Meanings and Expressions of Care and Caring for E _ Lders in urban ^ I Namibian families : A Transcultural pursing-6 tudy >

Since Namibia’s Independence in 1990, the population of elders—persons 65 years old and older— in urban communities is growing steadily. As such, requests for home health care, health counselling, respite care and residential care for aging members of society are overwhelming nurses and the health care system. This study expands transcultural nursing knowledge by increasing understanding of generic (home-based) patterns of elder care that are practised and lived by urban Namibian families. Guided by Madeleine Leininger’s theory of culture care diversity and universality and the ethnonursing research method, emic (insider) meanings and expressions of care and caring for elders in selected urban households have been transposed into five substantive themes. The themes, which depict what car­ ing for elders means to urban families, include: 1 nurturing the health of the family, 2 trusting in the benevolence of life as lived, 3 honouring one’s elders, 4 sustaining security and purpose for life amid uncertainty, and 5 living with rapidly changing cultural and social structures. These findings add a voice from the developing world to the evolving body of transcultural nursing knowledge. Synthesis of findings with professional care prac­ tices facilitates the creation of community-focussed models for provisioning cultur­ ally congruent nursing care to elders and their families in urban Namibia.

A b s tra c t Since Namibia's Independence in 1990, the population of elders-persons 65 years old and older-in urban communities is growing steadily. As such, requests for home health care, health counselling, respite care and residential care for aging members of society are overwhelming nurses and the health care system. This study expands transcultural nursing knowledge by increasing understanding of generic (home-based) patterns of elder care that are practised and lived by urban Namibian families. Guided by Madeleine Leininger's theory of culture care diversity and universality and the ethnonursing research method, emic (insider) meanings and expressions of care and caring for elders in selected urban households have been transposed into five substantive themes. The themes, which depict what car ing for elders means to urban families, include: 1 nurturing the health of the family, 2 trusting in the benevolence of life as lived, 3 honouring one's elders, 4 sustaining security and purpose for life amid uncertainty, and 5 living with rapidly changing cultural and social structures. These findings add a voice from the developing world to the evolving body of transcultural nursing knowledge. Synthesis of findings with professional care prac tices facilitates the creation of community-focussed models for provisioning cultur ally congruent nursing care to elders and their families in urban Namibia.

Introduction
The population of the world is growing older. In both developed and develop ing countries, the population of elderspersons 65 years old and o ld e r-is growing faster than all other age groups. By 2025, one out of every four persons in the developed world (about 25 per cent) and one out of every eight persons in the developing world (about 12 per cent) will be 65 years old or older (United Nations, 1991). This latter percentage constitutes over 70 percent of the world's elders as developing regions continue to experience burgeoning population growth.
Since Namibia's Independence in 1990, the number of elders in urban commu nities has increased steadily and re quests for home health care for elders have overwhelm ed com m unity health nurses. These realities are related most directly to rapid socio-cultural change, shifting population dem ographics and longer life expectancy. Throughout liv ing memory, Namibian families of all cul tural traditions have demonstrated high regard for elders. Women assumed the m ajor responsibilities of looking after aging family members and those with fragile health, while the entire family de voted time and resources to elder care. Today, many factors have altered family traditions. Opportunities for young peo ple, including women, are encouraging migration from rural homelands to cities where both men and women can pur sue education and careers. As younger members of urban families become busy with school or jobs, it becomes increas ingly difficult for them to provide ad equate social, physical, a nd /or em o tional support to their elders. Addition ally, the AIDS p andem ic in N am ibia poses an unprecedented health threat to the younger generation. As the lead ing cause of death and hospitalization in the country, AIDS is claiming the lives of women and men who constitute the work force-persons between the ages of 20 and 49 (National AIDS Programme, 1998, p. 2). What this means for elders is difficult to discern. Will they have any surviving children or grandchildren to care for them? Will they be the sole sup port for their grandchildren?
While AIDS is talking its toll on young people, demographic data suggest that Namibian people are living longer today than they ever have before. About 5.6% of the 1.6 million people in N am ibia -90,100 people--are over 65 years of age, and within this age group, 60% are over 75 years old, and 20% are over 80 years old (MOHSS, 1992). Like elderly indi viduals in other parts of the world, the frail oldest of the old in Namibia require a great deal of assistance and support ive care to remain at home. Chronic ill nesses, including arthritis, hypertension, recurring respiratory infections, cancer and diabetes are associated with in creasing age in Namibia. When families are not able to care for elders at home the options are limited. As Namibian nurses begin developing models of assistance and support for families and elders in urban comm uni ties, it is critical to know and understand culturally valued patterns of care within the family.
Purpose o\ the ó tu d y and

