter was my final hope. I arrived here because I lack any sources of support. If I had a source of income, like farmland, I believe I am capable of surviving on my own. (Asegedech, 27 April, 2021)*

Men are the primary breadwinners in the study area, and if a husband dies, the wife will find it difficult to maintain her usual lifestyle on her alone, forcing her to move for co-residential family care.

### **4.6 Neglect and inheritance dispute**

Among the various factors that lead older adults to leave their house and move in with another child is neglect by nearby children and possible abuse threats. Participants who are older adults who have moved away from their former homes note that they may be threatened and neglected by their children if they share a house or live in the same area. When there is a conflict of interest, children who are supposed to be a source of protection can end up being a threat to older people. Children and the surviving parent clash when one of the parents pass away about who will inherit what. Sometimes the argument is intensified to make older people fear their children and leave or move in with another child who can take care of them and protect them.

*One of my children begged me to give her a half of her father's property after my spouse passed away. I complied with her request and collected my village's elders and youngsters. I instructed my kids to split up their father's assets evenly. Then, one of my daughters steadfastly refused to split the acreage because she wanted to take all of her father's land by herself. We argue over this as a result, and I filed a lawsuit. I was permitted to use the land by the court. I gave her permission to take her share even after the court's ruling, but she persisted in pestering me. She intended to murder me. Due to the fact that I was living alone, I began to fear for my life. I left my house as a result and moved here to be with my children. (Gete, 15 April 2021)*

Some of the older adults were compelled to move out of their home and live with another child or relative due to abuse by a son who shared a residence with them. *Bogale* and *Yeshemebet* emphasize how frustrating it is that their sons have been neglecting them at home. They complained about how their married son, who lived in the same compound, was treated.

*My child displays challenging conduct and lives with me in one compound. I gave her a blessing because his wife is a lovely person. But my kid treated me badly. He ignored me for the first three and a half years after the loss of my wife. He never encourages me to approach close to the fire, even when I start to get cold, while he relaxes there. I become upset as a result, and I ask my other son to take me to him. (Bogale, 29 March 2021)*

Although older adults in this study want their children to provide them with care and safety, there are occasions when difficult relationships arise as a result of financial considerations and caregivers' abusive behavior toward older people. By escaping this toxic and violent relationship, the older adult's decision to move to a new co-residential family care setting is mediated by the presence of an adult child with a stronger emotional attachment.

### **5. Discussion**

The likelihood of co-residence is determined by the parents' financial dependence on their children, their marital status, and their capacity to perform activities of daily living (ADL) independently [17]. The move to co-residence is linked to older adults who are widowed having declining health [55]. As older adults with health issues are more likely to depend on others for a living, their physical and mental state affects

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

whether they choose co-residential family care. Changes in functional health status result in a requirement for additional family support and an increase in the possibility that older adults will live with children [1, 16, 17].

This study also shows that independent living is impossible for older adults due to their physical limitations in doing daily tasks. As a result, they are compelled to live together with their adult children since they require help with daily tasks.

The co-residence of older adults with their children was also found to be influenced by their marital status. Ruggles and Heggeness [24] observed that changes in older adults' marital status owing to separation, divorce, and widowhood enhance older people's need to co-reside with their offspring. This conclusion is consistent with the study's findings. The likelihood of co-residential living with children grows as a result of the change in marital status experienced during a period of widowhood [16]. The results also showed that the requirement for co-residence is not solely caused by a change in marital status, as older adults' decisions to do so may also be influenced by financial pressures and physical limitations that prevent them from living alone. Accordingly, a study by Audinaryana et al. [2] found that socioeconomically disadvantaged women, widows without jobs, and those who have had physical disabilities are more likely to live with their adult children.

Challenges arise for older adults who want to keep their independence due to economic issues. Due to their financial struggles, they are forced to change their living situation to co-residential care. According to earlier research [17], economic factors influence informal family care, and indicators of older adults living situations include their degree of education, occupation, and pension [1, 2, 17]. Owning material goods and working in the economy helps older adults keep their independence, but economic hardship makes it more necessary for them to live with children. While older people with high occupational levels and pension coverage live alone, shared living is more likely to occur when one's financial capacity is lower [1, 2]. In this study, agriculture is the main source of income for older adults, who also have lower literacy rates. Age-related financial pressures force them to rely on co-residential family care.

Older adults in the study area are vulnerable to challenges with their ability to support themselves due to the lack of social security programs. For people without access to farms, the economic burden is too great. The choice of older adults will be influenced by a variety of factors, therefore having financial resources does not ensure independent living. This study demonstrated that, despite having adequate financial resources, older adults often need to live with their adult children due to physical restrictions and inaccessibility of their residence. Some senior citizens who are unable to manage their property and live independently move their married adult children into their own homes.

This study also identifies other factors that lead rural older adults to change their living arrangements, including inheritance conflicts, abuse, and neglect by their shared child. However, earlier research has shown that older adults who experience violence or family conflict tend to live alone or stop sharing housing, contradicting this conclusion [56]. It is advantageous for older adults who have been mistreated or neglected to move to other co-residential care when other children are available who have stronger emotional bonds with them. Older adults move in with their adult children for emotional connection and a healthier parent–child bond [17]. The results showed that older adults who experience abuse usually arrange their living situation with a caring, close-knit adult child.

### **5.1 Conclusion and implication for practice**

Older adults decide to co-reside for family care for a variety of reasons, including physical limitations and health issues, an inaccessible location, separation and divorce, the loss of a spouse, economic difficulties, neglect, and disputes over inheritance. Future policy initiatives for the care of older people in rural areas should think about making local infrastructure development accessible, bolstering the family system, and extending support services. Physical, psychological, and social difficulties are forcing older adults in the research region to relocate for co-residential family care.

In Ethiopia, social work is still a relatively new profession. Higher education institutions should seek to open and expand gerontology social work education by developing faculty, curriculum, attracting a large number of students, and disseminating research findings in order to satisfy the requirements of older adults [57]. To offer care for this population group that is becoming more and more demanding, social work education generally and geriatrics social work training in particular should be increased.

Addressing older adults' social and psychological needs is just as important as meeting their bodily requirements. Interdisciplinary education must be prioritized if gerontological social workers are to be qualified. Geriatric social work interventions should include a biopsychosocial approach and interdisciplinary teamwork, especially with health experts, to address the complex needs of older adults and their family caregivers [58].

Senior centers should be built because they provide a number of advantages, including opportunities for older people to make new friends and find joy in life [59]. Additionally, the establishment of senior centers in rural areas would encourage selfcare and health management among older people living there [60]. Senior centers also encourage older people's involvement in the community through social interaction and friendships with other older people, both of which have been found to be important in other studies [61].

