Reducing neglect and improving social support for older people following a self-help group in the poor urban community of Jakarta, Indonesia

Abstract

Increasing age has an impact on the decline of organ function and results in increasing dependence on others, including family. Efforts must be made to increase older adult's’ independence to help them overcome naturally occurring changes and health problems. This research aims to determine the effects of the self-help groups as nursing interventions using guidelines of selfhealth monitoring and management on the incidence of neglecting and the social support of older people. A quasi-experimental design was used on a total sample of 208 people, consisting of 103 in the intervention group and 105 in the control group. An independent t-test was conducted before and after the intervention model to analyze the social support variable, and chi-square test was applied to analysis the neglect variable. The results showed the effects on the incidence of neglect of older people, and there were significant differences between and within the intervention and control groups (p < 0.05) in terms of social support. The intervention model demonstrated reduction of the incidence of neglect and an increase in social support. The results indicate that this program can be used as a guideline for health care center nurses in fostering self-help groups for older people in the community.

Introduction

As population is rapidly increasing around the world, Indonesia is currently entering an era of aging population. Indonesia was ranked fourth—after China, India, and the United States—with a population of 249 million, or 8% of the world population¹. There has been a steady increase of older people in Indonesia, as life expectancy has increased from age 65.5 in 1990 to 68 in 2000, then to 68.5 in 2004 and finally to 70.6 in 2009^1,2. Aging is often accompanied by the onset of various diseases, such as hypertension, arthritis, heart disease, diabetes, and emotional and mental disorders³ which can cause disabilities in older people and increasing dependence on family. Self-neglect is more common in older people who live alone and lack family support⁴.

In the urban communities of Indonesia, more women are working than in previous eras, resulting in less attention paid to older people. This condition is a risk factor for neglect of the elderly. The type of neglect that most often occurs is personal neglect, such as poor hygiene⁵, along with social neglect, followed by financial and physical abuse of the elderly in urban as well as rural areas⁶. The level of social relations and low social involvement are themselves associated with an increased risk of neglect⁷. To address this problem, the researchers in this study developed an empowerment model for older people through a self-help group using monitoring and intervention guidance. Independent management intervention increases interaction between peers and family⁸, which is effective at increasing abilities, understanding, and management of health⁹.

The purpose of this study was to examine the social support and neglect incidence following the intervention model of the self-help group using self-monitoring and intervention in Jakarta, Indonesia.

Hypothesis:

• A.

  The average score of social support of older people in the intervention group will be significantly higher than the control group.

• B.

  The percentage of neglect incidents of older people in the intervention group will be significantly lower than the control group.

Method

A quasi-experimental design with pre- and post-test intervention and control groups was used in this research study. The population was older people who live in Jakarta, Indonesia. A multistage sampling method was used to select two municipalities, from which two villages were randomly selected. The eligibility criteria were as follows: age of 60-74 years; live with family; not experiencing any visual or hearing disability; able to read and write; willing to follow self-help group activity; and willing to participate. The sample size was calculated by comparing two means formula¹⁰ with a significance level of p = 0.05 (two-tailed) and power of 80% to detect ≥ 20% difference in means. A total of 208 people were randomly selected and allocated to the intervention group (103) and the control group (105). Two participants in the intervention group dropped out due to illness. Instruments used were a demographic questionnaire; social support survey from Sherbourne and Stewart¹¹ that had been used in Jakarta, Indonesia by Sahar, Courtney, and Edwards¹² and Wati and Riasmini¹³ with reliability test-retest of 0.95 and 0.896; and Hwalek-Sengstock Elder Abuse Screening Test¹⁴ used by Wati and Riasmini¹³ in Jakarta, Indonesia with a reliability test-retest of 0.849 This study was approved by the Nursing Research Ethics Committee, Faculty of Nursing, University of Indonesia and the local government. Participants were fully informed about the research before being asked to provide written consent. The paired t-test, non-paired t-test, and chi-square test were used in this research.

Intervention model

Self-help group activities were done every two weeks for three months. The facilitator explained to the intervention group how to use the self-monitoring and the autonomy intervention guidance book. The facilitators consisted of the research team in cooperation with the nurse from the public health center. Processes followed by the self-help group were 1) elderly reflected their experience of using the guidance book to solve health problems; 2) elderly responded to their friend reflection; 3) at the end of session, the facilitator offered reinforcement. Every member of the intervention group received the guidance book and did self-monitoring and intervention at home. At the end of the research, the control group also received the same guidance book, and the processes were facilitated by the nurse from the public health center.

Results

Majority participants were less than 70 years old (71%) and 75% were female. Sixty-one percent of participants were married with educational background less than senior high school (66%), and most participants were not working (67%). Analysis showed no difference in participant characteristic between groups. In social support and neglect variables, there was also no significance. Both groups were equals, except the job. There was more not working in the control group compared to the intervention group.

The majority of participants were younger than 70 years old (71%), and 75% were female. Sixty-one percent of participants were married, with an educational background of less than senior high school (66%), and most participants were not working (67%). Analysis showed no difference in participant characteristics between the two groups. In terms of social support and neglect variables, there was also no significance. Both groups were equivalent except in terms of employment. The control group had more members who were not working than the intervention group.