P<?main o \ Inquiry
The purpose of this study was to expand transcultural nursing knowledge by gain ing understanding of generic (homebased) patterns of elder care within ur ban Namibian families.
An additional aim of the study was to identify cultur ally congruent m odels of comm unityfocussed nursing care for elders and their families. Emic (insider) meanings and expressions of care and caring for elders as lived and experienced by se lected urban families was the domain of inquiry for the study.

Theoretical framework
Leininger's theory of culture care diver sity and universality framed this research within the philosophy and science of nursing. According to Leininger (1985Leininger ( , 1988Leininger ( , 1991Leininger ( , 1995Leininger ( , 1997aLeininger ( , 1997b, the major premise of culture care theory is that care is a universal human experi ence w ith d iv e rs e m e a n in g s and uniquely patterned expressions in differ ent human communities. Culture, the gestalt of human experience and knowl edge, including "values, beliefs, norms, patterns and practices that are learned, sh ared and tra n s m itte d in te rg e n e ra tio n a lly ," influ en ces care meanings and expressions (Leininger, 1997a, p 38). Differences (diversities) and sim ila ritie s (universals) in care knowledge and practices among per sons, families, groups and communities are predicted by the theory to be shaped by, and therefore embedded in, world view, e nvironm ental c o n d itio n s , lan guage, and social-cultural dimensions of kinship, religion, values, lifeways, tech nology, politics, economics and educa tio n (Leininger, 1991(Leininger, , 1995(Leininger, , 1997a(Leininger, , 1997b. Furthermore, the theory predicts that care m eanings and expressions contribute to and explain health experi ences of individuals, families groups and communities (Leininger, 1997b). Health, from a transcultural nursing perspective, is a state of well-being that enables per sons to live their lives (Leininger, 1991;Andrews & Herberg, 1999). As such, 72 Curationis September 2000 health is defined, created and experi enced by persons and communities as they live in harmony with their physical environment (including their own biol ogy) and their cultural traditions.
Underlying assumptions in this study included the following: • Care is the essence of nursing and a distinct, dominant, central and unifying focus of the discipline (Leininger, 1991). • Caring for dependent elders within the family is a universal human experience with specific meanings and expressions that are culturally and socially deter mined.
• Urban Namibian families face unique experiences and challenges as they care for dependent elders.
• Urban Namibian families have devel oped culturally specific meanings and expressions of care and caring for elders that are essential for individual and fam ily health, survival and for preserving the integrity of the family. • Those members of the family who are primarily responsible for the care and well-being of elders will identify them selves and/or be identified by other fam ily members. • Family members who have primary responsibility for the care of dependent elders will discuss their caring activities and the meaning they ascribe to caring. • Culturally congruent nursing care is essential to the health of elders, their families and the communities in which they live. • C ultu ra lly co n g ru e n t care o ccurs when the nurse knows and can partici pate in emic and generic meanings and expressions of care. Additionally, the following orientational definitions, based on the culture care theory were fo rm u la te d to serve as guides to study the domain of inquiry: • Health -all that enables persons, fami lies and/or communities to live their lives.
• Culture care (noun) / caring (gerund) om om te gee -ways of assisting, sup porting and facilitating oneself or others toward health.
• Urban family with dependent elders.-a group of people related by m arriage and/or kinship that identify themselves as a family, have lived in an urban com munity for more than one year with at least one member of the family who is over 65 and dependent upon the family for assistance with activities of daily liv ing, finances, and/or other health needs.
• Urban community -a community of over 20,000 inhabitants and with a strong industrial, business and retail center.
• Key participant -a person who identi fies her or himself (or is identified by oth ers) as the primary care provider for the elderly in a family.
• General participant -a member of the family (other than the primary care pro vider) who has experience living with and assisting a dependent elder; a person who is frail and elderly and dependent upon family for care; and/or a member of the nursing profession or other health professions who have experience caring for the dependent elders.

