The elderly must not be seen as dependent receivers and a burden on their environment. Many o f them are still active in old age and contribute to agriculture, household activities, child care, play a role as adviser and pass skills and culture. Wherever possible, they will develop mechanisms aimed at maintaining access to food and resources and minimising exposure to risk. Apart from obvious measures to reduce nutritional vulnerability such as ensuring adequate food supply and (medical) services, the challenge is to meet immediate needs in such a way that capacities are promoted and vulnerability reduced (Anderson & Woodrow, 1991) such as sustaining productivity o f the aged and encouraging family support rather than collective care (Solomons, 1992).
An example o f an alternative response is the community development approach adopted by UNHCR and aid agencies in Rwandan refugee camps in Ngara district, Tanzania. This was based on facilitating sub-communities to identify their problems and needs, and subsequently provide funds to access resources to meet the identified needs. As w hole communities had fled together, there was some representation o f community groupings. Although these were not participatory in nature, it provided at least some stability. This resulted in group micro bans to single parents for petty trading, vocational business training through apprenticeship in existing businesses, community participation in the construction o f school buildings and setting up a network o f relugee social workers to meet the needs o f unaccompanied children and their foster parents (Reynolds, 1995). There were also activities geared to older people
such as training in business and home-based care to stimulate the community to care for elderly but at the same time encouraging the elderly to care for others where possible (pers. com. HAI Ngara).
Such an approach takes account o f older people's (and others) potentials and may increase their autonomy, provide opportunities to remain in control o f their lives, and to participate in the community, w hich conforms to the U N Principles for Older Persons (1991).
The HelpAge International intervention in Karagwe district
HAI’s aim was to ensure that elderly got equal access to cam p services such as food (general ration and supplementary food if necessary), health care and non-food items. HAI worked through lobbying and advocacy to other N G O s and supported (through other NGOs or independently) for those elderly who still did not have equal access.
HAI held extra non-food distributions to make sure all elderly people at least had a plastic roofing sheet and utensils, and at times extra goods like soap o r clothes were distributed. In th e HAI compound there were facilities for social and occupational activities (mat, basket and sandal making, sewing, black smith, pottery) for which materials were provided. A plot o f land in the camp allocated to HAI served as communal garden for older people. Inputs were provided and the produce was divided among ‘extremely vulnerable elderly’ and those w ho had provided labour. HAI organised literacy classes for older people (in Kinyarwanda and Kiswahili) and occasionally also eye clinics and o th e r events.
HAI worked through a network o f home visitors (usually belonging to the target group) and leaders o f th e elderly community. The most vulnerable individuals were regularly visited and assisted if necessary, and the local community w as encouraged to do so. Home visitors also delivered supplementary rations given out by Memisa and checked on social aspects. A nurse and physiotherapist with a rehabilitation team working for HAI treated older patients. The target group also assisted HAI for instance by providing labour.
Chapter 4 Nutritional vulnerability 74 MSF
Nowadays MSF includes children up to 10 years o f age in feeding programmes. If occasionally an adult presents him/herself (often referred by the clinics), the person is admitted on clinical grounds. In case adult malnutrition is a larger problem, MSF sets up separate adult feeding wards. Entry criteria are based on BMI 16 kg/m 2, but increasingly on MUAC 18.5 cm (no justification o f this cu t-o ff is provided) and a general clinical assessment o f weakness (o f which inability to stand is the most extreme). The gradual shift to MUAC instead o f BMI is based on the fact that BM I is very much population specific, and on preliminary data that suggest th at MUAC and mortality risk are fairly consistent betw een populations. N evertheless M SF still relies heavily on clinical judgements although these are hard to standardise, and expects this will remain so regardless o f developments in anthropometry. Monitoring older patients in feeding centres consists o f regularly checking weight and clinical status.
Elderly patients receive the same treatment as adults in terms o f diets, entry and discharge criteria. Since some older people never meet the discharge criteria because o f their constitution, a four to six w eek time limit is added to their stay in a therapeutic feeding centre. I f a thorough medical screening shows that they are sufficiently healthy and strong to be discharged, they are referred to a supplementary feeding o r social programme. M SF does not include social factors in their screening although this is regarded to be important. MSF usually operates in acute em ergency situations when there is no time to consider issues other than morbidity and mortality. Considering social aspects and running social programmes is left to other agencies.
It must be realised that adult patients cannot be controlled to the same extent as children. I f they feel hungry, they will not comply w ith recommended feeding regimes, even though non-compliance may be life-threatening. M oreover adults do not easily observe discharge criteria: some will leave the feeding centre as soon as they feel well enough to meet their obligations at home, while others refuse to leave (for security o r other reasons) despite meeting the discharge criteria (pers. com. MSF-Holland, 1999).
Oxfam
In an em ergency situation, Oxfam generally considers the elderly as a group that is likely to be vulnerable. This generic list also includes th e disabled, female headed households and children under five years o f age, whose nutritional status is used as a proxy for the condition o f the population at large.
Oxfam currently does not have a systematic approach to assessing vulnerability in the elderly. Anthropom etric data are not used, m orbidity and mortality data are usually disaggregated as under and over five years o f age, and socio-economic data are generally presented at the household and not at the individual level. Clinical signs o f pitting oedema have been used to include elderly in feeding programmes, but w ith time criteria for discharge to avoid long-term inclusion o f o edem a cases due to medical conditions. However som e offices use community based inform ation for identification o f vulnerable people. An example com es from development program m es in flood prone areas in Bangladesh w here a list with vulnerable individuals was developed w ith the community prior to a crisis.
Oxfam handles no standard criteria for anthropom etry, clinical signs o r social aspects. It is believed that a screening tool for nutrition program m es should be based on social rather than anthropom etric criteria since kyphosis poses problems to the use o f anthropometry and vulnerability in the elderly often has a social origin (pers. com. Oxfam-UK, 1999).
Chapter 5 Study design and methodology 76
5.
Study design and methodology
The study involved the collection o f quantitative and qualitative information regarding older refugees. Quantitative information consisted of:
1. Anthropometric measurements.
2. Functional ability assessment by means o f a questionnaire regarding independence in activities o f daily living (ADL) and performance in simple physical tests.
3. Clinical screening by observation and questionnaire. 4. Socio-economic and dietary issues by questionnaire.
Qualitative information w as obtained through in-depth and group interviews with elderly people, interviews with key informants and observations.
Hypothesis and objectives
The purpose o f this study was to examine the determinants o f nutritional vulnerability among older adults and elderly people in refugee camps. It aimed to test the following hypothesis:
The nutritional status o f older adults and elderly people in refugee camps is determined by functional ability, socio-economic conditions, health status and access to food.
The objectives o f the study were:
1. To describe the anthropometric status and functional ability o f older refugees. 2. To describe the socio-economic conditions, health and food access o f older refugees. 3. To identify the determinants o f nutritional vulnerability among older refugees.
The study included people aged SO years and older. Although it is acknowledged that it is not possible to give a single definition o f ‘the elderly’, the W HO uses the age cut-off o f 60 years to define old age (W HO, 1989). How ever older adults aged 50-59 years were also included since life expectancy is low er in developing countries. M oreover biological ageing may begin earlier due to undem utrition, exposure to disease, physical work patterns and harsh living conditions in general (Kalache, 1991).