Table 1 describes the mean score of social support in the intervention group increased from 46.51 to 53.94 after the implementation while the mean of social support in the control group decreased from 47.72 to 43, which both showed there were significant differences in the intervention group and in the control group (p value = 0.000 and 0.004). Besides, there was also significant neglect before and after intervention in the intervention group (p value = 0.002). It means older people in the intervention group had a lower incidence of neglect compared to the control group (Table 2).

Table 1.

Analysis of social support and neglect before and after intervention with an elderly self-help group model at Bukitduri and Ps. Minggu, in Jakarta Indonesia (n = 208).

Variable	Group	Mean	SD	95%CI	T	p value
Social support	Intervention
	Before	46.51	10.55	4.947-9.907	5.940	0.000
	After	53.94	8.55
	Control
	Before	47.72	11.85	1.554-7.875	2.958	0.004
	After	43.01	10.49
Neglect	Intervention					0.002
	Control					0.361

Table 2.

Analysis of social support and neglect after the implementation of the self-help group model in intervention and control group at Bukitduri and Ps. Minggu in Jakarta, Indonesia (n = 208).

Variable	Group	N	Mean	SD	95%CI	p value^*
Social support	Intervention	103	53.94	8.55	8.314-13.551	0.000
Control	105	43.01	10.49

*

Uji independent t-test.

The means of social support in the intervention group were higher than the control group. The independent t-test result was p > 0.05, indicating significant difference in social support between the groups

The chi-square test results in Table 3 show that there were significant differences in terms of neglect in the intervention group (p value = 0.000). An OR value of 0.288 means that older people who did not receive the intervention model are at a 0.288 higher risk of experiencing neglect compared to those who received the intervention model. This result was understandable, given that the intervention was only conducted for three months.

Table 3.

Between-group analysis of neglect of elderly after implementation of the self-help group at Bukitduri and Ps. Minggu in Jakarta, Indonesia (n = 208).

Variable	Interventi on group		Control group		Total		OR	95%CI	p value^*
	N	%	N	%	N	%
Neglect
1. No neglect	49	73.1	18	26.9	67	100	0.288	0.120-0.432	0.000
2. Neglect	54	38.3	87	61.7	141	100

*

Uji Chi-Square.

Discussion

Difference in social support for the elderly in the intervention and control groups

There was a significant difference in social support before and after implementation in the intervention group (p < 0.05). Multivariate analysis using Mancova showed no confounding variable. This intervention model was almost identical to the research of Boen which showed a higher score in the social support group that followed the self-help group, compared to the control group¹⁵. The effect of social support was greater among female participants¹⁶. Participants in this research conveyed in the self-help group meeting that they sensed changes in their interactions with friends and family and felt physically and psychologically better, compared to their condition before the self-help group.

Social support can extend life expectancy in older people with a major disease or older people who experience difficulty performing daily activities¹⁷. Participants in an intervention group learn more about health problems and their prevention. This was demonstrated by Deng et al, in which intervention with a peer support system was effective at increasing the ability, understanding, and control management of patients with type 2 diabetes⁹. Self-help group organization was perceived as positive, not only to the participant, but also to the service provider, which can decrease utilization of health care services and promote efforts to maintain the health of older people in the community. The lack of social support can also be a risk factor for self-neglect^9,18.

From these discussion results, it can be concluded that older people who followed the self-help group intervention model with autonomous monitoring and intervention perceived social support better than older people who did not follow the intervention model.

Difference in neglect of older people between intervention and control groups

There was a significant difference in neglect before and after the intervention model in the intervention group (p = 0.05). The results of the multivariate analysis showed no confounding variable. Nguyen et al explained that closeness to friends offsets the impact of negative family interaction in terms of happiness and increased self-esteem¹⁹. The self-help group intervention model can facilitate closeness between older people and increase their sense of independence.

There was also a significant association between disability level and the incidence of neglect. Disability decreases independence in the elderly, which increases the possibility of neglect²⁰. The impact of independence on the lives of older people was also reported in a study²¹. After the intervention of the self-management program, the score of self-efficacy and the valuation of life remained steady in the intervention group, while they decreased significantly in the control group. Ramlah suggested that neglect in elderly happens because caregivers and elderly do not understand each other situation and the weak like elderly become a victim of neglect²².

Self-management programs increase client activities, including self-care activities²³. The lack of self-care is a form of self-neglect that often happens in older people^5,24. The intervention model helps participants to control their health so that self-care can be maintained and psychological changes can be prevented or minimized. While neglect often happens to older people who live alone and lack family support⁴, the self-help group intervention model can help optimize their health. Older people with chronic diseases, physical limitations, and dependence on others for activities of daily living also experience neglect²⁵. Older people are neglected by their relatives due to them not being sensitive to the older people needs or using offence words²⁶.

The decrease in neglect in the intervention group occurred because the group allowed members to share their experiences, thus reducing isolation and building self-confidence. In addition, the self-monitoring and intervention book gives older people the ability to solve their own problems without being completely dependent on a family member. Some older people stated that the support group activities with the self-monitoring and intervention really helped them to solve their problems. Elderly can become less dependent on their children and can tolerate if their children can’t always be there to help them²⁷.

According to this research and the discussion, incidences of neglect decreased significantly in the intervention group (p value = 0.002), but not significantly in the control group (p value = 0.361). Therefore, it can be concluded that the self-help group intervention model decreased the incidence of neglect in older people²⁸.