The creation of daycare facilities helped older adults live better lives by addressing their loneliness and sense of isolation [62– 64]. Additionally, because older adults in nuclear families are more likely to suffer from depression than those in joint families, the importance of family caregivers for older adults should not be minimized [65]. Besides that, it is important to recognize the role that family support plays in reducing loneliness in old age, especially for people who do not get enough family time [63]. It is also important to offer assistance to rural older adults' family caregivers in order to lessen their burden of caregiving. Training in caregiving [66], financial assistance and reimbursement for the care given to senior citizens [67], and provision of farmlands for family caregivers are significant.

The creation and implementation of home care for senior citizens, which is currently a favored style of care, should involve social workers significantly [28]. It is essential to increase older adults' access to healthcare. Additionally, daycare and family care arrangements could be combined with services like health education and entertainment programs.

It is important to provide material assistance and expand community health insurance programs. The quality of life for older people in rural areas will improve thanks to gerotechnology or the provision of assistive gadgets for incapacitating medical issues. To support older people in rural areas and lessen the strain on family caregivers, it is crucial that all stakeholders—including governmental and non-governmental organizations, religious institutions, and human service professionals—play their part.

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

### **5.2 Limitations of the study**

"Why do older adults in rural areas in the research region seek co-residential family care?" is the topic that this study seeks to address. A co-residential family care arrangement's sorts of services, older adults' needs, interactions, and problems are not examined in this study. Furthermore, conclusions from the study should not be extrapolated to apply to other older adults receiving co-residential family care outside the study area.

### **Acknowledgements**

I would want to show my gratitude to all the respectable senior citizens who took part and shared their expertise, opinions, and experience by sparing their time and energy. Without their gracious attitude and active participation, the study may not have been able to be completed. They were incredibly cooperative and supportive. Because of them, my time in the field was really intriguing and enlightening. Fourthly, I would like to express my gratitude for the assistance and collaboration of the Gudoberet Kebele Administration, the Bassona Werrana Woreda Administration Office, and the North Shoa Zone Labor and Social Affairs Office during the data collection process.

### **Funding**

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

### **Declaration of conflicting interests**

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

### **Ethical approval and consent to participate**

Ethical clearance was obtained from Mizan-Tepi University research directorate. The aim and potential benefits of the study were discussed with all older adult participants. Written informed consent was taken before involved with participants.

*Rural Health – Investment, Research and Implications*

### **Author details**

Kidus Yenealem Mefteh Department of Social Work, Mizan-Tepi University, Mizan-Aman, Ethiopia

\*Address all correspondence to: yenealemkidus@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Older Adults in Co-Residential Family Care: Circumstances Precipitating Rural Older Adults... DOI: http://dx.doi.org/10.5772/intechopen.110139*

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### **Chapter 13**

## Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner Violence in Rural Contexts

*Heather Helpard and Lori E. Weeks*

### **Abstract**

Researchers and health care providers know little about older, diverse women who experience intimate partner violence (IPV) within rural contexts and their service and support needs. In addition, rural older women experience significant geographic disparities in health status and outcomes, socioeconomic inequities, and access to appropriate services, creating unique challenges. In this study, we sought to contribute knowledge and innovative approaches to conceptualize and respond to identified specific needs and challenges older women experiencing IPV in rural contexts face. This study draws on the thematic analysis of 14 interviews with diverse rural New Brunswick and Nova Scotian women who experienced IPV or service providers supporting older rural women who experienced IPV. Findings from this study culminated in the following themes: *retaining the traditional web, breaking threads, spinning new connections, and remodeling the web*. All these patterns played out within rural contexts where identified supports and challenges encouraged or hindered older rural women's agency and supportive workers' abilities to spin supportive connections and create innovative solutions to meet the needs of older, diverse rural women experiencing IPV. These findings will serve to inform future person-centered, supportive, and collaborative approaches and strategies for future and relevant service provision, education, and research for this population.

**Keywords:** intimate partner violence, older women, diverse women, rural, Canada

### **1. Introduction**

Within Canada, women are victims in approximately 80% of reported intimate partner violence (IPV) cases [1]. IPV "refers to any type of abusive behavior that occurs between intimate partners, such as spouses or common-law partners" [2]. While researchers and service providers have paid more attention to IPV in younger women, a global aging population warrants a closer look at IPV rates in older women [3]. While accurate prevalence data is challenging to obtain, global data suggests that 16.5–54.5% of women over 45 years of age may experience IPV [3]. Researchers

suggest that older women may experience IPV differently than younger women due to an increased likelihood of comorbidities and dependency on a perpetrator for physical care and financial support [3]. Our knowledge of IPV rates and experience in a diverse cohort of women remains inadequate [2].

What complicates the matter even further is that in many rural and remote areas in Canada, including those in Atlantic Canada, women comprise a higher proportion of the rapidly aging residents [4]. New Brunswick (NB) and Nova Scotia (NS) are credited as two of the oldest Canadian provinces. Researchers estimate that almost half of the population of New Brunswick (NB) and over two-thirds of the people in Nova Scotia (NS) live in rural areas, and many who live in these places are older women with different languages, ethnicities, and comorbidities [5–8]. Across Atlantic Canada, many of these diverse older rural women live alone, are widowed, married, or live with a common-law partner, experiencing significant differences from those living in urban areas in terms of illness burden, mortality, and socioeconomic status [5–8].

IPV incidence between rural and urban Canadian women exists in Atlantic Canada, with rural women experiencing the highest overall rates of IPV compared to their urban counterparts in recent years [9]. Many older rural women live in lowincome situations with poor health outcomes [10] with experiences of geographic isolation, inaccessibility to healthcare services, and unique sociocultural characteristics that may shape decisions, self-esteem, and health behaviors [10, 11]. However, such statistics often do not capture diverse groups of women at different phases of their lifespans or in various contexts in which these women live [12, 13]. Often, researchers describe women who have experienced IPV as a homogeneous group in reports and studies, leading to the development and implementation of supports and resources that may not meet the unique needs and circumstances of older and diverse groups of women living in rural settings [2, 11, 14].

Many define rural areas in terms of population or distance from the closest urban center, implying, to some degree, social isolation and inaccessibility to healthcare services and resources [15, 16]. These significant geographic disparities in health status and health outcomes, socioeconomic inequities, and limited technological and transportation access to appropriate services create unique challenges to providing supportive services [17]. The literature suggests that factors such as a lack of human and material resources and large geographical distances between communities [17] can create unique challenges for supporters working with this population. To address rural healthcare resource availability and accessibility issues, researchers have called for the formation of comprehensive rural health frameworks, recommendations, and innovations among critical stakeholders in the community, rural communities, and healthcare providers [17]. However, what remains are struggles with funding, housing, and culturally appropriate care [18].