Research úuestions
Questions relevant to the domain of in quiry included: 1) What is the experience of caring for dependent elders in urban Namibian families? 2) What are the emic meanings and ex pressions of care and caring? 3) How does the cultural context of the urban com m unity influence meanings and expressions of care for the elderly? 4) Which family members assume pri mary caring roles? and 5) What cultural differences, if any, exist in care m e a n in g s and e x p re s s io n s among urban Namibian families?
Research K/|<sthtfd and P^s i g n Leininger's (1991) ethnonursing qualita tive research method was used to guide this study. The Stranger to Trusted Friend and Observation-Participation-Reflection (OPR) enablers (Leininger, 1991, pp. 91-94) provided the researchers with sys tematic and respectful ways of entering into the communities and lives of partici pants, engaging them in meaningful dia logue and leaving them with apprecia tion for their contributions to emic and generic understandings of elder care within the family.

Inviting Participation and
Respecting Participants' Persons from urban com m unities in a 73

Curationis September 2000
large metropolitan area were invited in a purposive manner to participate in the study. Com m unity health nurses and members of the research team identi fied m ost of the participant. Eleven women between the ages of 21 and 71 who had cared for a dependent elderly family member at home for 2 to 15 years were key participants. Additionally, there were 18 general par ticipants in the study. The most com m on k in s h ip re la tio n s h ip s betw een elders (care receivers) and the key par ticipants (primary care-givers) were par ent-child and grandparent-grandchild. Key participants had lived in the city for six or more years. All but one were sin gle. Two were widows and five had never been married. The 18 general partici pants included elderly members of the comm unity, frail elders who were de pendent on a family member for care, professional nurses, other family mem bers and m embers of the com m unity who were responsible for elder care.
Two institutional review boards for the protection of human rights in research • 1 love Ouma, that is why 1 care for her.
• We are her children, that is why we care for her.
• 1 know they will look after me. 1 don't even think about it (elderly participant).
• 1 do not plan for tomorrow or the fu ture. Why? We live from day to day.
• 1 ask people to pray for me and for my father.
• All my worries, 1 pray about. What good is worry. God will provide.
• Praying for an elder is very impor tant. They appreciate it very much.
• We must respect our elder's and keep them clean and never leave them alone. They should always be seen in dignified dress.
• My family respects me and listens to me (frail elderly participant.) • 1 must look after my mother. If 1 don't she will be unhappy until she dies. • This is my father's house, 1 will in herit it someday.
• The nicest thing about caring for my mother is love. This is the most reward ing and 1 feel happy.
• The nicest thing about caring for Ouma is that she is always friendly.
• Both the old and young give and re ceive. The elderly are sometimes giv ing advice.
• Caring for a parent is giving and tak ing. They mostly give appreciation. Credibility: The believability of direct evidence from the people and the environ mental context as truths to the people. (Interview and observational data col lected over two years, and participants interpretations and explanations.) Confirmability: Documented verbatim evidence from the people who can firmly and knowingly confirm the data or findings. (As categories and patterns begin to emerge, they are taken back to the informants for verification.)

