Community-based model for improving well-being and care of older persons in Namibia

Abstract

Introduction/background: Population ageing is accelerating globally and in Namibia, where formal family support structures are increasingly under strain. Strengthened community-based care services (CBCS) are, therefore, essential for sustaining the health and social well-being of older persons. However, in this regard, empirical evidence from low- and middle-income countries (LMICs) remains fragmented and limited, hindering policy and service development. This study addressed these gaps through a programme of work culminating in the Namibia Community-Based Model for Improving the Well-Being and Care of Older Persons, which incorporates individual, social, health-system and structural determinants. This study was achieved through five objectives: it mapped existing CBCS approaches, examined older persons’ awareness and attitudes towards old-age homes; assessed the readiness of old age homes; profiled the prevailing health status and social living conditions of Namibian older persons aged 60 years and above; and developed the model for improving the well-being and care of Namibian older persons. Methodology: A multi-method approach was utilised. For Objective 1, a scoping review was conducted in accordance with the 2022 Joanna Briggs Institute Manual for Evidence Synthesis. The review employed Rayyan for screening, de-duplication, and reporting, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. For Objective 2, a mixed-methods, cross-sectional survey was conducted among community and old age home residents (≥60 years) across three regions. Quantitative analyses were performed using the Statistical Package for the Social Sciences, Version 30 (SPSS v30), (α = 0.05), whereas qualitative interviews with key informants were manually analysed thematically. Objective 3 entailed a structured checklist assessment of six old-age homes in the Khomas and Hardap regions (four private and two public); none were found in the Ohangwena region. The facilities were evaluated to compare the bed capacity, staffing, infrastructure, emergency readiness, and accessibility. For Objective 4, the results were informed by the cross-sectional survey administered to 304 older persons in communities and old-age homes. Correlation analyses and binary logistic regression were employed to examine the relationships between health outcomes and sociodemographic, regional, and service utilisation variables (α = 0.05). Insights from all four objectives informed the fifth objective, which was to develop a community-based model for Namibia to improve the well-being and care of older persons. Results: Objective 1 (scoping review). Twenty-two articles met the inclusion criteria. LMICs face systemic constraints in establishing comprehensive and sustainable frameworks for older-age support, including inadequate pensions, a scarcity of trained geriatric providers, and reliance on informal caregiving, all amidst the context of under-resourced primary care and residential services. Households with older members require additional income to sustain living standards comparable to those of households without older persons. The review emphasises the importance of CBCS, aligning with aspirations for ageing in place. Objective 2 (awareness and attitudes). Preferences indicated a marginal overall difference between remaining in the community and moving to old-age homes, with statistically significant associations between living arrangements, educational attainment, and the number of dependents to preferences for living places (P < 0.001). Qualitative data highlighted pension misuse, transportation barriers to vii healthcare, and caregiver burdens. The study notably integrates quantitative and qualitative perspectives in Namibia, highlighting the viewpoints of caregivers and community leaders and demonstrating the need for targeted awareness, caregiver training, and the expansion of affordable, well-equipped old age homes for older persons. Objective 3 (old age homes capacity and preparedness). The correlation between the bed capacity and occupancy displayed a near-perfect linear relationship (R²≈0.98; ŷ=−4.29+1.06x), indicating operation at or near full capacity, with some residences experiencing over-capacity. Private facilities consistently outperformed public ones in terms of staff, age-friendly amenities, service infrastructure, and emergency preparedness, although they were more expensive. The improvement requirements ranged significantly: public old age homes required extreme renovations/service gap remediation, whilst private homes needed either routine maintenance or medium-priority upgrades. Objective 4 (health status and social living conditions). Among 304 older persons, the predominant diagnoses were musculoskeletal disorders (179; 58.9%) and hypertension (176; 57.9%); about 60% of older persons relied heavily on daily medication. Numerous older persons reported positive residential satisfaction, comfort and safety; nevertheless, loneliness/isolation, financial hardship, and transport difficulties were common. Logistic regression revealed lower odds of current illness and perceived loss of independence among residents of old-age homes compared to their community counterparts (p < 0.05), after accounting for covariates. Objective 5 (Model synthesis). The Namibia Community-Based Model was developed. According to the panel validation results, the model achieved ≥80% agreement across all five Chin and Kramer criteria for model validation (clarity, simplicity, generality, accessibility, and importance), thereby demonstrating high agreement and acceptable validity. It positions older persons within interlocking concepts: individual/biological and health factors, social and community environments, health and care services and institutional/structural enablers. It prioritises caregiver support and professionalisation, as well as decentralised, regulated, and equitably paid long-term care, integrated chronic disease management and screening, and multi-sector collaboration across various sectors. Implementation can be done in phases/stages rather than strictly sequentially, with continuous monitoring and refinement. Conclusion: This study demonstrates that Namibia’s rapidly ageing population faces simultaneous challenges, including multimorbidity and medication dependence, limited household resources, inconsistent service capacity, and significant disparities in quality and accessibility between public and private old-age homes, as well as social barriers such as loneliness and restricted access to transportation. Although older persons often prefer to remain in their preferred home or community setting, this preference varies depending on several factors, including education, family obligations, and the availability of support. Strengthening community-based approaches and services through public awareness, caregiver training and support, enhancing geriatric competencies, providing accessible and age-friendly services, integrating chronic care, and ensuring equitable financing and regulation of residential alternatives are both urgent and feasible. The proposed model offers a practical, evidence-based framework to inform policy and practice, thereby enhancing the dignity, autonomy, and quality of life for older Namibians.