From a geographical standpoint, "rural" was defined in this study as an area with fewer than 10,000 people [19]. However, rurality embodies more than population density and geographical distance to the nearest urban center. Within these geographically defined and designated areas exist eclectic ways of life created and maintained by patriarchal family structures, resilient attitudes, cultural and religious values, and stereotypes [20, 21]. Such attitudes, values, and ways of life may shape self-worth, purpose, and behaviors [11] in older, diverse rural women in Atlantic Canada and their attitudes, behaviors, and supportive needs in response to IPV experiences. Within this rural context, one can experience being embraced or "othered," depending on the degree to which one identifies with valued and revered ways of rural life and membership [14].

### *Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

Researchers and healthcare providers know little about how older women experience IPV in rural contexts and their service and support needs. In addition, rural older women experience significant geographic disparities in health status and health outcomes, socioeconomic inequities, and limited technological and transportation access to appropriate services, creating unique challenges to providing supportive services [10]. While it is clear that intimate partner violence can occur with women in any context and at any stage of their lifespan, older women's experiences of intimate partner violence are both a significant and understudied phenomenon [3, 22–25]. In addition, little is known about the needs of diverse older rural women aged 50 years or older who are living in rural contexts [26]. Without such knowledge, it is very difficult to understand how rurality and living within a rural geographical area facilitate or create barriers for older, diverse women seeking support for intimate partner violence and to determine what supports are needed to address gaps within rural contexts for women living with IPV that are different than what may be required in urban settings.

Our research team identified the need to understand how rural contexts facilitate or create barriers for these women and their service providers, who supported them in a paid or unpaid capacity. Thus, this study aims to gain insights into the needs of rural, diverse older women who had experienced IPV.

### **2. Methodology and methods**

As part of a study funded by the Justice Partnership and Innovation Program-Family Violence Initiative by Justice Canada, "Identifying and Responding to the Needs of Diverse Older Women Who Experience Intimate Partner Violence: The RESPOND Study," [27, 28], team members conducted interviews with diverse and older NB and NS women who experienced IPV and service providers supporting these women who had experienced intimate partner violence (IPV). The research team accessed interviewed participants by extending invitations to surveyed service providers in the project's second phase and distributing created study recruitment posters through organizations that provide services to women with IPV [28]. Also, women who experienced IPV could find these recruitment posters on public bulletin boards (e.g., health centers) and social media (e.g., Facebook and Twitter) [28]. Within these interviews and for this study, the research team identified the need to understand how rural contexts facilitate or create barriers for these women and their service providers, who supported them in a paid or unpaid capacity.

The inclusion criteria for participants included: (a) individuals who identified as a woman, including transwomen and femmes, (b) individuals who self-identified as a member of a visible minority or identify as an official Francophone language minority, (c) women who experienced IPV in midlife or older who are not currently in an abusive relationship or residing with an abusive individual, (d) women who were currently residing within a New Brunswick or Nova Scotia rural community and not a care facility, and (e) those who could be interviewed in French or English. Data collection resulted in a thematic analysis of 14 interviews (2 women and 12 supporters of older women who have experienced IPV in rural NB or NS) (**Table 1**). The study sample included six bilingual service providers from New Brunswick and six supporters of older women in Nova Scotia who supported older women who had experienced IPV in a rural setting. In addition, 1 NS Arabic woman and 1 NB Francophone woman, who both experienced IPV, participated in interviews.


### **Table 1.**

*Description of interview participants.*

A feminist theoretical perspective informed this qualitative research analysis, supporting participants' involvement in the knowledge co-creation process and providing a lens to observe and consider how factors and structures within the rural context facilitate or create barriers for study participants. It was also rooted in constructivist approaches, which support relativist ontological views (e.g., different observers may have different viewpoints about what counts as truth) and underpinnings of pragmatism (e.g., human knowledge and values are situated in events and services to address practical issues in the everyday world), symbolic interactionism (e.g., subjective meanings of and realities through constant social interaction, language, and communications) and constructivism (e.g., truth and knowledge are constructed by humans as they engage with the world they interpret [29–31].

Inductive thematic analysis is a highly flexible method amenable to a range of epistemologies and research questions. Themes, often defined as abstract entities, capture or unify individuals' experiences into meanings and patterns [32], offering a rich and detailed account of participant voices by highlighting similarities, differences, and surprising insights within the data. Using Braun and Clarke's six-phased iterative [32] and reflexive process, the research team initially read through interview data stored in well-organized and labeled archives. In biweekly research meetings, phone conversations, and a couple of workshops, the research team annotated data items in the interviews to document ideas of potential codes and then refined these codes further in team meetings and discussions. The research team used the initial codes to organize meaningful concepts found within the data. Then, the research team interpreted the codes to develop data themes and subthemes, with the aid of theoretical and reflexive memos and field notes about potential codes and themes within the data. Finally, the research team organized the themes, subthemes, and codes into a thematic map to visualize relationships and patterns among the data. Themes were continually reviewed and refined by the research team (collapsing or breaking apart

*Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

### **Figure 1.**

*Remodeling the web: the experiences and needs of older diverse women who had experienced IPV and unpaid and paid support workers.*

some themes) for referential adequacy to the raw interview data and written observations and field notes during the interviews, leading to the final definition and naming of themes. The completed thematic diagram (**Figure 1**) tells the story of the data. One-third of the interview transcripts were in French, so the expertise of two bilingual research team members took the lead in documenting English translations of the French transcripts, using detailed memos to capture inherent meanings and patterns relevant to the francophone culture. In the interview with the Arabic woman, an Arabic interviewer included notes and explanations in the transcript to clarify aspects of Muslim culture. A research member on the team offered insight and expertise during discussions about interview content shared by black Canadian support workers.

Due to time limitations, the research team did not complete member checking during the data analysis. However, member checking was sought during the presentation of findings at national and international conferences. In summary, according to Lincoln and Guba's [33] trustworthiness criteria, many members of the diverse research team were involved with prolonged engagement with the data and data analysis process, interview translation, as well as peer debriefing at regular research team members and retreats, leading to logical, detailed, traceable and clearly documented analysis processes supporting interpretations and findings derived from the interview, data analysis decisions, personal reflections and insights from the interview data.

The Research Ethics Boards granted ethical approval for this study at Dalhousie University, the University of New Brunswick, the Université de Moncton, and the University of Prince Edward Island. All participants provided informed consent before the interviews began and received a \$25 honorarium.

### **3. Results**

Four overarching themes emerged during the data analysis process. Themes of "Retaining the Web," "Breaking the Threads," "Spinning New Connections," and

"Remodeling the Web,", and related subthemes (**Figure 1**) provide an interpretation of diverse older women's as well as paid and unpaid supporters' experiences, challenges, needs, and opportunities regarding IPV support and service needs within complex and ever-changing rural settings within Atlantic Canada. These findings and a diagram (**Figure 1**) evolved from secured interviews between members of the research team and study participants, as well as researcher memos during an analysis process guided by Braun and Clarke's [32] six phases of thematic analysis. **Figure 1** depicts the relationship between these themes and subthemes.