Meaning-in-context:
How meaningful or understandable findings are to the people living in the experience. (Being attentive to context and going back to the participants regularly to check on out emerging patterns and hunches.)

Recurrent patterning:
Documented evidence of repeated patterns, themes and acts over time.  (Leininger, 1997, pp. 44-45;Leininger, 1991, pp. 112-114) approved the study. The review boards represented the institutions with which the team of researchers were associ ated. An Informed Consent Statement was read to each participant in the lan guage of her/his preference (Afrikaans or English) prior to the first meeting with them. Each participant signed or made her/his mark on the statement.

CoW,ecï\ng. Describing
and Documenting raw data Participant-observation and data collec tion was based on the following philo sophic, epistemic, and ontological prin ciples: • maintaining a perspective of open dis covery, active listening, and genuine learning in the total context of the par ticipant's world • being active and curious about the "why" of whatever is seen, heard, or ex perienced, and being appreciative of what participants share (reflecting on local emic viewpoints and etic or profes sional ideas • recording whatever is shared in a care ful and conscientious way to preserve full m e a n in g s and p a rtic ip a n t's ideas (Leininger, 1991, pp. 107-109).
As such, meetings with participants were conducted, for the most part, in their homes in a language they were most comfortable speaking.
A semi-structured interview guide was piloted and used to guide conversations with participants. Analysis and interpretation of meaning were contem plative processes where hunches and sym bols were identified and prelim inary interpretatio ns were made in the form of memos. Memos at te m p te d to a n sw e r th e q u e s tio n s , "W hat's happening here?" and "What does this mean? When categories and g roupings of data began to emerge, descriptive codes were assigned to data groupings and comparisons were made  Table I.
D u rin g th e fin a l p hase o f th e ethnonursing analysis, substantive con cepts were abstracted (distilled from the patterns) and relationships between and among patterns and substantive con cepts were identified. At this point, pat terns were transposed into substantive themes depicting what care for elders means within urban Namibian families. Tables II presents raw data (emic verbal descriptors), patterns and substantive themes that emerged from data analy sis.
Rigor, or trustworthiness of the study was demonstrated by being attentive to cred ibility, confirmability, meaning-in-context, recu rren t p atternin g, sa turatio n and transferability (Leininger, 1997;Leininger, 1991). We are her children, that is why we care for her. An elder said: They will look after me. I don't even think about it. I do not plan for tomorrow or the future. We live from day to day.
I ask people to pray for me and for my father. Praying on your knees is where you get your strength.
I might get weary but the Lord doesn't get tired. All my worries I pray about. What good is worry? God will provide.
Praying for an elder is very important. They appreciate it. -Substantive Theme One: Nurturing th e LleaLth of the Family The first substantive theme, nurturing the health of the family, was supported by the socio-cultural dimensions of kinship and religious and spiritual beliefs. Partici pants explained that "family members are expected to look after one another" in Namibian society. Patterns of being p h y s ic a lly pre sen t and a va ila b le to elders were important caring activities. A 54-year old woman who was caring for her 88 year-old father simply stated, " I never leave Pa alone." Likewise, the eld erly expected to always have someone in the family close by them. When one person in the family assumed a primary caring role, this freed other family mem bers to pursue their own dreams and ambitions. It also kept the family mem bers' feelings of pride about the family in tact. A participant said, "The children are happy I am doing this [caring for her father], they would not like to see their grandfather in an old age home." Other studies have noted that a family's emo tional well-being and ability to function is influenced by successfully providing care for elders within the family (Carruth, et. al., 1997;O'Neill & Sorenson, 1991).
Caring for an elderly parent or grandpar ent was considered a full-time commit ment. This was described and demon strated in a variety of ways. Only two of the eleven key participants worked out side th e ir hom es. M ost care givers elected to forgo education or em ploy ment, explaining that "caring is my life now." A young woman said that when she began caring for her mother she re signed from a job. Participants said that giving up a job was risky, as it meant that one became dependent upon other fam ily members for support or one had to "make do" on an elder's pension check of $N160 ($US30) per month. In their study of care giver hardiness, Piccinate & Rosenbaum (1997) noted that the commitment of the care giver was criti cal to their being able to carry on the care giving role. The other pattern supportive of nurtur ing the health of the family was attend ing to the physical and spiritual needs of the elder. All participants, spoke of a deep and fundamental faith in God. Liv ing that faith by praying for each other and helping people in need, beginning with members of their own families, were consistent practices in Namibian society. Verbatim descriptors related to attend ing to the elder's physical and spiritual needs included descriptions of what was done for the elder for example: "She baths herself, but I do the washing and cleaning and cooking. I also go with her to the clinic. On days when she cannot see, I must then give her tablets." Walking with the elder to church or tak ing them via a taxi or car, praying with them and for them, and reading the Bi ble together, were some of the more pragmatic and visible ways that spiritual needs were being attended to on a daily basis. In another study by Chang et al. (1998), it was noted that care givers of disabled elders who relied on religious or spiritual beliefs to cope with care giv ing had a better relationship with care recipients and lower levels of depression and role submersion.