### **3.1 Retaining the Web**

"Retaining the Web" (**Figure 1**) is a theme that represents the chronic barriers faced by study participants. The perceived present reality for participants in Atlantic Canada is living or working in a contained and restraining web. Societal structures, stigma, trauma and invisibility, discriminatory and oppressive gender roles and hierarchies, age, racial, and language stereotypes, and inaccessible human and material resources to assist with IPV shape this web. This theme also captures the perceived barriers that older, diverse women experience when attempting to access IPV services in rural settings. This theme subdivides into the subthemes, 'meeting traditional gender role expectations,' 'being inside the rural circle,' and 'living with limited accessibility.'

### *3.1.1 Meeting traditional gender role expectations*

Many study participants described older, rural women as entrenched within a present-day web of power inequity shaped by patriarchal ideals and the need to meet traditional gender role expectations. Denise, an outreach worker from NS, reveals, "For older women, the kind of deal was the husband is the breadwinner, and the wife took care of the home." This division of roles and responsibilities within the home places older, rural women in a vulnerable and dependent physical, emotional, social, and financial position within their relationships, a reality that may promote and escalate feelings of helplessness, isolation, and oppression. Mary, a 48-year-old francophone woman who experienced IPV, echoes these sediments, saying, "If you can't beat him, keep quiet, so you don't upset the boat."

Meeting traditional gender roles means accepting and upholding a climate of selfsacrifice for older, rural women in preference to others' needs. Within such an atmosphere, older, rural women's potential physical and emotional isolation may escalate when IPV occurs within the home. Reflecting on her IPV experience, Mary remembers such feelings, saying, "I realized how my life was going to go. You can insult me and beat me to the point of killing me if you want. I accept it, I love you, but you must never get your hands on one of our children." Compatible cultural and religious beliefs can further reinforce patriarchal ideologies and gender role expectations. Denise comments, "Certain religions encourage couples to work out things no matter what … such a damaging power differential. And I think there is a lot of shame and stigma". Raj, a 53-year-old Muslim woman who experienced IPV, shares, "in my religion, when a wife is patient and tolerates whatever happens with her in the marriage life, she will go to heaven" (Raj). Raj further describes what toleration entails, sharing,

*We [the wives] allowed our husbands to trampling and stepping on our dignity. Trampling on our emotions. Trampling on our comfort and trampling on you [the wife] … If not, you will lose your life and your children and family*

### *Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

Also, older women's feelings of self-worth align with meeting traditional gender role expectations within rural contexts. Cathy, an IPV outreach worker from NB, explains, "They [older women] are often told [by their husbands or partners] that they can't make it on their own." Denise agrees, considering the older, rural woman who has been a caretaker and homemaker "might not have any savings at all." This limited ability to make it on their own may also come from little formal education and work opportunities.

### *3.1.2 Being inside the rural circle*

Penelope, a victim service worker from NB, describes the rural context as comprised of "little cliques which define a degree of acceptance of how you will be treated." Lenore, an NB victim services coordinator, reveals, "The level of secrecy here is huge … senior women have the burden of the well-being of the family on their backs; the honor of the family … We mustn't break up the family." The health and supportive benefits of living in a rural context apply if one is part of the inner circle that ascribes to and embraces these gender role expectations, beliefs, and secrecy related to IPV. Nathan, a counselor at a shelter in NS, reflects, "Diverse women face additional challenges in a rural community. They feel shamed when discussing their case with anyone, and many do not understand their culture … they suffer a lot" (Nathan).

Discussion and acknowledgment of IPV happening in rural households are subject to stigma and discrimination. Older, diverse women can erode the rural culture of secrecy by speaking out about IPV experiences. In that case, they risk stigma, racism, potential rejection and isolation from family, friends, and the community, and social exclusion from membership and support offered to those within the rural circle. Lenore shares, "There were horrible rumors out in the community about who was accessing the shelter." Such stories spread throughout a rural community not only threaten older women's self-esteem and how they will be viewed and accepted by others but also create a barrier to their comfort level in accessing services. Therefore, for an older, diverse woman to be outside the circle in a rural community because exposing the secret of IPV means risking rejection from supportive networks, cultural groups, relationships, financial security, dignity, and personal safety. Harriett, an executive director for a rural women's resource center in NB, believes that such aspects of a rural way of life hinder older, diverse women's sense of security. She indicates that these vulnerable women must have the "ability to feel safe in reaching out both within the community and outside the community as they [older, diverse rural women who experienced IPV] have a real lack of anonymity and a lack of privacy."

### *3.1.3 Living with limited availability*

Within the rural context, Linda, a community social worker from NB, reveals that paid and unpaid support workers continually strive to find culturally relevant human and healthcare resources for older, diverse women experiencing IPV from "a pool that is getting shallower and shallower." Many study participants shared that IPV services in rural communities were directed "mostly towards younger women … those are the women that suffer domestic violence the most" (Harriett). It was not common among study participants to consider older women with IPV as a distinct population requiring unique resources and services because "they [older women] do not want to go to where they are known" (Linda). Janice, a manager at an adult program in NB, spoke about the lack of specific IPV services for older women.

She explains, "There are no services specifically for older women … we don't see them. Young women are open to different services … older women are the opposite … they want to keep everything a secret." The lack of visibility and attention to older women with IPV in rural contexts resulted in the development of generic programs and the construction of shelters that did not consider modifications such women with illnesses or disabilities may need. Pat, a worker at a shelter in NS, discloses, "We do not have a lot of staff or facilities or the money to put equipment in for or care for older women with illnesses and disabilities… They can try to get a room on the main floor to avoid stairs."

Moreover, Harriett comments, "It is difficult to find someone who wants to work but also speaks French at the same time. It's a constant, constant battle." While NB is a bilingual province, Francophone providers and resources are often in short supply. Mary claims, "services are not as available to Francophone women everywhere, and that affects who I go talk to and if I decide if it is worth the time to go through that to try and find someone who understands." Linda expands further on language issues for immigrant women in rural contexts who speak neither French nor English:

*Speaking neither English or French makes it a big challenge and unfortunately, in this case, it was not the priority to deal with the violence she [a client] was experiencing. We could not do therapy with this person, you understand, because the language barrier was just too big … We couldn't understand each other enough.*

In rural contexts, there exists limited accessibility to providers, services, and resources to meet the specific needs of older, diverse rural women and for those who are trying to help them from a counseling, treatment, supportive, or legal perspective. Linda shares, "We have to contact many people to help with translation … it's a big challenge, and most times we can't get the help, and we can't offer the help and support we usually offer to other clients." In addition, study participants raised concerns about older, rural women's limited accessibility to centrally located and distant IPV services in rural contexts and support workers' ability to access them in their homes. Linda divulges, "Isolation is a big obstacle. Transport and isolation in the region [rural settings]. There is nothing close, and there are no other services here [rural town] that offer domestic violence services." Therefore, Linda discloses that older, diverse women must rely on others within the rural circle for support, even if they are the perpetrators of abuse. She shares, "There are no buses in Kent County. A client of mine had to depend on a taxi where, at one point, it was the abuser driving her. The fact that we had a client, and it was her ex-spouse."

Janice spoke about the "lack of protection and privacy for the elderly in rural areas from the eyes of rural residents if they are made to access local programs and shelters." Linda expands on this point, saying, "Adult protection can do nothing to help them [older women] as long as they understand what is happening … there is nothing they can do. Police services are also the same thing." Mary, an older Francophone woman, claims, "Without any care of the hard time to find help and get there, no one comes to me." This need for service within the home environment may be an important consideration for older, diverse women in rural settings who have, as Janice asserts, "lived in their homes for decades, and it is all they have ever known." It may not always be easy for older women to relocate to another place, such as a nursing home, when, as Linda notes, "You've been through 60 years of abuse, and there is no counseling offered there." What also makes it hard for rural, older women to leave their homes, families, and communities to access outside services and alternative housing arrangements is to leave their animals. Linda acknowledges, "We can't have

*Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

animals at our shelter, you know … there are other services for animals, but it is not good for their [older women] dog or cat or horses to go to the other side of the province or for women to leave them behind."

### *3.1.4 Summary*

"Retaining the Web" represents how older, diverse rural women and unpaid and paid supporters continue to live, work, and exist within a societal structure shaped by patriarchal ideals and traditional gender role expectations that are accepted and supported inside the rural circle. These ideologies, as well as cultural practices and religious beliefs that align with them, permeate and influence healthcare provision and planning, family and community relationships, and political and legal systems. With the rural inside circle being a primary means of support, older, diverse women with IPV risk isolation, alienation from their home, family, and community, further poverty, stigma, and shame in a rural context that provides limited access to outside services and resources supportive of language and cultural needs, as well as financial and legal protection.

### **3.2 Breaking the Threads**

"Breaking the Threads" (**Figure 1**) is a theme that captures actions identified by study participants that are needed to fracture the retained web in rural settings, such as the patriarchal societal structures, traditional gender role expectations, stereotypes, and age, racial, and language discrimination. The theme subdivides into two subthemes, 'finding a voice' and 'promoting community awareness.'

### *3.2.1 Finding a voice*

Within present-day rural contexts, study participants have found that older, diverse women who have experienced or are experiencing IPV have been silenced and oppressed within their homes and communities. Britney, a worker with victim and police services in NS, observes, "Older women do not often realize that they have been abused … they think that is just the way life is … so they accept it as the norm." Linda concurs that "the elderly more than the young do not realize it is violence."

To 'break the threads' that perpetuate this silence and oppression requires reawakening and reflection before an onslaught of education. There is a need for these women to 'find a voice' through storytelling with a trusted healthcare provider, family member, friend, or cultural representative in a safe and secure place. Raj recommends, "Don't be silent … Women should share their pain with someone and get someone they trust involved." However, Cathy cautions, "It's just taboo… they [older women] want to hide more … they want to keep everything secret to avoid backlash, embarrassment, loss of home, and hurting others" (Cathy). Denise agrees, "Women might feel too embarrassed to tell their story to someone that's so close in the community, or they might not trust that privacy will be kept." In addition, Lenore, an NB victim services coordinator, agrees, "It's an obstacle to go and show them they have the right to be someone, to be understood, to be loved and to have support." To address these concerns, Katelyn, a staff nurse from NS, shares, "I listen to their story. I hear what they have to say … reading between the lines, looking at their gestures. I always leave the door open for them to share and express." Linda believes trust can be gained by:

*Sending them messages and assuring them [older women] they are beautiful, intelligent, and strong … asking them to write in a journal or share pictures to discuss … encouraging them to tell a bit of their story and taking the time to listen …*

Furthermore, in a rural context, Linda proposes, "attention to a location, like beside a hospital or connected to a business, would not let others see them come into my office, and it ensures client confidentiality." However, other study participants felt that a primary consideration of gaining trust in older, diverse women with different cultural backgrounds and languages was to advocate for more support workers and care providers who could identify with their background and lived experiences. Irene, a support worker with black women in NS, recommends "Having people that look like those individuals who are providing service … making sure they are culturally relevant, making sure they're grounded in that person's culture." Nathan expands on this point, noting, "It is also important to have providers of the same generation as the victim … the same age range … which may help with trust for victims to tell the story to someone relatable."

### *3.2.2 Promoting community awareness*

When questioned about specific IPV services and supports for older, diverse women in rural contexts, many study participants indicated that there were few or none. Penelope shares, "We offer the same services as we can, regardless of age group." Denise agrees, saying, "First of all, we just do all the same things that we do with all women." Nathan discloses, "I find that we never treat anyone of any age difference, but I find there are more resources allocated for younger women experiencing violence or intimate partner violence than older women." Older, diverse women experiencing IPV were generally not thought of by participating support workers as a group with unique needs and were invisible. Mary divulges, "I feel many have turned their backs on me … You fall on your own" (Mary). To 'break the threads,' there need to be ways to channel older, diverse women's voices so that community members can be informed about intimate partner violence and change some previous mindsets. Denise suggests:

*There needs to be changes to support this population in general, I think that other service providers like doctors, nurses, lawyers, judges, social workers, community leaders, like everyone in the public needs to be trained and aware of intimate partner violence needs in all groups within the older generation … like generational and cultural competence.*

Harriett, an executive for a rural women's resource center in NB, believes community awareness starts with "a lot of social media, going out and talking about it and getting information out … We have to widen our scope and try to get the word out in these ways." While older, diverse women are less visible on social media, Penelope reflects:

*Awareness, our young people have it. Older women are less on social media … but this mustn't stop us all from getting their words and messages out. We must keep going because putting out the message can narrow the gap between the generations in our rural communities.*

While such actions to educate and inform others in the rural community are essential, Irene implies the message is more complex. She cautions that in rural contexts,

*Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

"it is important to acknowledge that systemic racism has impacted how other people outside the community interpreted the community of black older women where intimate partner violence is an issue." The training and messages to healthcare providers and rural community members must also be authentic. "Whenever there is a type of forum that's organized within the community, talks about community experience or community needs with intimate partner violence, they [older, diverse women] need to be there to participate and give those first voice stories" (Irene). Katelyn stresses the need also to "get the information down or getting research, having research guide the messages for the community and even having focus groups … getting it down accurately on paper. Getting it written and shared." Nathan outlines a role for himself in this process, saying, "As a man, I feel there need to be support groups with men to raise awareness with men about violence… stand up against violence, … support the cause … to balance the process."