Susan cared for her 88 year old father for 8 years until he died in April o f 1998. Susan is an
"only" daughter and therefore knew that it was her responsibility as well as her privilege to care for her father. Important caring practices for her were never leaving him alone, looking after his emotional well being as well as his spiritual and physical well being, and keeping him from making choices that she viewed as destructive to health. For many years Susan's father smoked. As he became older, Susan felt he must quite smoking because he was coughing a lot. Susan and her friends began praying that her father would stop smoking and he eventually was able to give up cigarettes completely. So for the last five years of his life he did not smoke. Susan also had made arrangements with the pension agency to fetch her father's pension herself. "This," she said, "prevents thieves from stealing his money. " Pensions are distributed in cash-N$160 per month, which is about US$35. Many times Because Susan was an only daughter, she often felt very alone with her caring re sponsibilities. Sometimes this frightened her, and sometimes she felt sad and guilty for becoming frustrated and impatient with her father. She could not even go next door to have tea without thinking that he may need something and try to get up and he would fall. Susan's primary values were care of one's kin, but she also wished she could get "out of the house" more and perhaps try getting a job and earning a bit of cash, so that she would have some money to spend on things she needed for the house, as well as on nice food.

Verbatim (literal) experiences shared bv other participants:
• We must respect our elder's and keep them clean and never leave them alone. They should always be seen in dignified dress. • My family respects me and listens to me (frail elderly participant.) • I must look after her. If I don't she will be unhappy until she dies. • When Pa is very quiet, I tell him to smile. Also, I ask him if he is sick. He says that if he doesn't talk to me, he can talk to God. • I talk to children and elderly alike. I tell them not to abuse alcohol and to look after the elders so they do not suffer. • Caring for an elder means you have a protecting role. • I pick up his pension...it is hardly enough to steal...but it would be very unsafe for him.  (Keith et al., 1994). P a rtic ip a n ts , re p re s e n tin g Nama, Damara, Coloured, and Baster cultures, did not share this form alized kinship practice with the Herero. Nevertheless, all participants spoke of the importance of respecting an elder for their life and the contributions they have made to the well-being of the family.