### *3.2.3 Summary*

"Breaking the Threads" represents an initial starting point to unravel the constraints of the present-day web to help older, diverse women in rural contexts reawaken and 'find a voice' to help them recognize and understand they are victims of IPV and to feel comfortable and safe to share their stories with trusted health care providers and, preferably, with those who look like and can identify with their cultural backgrounds and generation. The rural community, and public, including health care providers, men groups, and community leaders, may need to participate in training as well as research and knowledge dissemination of first-hand stories from older, diverse women to raise community awareness that they experience intimate partner violence and systemic racism in rural communities.

### **3.3 Spinning New Connections**

"Spinning New Connections" (**Figure 1**) is a theme that represents the study participants' perceptions of the need for the creation of new threads and connections within their immediate surroundings, as well as with local and distant communities and intersectoral and healthcare partners. Participants suggest that such innovation, re-imagination, and creativity are required to build a new foundation for future initiatives and models of care that better meet their needs to cope, live with, and address IPV in rural settings. The theme subdivides into two subthemes, 'building supportive networks,' and 'creating collaborative community connections.'

### *3.3.1 Building supportive networks*

In present-day rural settings in Atlantic Canada, study participants spoke of the social and geographic isolation experienced by older, diverse women who had experienced or are experiencing IPV. Linda observes, "the elderly often have nobody. You know we see that often." Mary shares, "It is so important for me to be well surrounded with whom I share strong bonds like family and friends and others who can understand you… it is amazing how good it makes you. It reassures you."

What complicates social and geographical isolation with the need for informal, supportive networks is that many IPV services and resources for women are outside the home and local, rural community. Denise shares, "Many services providers are stretched too thin in rural areas and prefer women meet them where they are for

service regardless of if they [older women] live far out of town and have no vehicle." For these reasons, Harriett imparts, "they [older women] need someone they trust, like family or friends or a support person, to kind of lead them to services and resources or come with them … or learn do this on the Internet." On the other hand, older women uncomfortable with technology or with no support persons may require healthcare providers also travel to meet these women where they live or steer them in a direction where they can meet others with similar interests and backgrounds. Denise discloses, "Specifically with the older population, I find I do more home visits than meeting in the office" (Denise). Nathan suggests that "it would be great if a group from an institute goes to where those older women are in their home and supports them to stay there." Social support networks make older and diverse women feel more connected and closer to home in rural settings. Groups within the local community can be found in places such as "within churches to pray, sing, or hum" (Katelyn) or homes. Irene, a supporter of black women in NS, elaborates further, sharing:

*We have done women's circles, where it gives them the Opportunity to share resources that have helped them. We have also had long kitchen table talks, specifically about being a survivor, what that looks like, and providing some peer support.*

Older and diverse women who do not speak French or English could create informal support networks using "apps and writing and non-verbal communication to get to the place with others who do not speak their language" (Irene). Irene further elaborates, "social networking can involve something as simple as a senior's group or women's circles in the community where they [older diverse women] can crochet and knit and talk and eat … incorporate mental health." Also, Raj feels that building supportive networks with older and diverse women in rural settings needed to incorporate culturally based rituals and practices of expression to bring people together. She states:

*I want to say rituals. A lot of women use their rituals … Like one of the ladies did henna on her hands and feet. And it was around her coming through her journey. There are things like Bollywood dancing and activities from the Muslim community. They get together and talk about their experiences, but it's through dance, and expression of creativity like plays and different things like that (Raj).*

### *3.3.2 Creating collaborative community connections*

To 'spin new connections' requires forming and nurturing collaborative partnerships between older, diverse rural women who have experienced or are experiencing IPV, their advocates, community organizations, and the justice system. The strength of community connections in rural settings is imperative to offset the issues surrounding limited accessibility to others and resources. Within rural contexts, Raj believes, "Partnership is power!!! I think civil society and the government need to work together hand in hand with us without any hierarchy or power struggle for change."

A key priority identified by study participants is to be "part of reworking the puzzle of resources within the community" (Katelyn). The involvement of older, diverse women and their advocates to streamline and connect multiple IPV referral processes, healthcare providers, resources, and related services in private yet accessible, "central multiservice locations, satellite clinics, mini prevention offices and virtual programs across and between rural contexts" (Denise). Also, it is imperative to educate older, diverse women and advocates about their availability and how to

*Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

access healthcare resources and services, as well as to "understand legal statutes and navigate judicial processes" (Britney). Irene sees "huge barriers to older women when there is a lack of knowledge about where services are, who providers are, and what can be offered in rural communities." Lenore suggests:

*We need to reach them [older diverse women] more … for discussion and education. Perhaps, … going to their homes to offer them little presentations on supports and services, laws, policies, and healthy relationships.*

In rural contexts, there are diminished RCMP services, communication, and safety concerns. Denise mentions, "There's often only one RCMP officer patrolling like a rural area … it takes police what seems like forever to them [older women] to get there." Lenore reveals, "Older women are very sensitive to police comments… bad attitudes of police regress women in their efforts to make statements or press charges." Linda expands on such experiences, sharing, "Women can be vulnerable as laws and judicial processes often punish the victim and put all the responsibility on the victim." More work is needed to "improve laws, policies, and justice for vulnerable victims and populations of IPV crime and helping judges understand the issues of complexity and violence." Lenore contends, "We all work for the people" (Lenore). Katelyn reveals, "There's not a lot of trust with agencies and organizations…. most of the time they are not staffed with black people." Irene asserts:

*I think some of the recommendations would be we need more people in support roles that look like us, that are trained to… Because I mean the thing about it is that we know the African-Nova Scotian experience. But having the supports through that experience are lacking.*

Therefore, older, diverse women and their advocates must work toward forming collaborative partnerships with Multicultural Associations, diverse elected counselors, healthcare providers, and the judicial system in developing more culturally appropriate IPV healthcare, police, and judicial services, as well as language translation and educational resources.

Other forms of health care delivery from health care providers and support workers could involve case-based management approaches and partnerships with local church organizations. Denise reveals," A lot of times older women are more connected with church organizations… like in a counseling capacity, a friendship capacity, and for food, shelter, transportation, and financial aid." However, Harriett maintains, "What we are noticing with older women … is that there is no affordable housing for them to meet their needs, including mobility issues …. they are on Income Assistance." Older women, often in more dire financial situations, do not have the means to work. Without provided secondary housing, there are only the "shelters with the bare minimum with no special beds, and not very accessible at times with … at our place having to walk up at least 6 stairs to get into the building itself" (Nathan). For older women who choose to stay in their homes, Lenore indicates, "They [older, diverse women] should continue to receive services … as well as resources to equip them to be safe and to defend themselves."

On a positive note, to address financial aid needs, Denise insists, "Older women so a really good job with fundraising initiatives and getting their name out in rural communities … using social media platforms more." Harriett shares, "Some of us [support workers] have really good fundraising campaigns … like toonie draws and … a Chase

the Ace champaign raising \$300,000.00 … and a safer pets program … Not one penny of government funding." Linda advocates for "more subsidized funding for programs for older women from the government." In particular, Linda indicates, "If we had subsidies, we could have more specific IPV programs for older, diverse women … to touch more on the problems they are experiencing."

### *3.3.3 Summary*

"Spinning New Connections" represents and addresses mechanisms and strategies to facilitate building eclectic informal, supportive networks and creating multiple collaborative community connections. Both will thread together as a solid foundation for creating a new web that better serves the unique needs of older, diverse women who have experienced or are experiencing IPV and paid and unpaid support workers in rural Atlantic Canada. There is a need to facilitate and strengthen meaningful informal networks with family, friends, and groups of older women that share experiences and support generational and cultural roots within the home, local rural settings, and between rural settings. The involvement of community churches, judicial, multicultural, and fundraising organizations, government subsidy funding, police, and health care providers and support workers in partnership with community leaders and advocates, and older, diverse rural women who experienced or are experiencing IPV is paramount to facilitating a collaborative, inclusive, and connected approach that serves to dismantle previous power and oppressive hierarchies that serve to silence and isolate these women within their rural communities.

### **3.4 Remodeling the Web**

"Remodeling the Web" is a theme that represents the study participants' vision for a new, supportive web. This remodeled web, created in partnership with older and diverse women and support workers, has a supportive infrastructure more attuned to the needs of the study participants. This unique and evolving web supports transparency, equitable voices, preventative and meaningful services, appropriate human and material resources, and connections that meet the needs of diverse older women and support workers in rural Atlantic Canadian settings. The theme subdivides into two subthemes, 'enhancing older women's visibility,' and "redefining self-worth and purpose."

### *3.4.1 Enhancing older women's visibility*

In the present-day web, older and diverse women are invisible and devalued within the family and rural context. Denise observes, "While all services welcome access by older women … Like you see people taking in cutsie voices to older women, or like infantilizing them." Irene feels:

*It is not appropriate for me to assume I know the answers for them … I ask permission, and I encourage them to self-advocate or play an engaged role in our talk, so the real person in front of me appears in a space of conversations that are the bigger picture.*

Older and diverse women who have experienced or are experiencing IPV should be visible at the center of the remodeling web. Traditionally, there has been a "topdown" approach to developing resources and services for women experiencing IPV, with little attention to older and diverse women in rural contexts. Irene reasons

### *Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

that "women end up accessing and receiving services and even kind of controlling what those services are by influencing what those services are is by having someone endorse that service." The people that favor these services are, as Harriett describes, "Government officials and a community board … who imply what they do is what this the community wants. But it doesn't mean that they are representing the women themselves." Instead, opportunities for "dialogue and different understanding with older and diverse women is needed, asking a lot of questions … and exploring all the possibilities of choices and resources and services to follow" (Irene).

It is also essential to have, as Irene states, "Diversity on our board of directors …. and advocates available for women of color … diversity of service.. with opportunities to expand and grow and learn and to reach out in new ways." Raj says, "I advise the bigger society to seek the truth. To see women and return and maintain women's right." Katelyn believes, "People who understand this population [older and diverse women] have an understanding then, some insight into their IPV experiences, community concerns, and needs." Irene also contends, "They [older and diverse women] need to be seen and at the center making sure the resources are relevant to their experiences, generation, making sure they're culturally relevant … grounded in their culture."

What is also really important is to show respect to the older and diverse women who have taken the steps, with the support of their advocates, informal, supportive networks, and community partners, to become visible in rural settings. In a remodeling web, let resources and services "center around the women who are IPV victims, not the abusers" (Katelyn). Katelyn thinks, "These women should be honoured … there needs to be respect and admiration … not stigma, shame, or discrimination." Linda advocates:

*We need to from their [older and diverse women] resourcefulness and sense of caring for people who have been through a similar situation … making visible themselves and sharing the information and experience they received.*

### *3.4.2 Re-defining self-worth and purpose*

Within a remodeled web of resources and support with the older and diverse rural women at the visible center, there is a renewed opportunity for them to redefine a sense of self-worth and purpose for the future. Raj recalls, "He made me weak and not trusting myself. He was always humiliating me. He let me feel that I am a weak woman, and I am nothing." Mary pleads for others like her to "Run! Run! Get out of it! Because it never gets better" (Mary). Denise feels that a supportive, collaborative approach with this population in a remodeled web can help these women realize "it's me first, it's my health first. And I need to be here to be present for the rest of my family." Harriett agrees, saying:

*We could see their strength, but they [the older, diverse women] don't see it. I think they could see it; it would make much more of a difference. If there was a way we could help them see that, it could give them a sense of worth and purpose. Because they really have gotten to this point, they are by being strong (Harriett).*

A remodeled web allows these women to recognize their resilience and resourcefulness and use those strengths to move forward after "so much shock and heartbreak." Denise contends, "Finding themselves [older and diverse women] after IPV means kind of coming out on the other side of that and developing self-esteem and self-love." Within the remodeled web that is forever changing, these women have the opportunity to "recreate themselves after thinking like it's too late for that … inspiring others like them of what resiliency truly is" (Denise). Katelyn shares that this process is "peeling away the layers and seeing a purpose … and saying, 'I'm going to do for myself'" (Katelyn). Linda shares, "We [support workers] can bring out their [older and diverse women] by bringing out their qualities that don't see themselves, you know … with tools to boost their self-esteem." Katelyn agrees, saying:

*Giving women the empowerment or letting them know that, yes, you do have power, yes, you can do something, you're not a victim, you've overcome much, you know … I honour you … You have a part in this too … there's some things you can do … receive the help you need to build up the self-esteem and to build up the self-worth.*

### *3.4.3 Summary*

"Remodeling the Web," represents the supportive and openly changing environment that centrally locates, shapes, and gives visibility to older and diverse women's presence within rural communities, their role as partners with advocates, health care providers, support workers, community organizations, stakeholders, and leaders. From a grassroots versus "top-down" approach, older and diverse women are at the center of their IPV program and service development, research, and mentorship of others with similar experiences and their continual personal self-growth journey.

### **4. Conclusions**

This study aimed to understand how rural contexts facilitate or create barriers for older and diverse women and their service providers, who supported them in a paid or unpaid capacity. The results of a thematic analysis of 14 interviews (2 women and 12 supporters of older women who have experienced IPV in rural settings of Nova Scotia or New Brunswick, provinces located in Atlantic Canada. Four overarching themes, "Retaining the Web," Breaking the Threads," Spinning New Connections," and "Remodeling the Web," and related subthemes (**Figure 1**) emerged. These findings interpret study participants' experiences, challenges, needs, and opportunities regarding IPV support and service needs within complex and ever-changing rural settings within Atlantic Canada. The study findings suggest future practice, education, and research considerations for further discussion and attention.

### **4.1 Practice implications**

The study's findings support the need to change or augment present-day ways that healthcare providers, resources, and community supports can be aligned and accessed for older, diverse rural women who have or are experiencing IPV. Previous study findings suggest that, for older women, geographic isolation, patriarchal and religious values, mistrust of health care and service providers, and traditional gender role expectations may complicate leaving an abusive relationship [34]. Study findings suggest that health care, support providers, and trusted community leaders may be vital in facilitating social networking, mentoring, multidisciplinary, intersectoral, and rural community partnerships with populations of older and diverse women who have experienced IPV in rural contexts.

### *Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

First, there needs to be more recruitment of culturally diverse healthcare providers and a partnership with community leaders and organizations who represent older, diverse women, whether in language or cultural differences. Past research findings on older and diverse women experiencing IPV suggest mixed reactions to trusting the genuineness of health care and service providers and police, particularly if they did not look like or come from the same cultural background [34, 35]. Second, social networking strategies need to encompass cultural traditions and creative and innovative expressions which resonate with this diverse population. Health care and service providers may need to meet older and diverse women's needs where they are located instead of expecting them to travel to them. Often travel to centrally located facilities, such as known shelters within rural settings, may compromise older and diverse women's anonymity, confidentiality, and privacy. Research findings support that older women in rural locations face significant challenges in leaving IPV relationships, such as social and geographic isolation and fear of consequences of retribution by the abuser if they access services in their hometown [2, 27, 34].

Third, service providers need to engage more with these women to determine how to ensure their safety in their homes with their animals and decide which type of housing, financial, cultural, educational, and support are required if they must relocate. Study participants also preferred to have IPV services and resources, as well as other accessible services, under one roof in a confidential location. Researchers have uncovered similar suggestions in previous studies where older women in rural settings fear leaving IPV relationships and the only way of life they have known [2, 27, 34]. Fourth, there needs to be the development of more local rural collaborative forums and workshops for healthcare providers to understand rural life's unique challenges and benefits, including the additional challenges older, diverse women face in these areas. Past researchers confirm this to be an understudied area in literature [27]. Fifth, there needs to be further discussion of how older, diverse women access translation services in health care and the justice system and knowledge about what services or not qualify them if they are not Canadian citizens. Again, past researchers have identified that research and intervention in this subject area have yet to be widely studied [27].

Sixth, there also needs to be programmed to promote self-worth in women, not only at their stage of life now but for future generations of women, which includes men's supportive voices. Past research on the engagement of rural Nova Scotian women in physical activity behavior post-myocardial infarction suggest that the level of self-worth may significantly impact health behavior decisions of putting oneself first [11]. Seventh, study participants suggested there need to be better accommodations for older women with disabilities in shelters, which did not have wheelchair ramps and safety measures or assistance with disabilities and medications, and secondary affordable and accessible housing options. This lack of attention to providing adequate support for women in the design of affordable and accessible housing may be due to previous study findings that support little attention has been paid to older women in creating IPV interventions [27].

Eighth, service providers need to advocate for changes in safety, transportation, legal services, laws, and policies to support the victim versus the abuser. Past researchers have shared similar findings related to rural women's hesitancy to approach police officers to report IPV for fear that the judicial system will have further victimized them and that they will have severe consequences from their abuser [34]. Finally, healthcare and service providers, community leaders, government officials, and researchers need to direct future efforts toward discovering flexible employment options and re-examining needed financial aid, safety and protection, affordable housing, and resources to help diverse and older women remain in the home, including considering animal and pet support.

### **4.2 Education implications**

Study findings suggest that health care and service providers should work with community partners, government officials, and stakeholders to develop, fund, and include more rural content in professional education curriculums and increase rural preceptorship opportunities for students. In particular, study findings suggest a need to educate health service providers and promote community awareness of the incidence and unique service and resource needs of older, diverse rural women who have experienced or are experiencing IPV. To date, government, and community IPV services and resources have primarily focused on younger women and children inside and outside rural areas [27, 34]. Consistent with previous research findings, study participants expressed little awareness that older and diverse women who had experienced or were experiencing IPV represented a unique group with specific service and resource needs [34].

Study findings suggest that support workers perceived older and diverse women who had experienced IPV to be more dependent on their partners. Study participants felt that older and diverse women were not always aware that they had been abuse victims and were unacquainted with what resources and services were available and how to access them. Also, they shared that these women often did not have a lot of educational social support, and financial resources. They shared that these women were more at risk of being victimized by the legal system and socially isolated, especially if they were required to relocate from their homes in rural areas due to IPV. Study participants felt that more healthcare providers must conduct in-person educational sessions at centrally located places in the rural community or within their homes to overcome financial and transportation obstacles and ensure anonymity, dignity, and safe spaces. However, part of these educational sessions should involve asking questions about what is contextually and culturally relevant for women, including issues about safety and protection and how to access supportive healthcare and legal resources in and outside rural contexts.

### **4.3 Research implications**

In this study sample, there was less representation of older and diverse women who had suffered IPV than support providers. However, there is a need to develop trusting relationships with community and organization leaders who identify or have access and trust with older and diverse women who have experienced IPV to avoid exploiting these women in the research process. Therefore, chosen research designs and methods to study IPV should centrally locate older and diverse women's voices and perspectives. Future research studies are needed using socio-ecological approaches and participatory research methods, such as photovoice and art ensure participants' visibility, engagement, and empowerment throughout the research process. Such research may help develop, implement, and evaluate future rural programs and services that reflect diverse women's voiced needs.

### **Acknowledgements**

We want to acknowledge all members of The RESPOND ANORT research team for their contributions to this research and their valuable comments and feedback.

*Remodeling the Web: Supporting the Needs of Older Women Experiencing Intimate Partner… DOI: http://dx.doi.org/10.5772/intechopen.109767*

This research was supported by funding from the Justice Partnership and Innovation Program-Family Violence Initiative, Justice Canada.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Appendices and nomenclature**

Please refer to **Table 1** for participant pseudonyms and descriptions.

### **Author details**

Heather Helpard1 \* and Lori E. Weeks2

1 Saint Francis Xavier University, Antigonish, Nova Scotia, Canada

2 Dalhousie University, Halifax, Nova Scotia, Canada

\*Address all correspondence to: hhelpard@stfx.ca

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### Section 5