S ubstantive Theme four-.
Sustaining S e c u rity and Purpose for L ife Having a place to live and a reason for living was important to all persons in the study-care givers and the elder recipi ents of care. Sustaining security and purpose for life in the midst of uncertainty was a mutual process where the elder and the care giver alike contributed to each other's security and sense of pur pose in a variety of ways. Many of the homes in which the elder and primary care-giver were living were owned by the elder, and all but one elder shared their pension checks ($N160 per month or $US30) w ith the care giver and the household. Many elder's felt they were "working for the children," and the chil dren were "working for them." Substantive Theme pVe: Living w ith rapidly changing cu ltu ra l and social s tru c tu re s As cultural change sweeps th rough Namibian society, Western values of in dividualism and personal achievement are becoming more and more desirable. Since Independence in 1990, educa tional opportunities, employment, and m obility have touched the lives of all Namibian people. Key participants who were committed to caring for their eld erly relative said that it was not always easy. One care giver who found it nec essary to work outside her home said, " I love my mother...but I feel a great deal of stress. It is difficult to cope and I do not really care for myself...I do not have tim e." Others who were managing with the elder's small monthly pension check and help from relatives expressed worry that the children were not learning the values of the culture, particularly the value of caring for the elderly.
Nursing care Within the community C ulture Care Preservation Participants felt that the patterns and substantive themes describing and ex plaining the meanings and expressions of care for the elderly should be pre served and strengthened. Clearly all participants in the study-frail elderly and their care givers alike-believed the well-being of the family, as well as the integrity and dignity of elderly members, were maintained when elders lived at home. It also became evident in the study that participants were seeking se curity and purpose in their lives, a sub stantive theme they wanted not only pre served, but strengthened. C ulture Care Accommodation C ulture care a c co m m o d a tio n refers those professional actions and decisions undertaken w ith the person, fam ily, group or community, are deemed ben eficial to health and well-being. Family care givers of elders have a formidable responsibility infused with a great deal of self sacrifice. Nurses must realize that it is the family and primary care givers that are the constant in the care of the elders. How to support the family, then should be the primary goal of nursing. In th is study, p a rtic ip a n ts said they wished nurses could make more visits to the homes in the community where elders live. In this way, the professional care system was viewed as helpful, but not substituting for family care giving. From an etic perspective, elders and fam ily care givers were perceived as being in need of direct nursing care, health counselling, health assessment, and resource linking. Care givers said, "Just knowing if I'm giving him the right tablet or if I must get something differ ent would help me." And, " I don't know where to turn for help." More nurses are needed in the comm u nity to make family health assessments and offering counselling and guidance about the care of elders are needed. Nurses must bear in mind unique pat terns of care and the meanings attrib uted to these patterns. For example, trusting in the benevolence of life as lived is supported by the patterns of prayer and letting go of worries. Nurses will need to be creative in encouraging fam ily care givers and elders to talk about their worries, as this is not a common practice. Respite care for elders in the com m u nity would give family care givers release time from their full-time commitments of always being present with the elderly person. It would bring peace of mind, as well, as they would not have to be playing the protective role 24 hours a day. adopting practices that are new and more beneficial to the individual, group, or community. Since participants be lieved strongly that the patterns and sub stantive themes reflecting the meanings and expressions of elder care be pre served and strengthened, the focus of repatterning should take the form of find ing creative ways to strengthen the sub stantive them es.
For exam ple, how does one instill in young people a re spect and regard for their elders today when they are told by the dominant cul ture to think about "me first?" How do elders relate to young people who are living in a society where common tech nology is difficult for them to imagine? What do women do when they want to attend the university, obtain a degree and pursue a career, and also believe in their kinship obligations to family? Is there a role for community nurses in the needs of the elders and their families.

Conclusions and recommendations
Findings from this study will be valuable on several levels. ' First, data w ill pro vid e nurses and health care providers in Namibia with guidance for developing culturally con gruent nursing care and community re sponses to families and elderly members in urban communities. * Secondly, information related to health patterns of the elderly will raise public and p ro fe s s io n a l a w a re n ess o f the needs of this growing population group. * Thirdly, it provides guidance for struc tural changes in the delivery of health care and community health nursing serv ices. Clearly, more social and nursing support for elders in the community are needed. As less adult women care giv ers are available, more elders will be in need of respite care and old age homes. Those families who do take on the com mitment to care for an elder will need support at home. It is anticipated that additional research questions w ill be generated from this study. The largest health resource in Namibia is currently nurses. More nurses are needed to meet the community health needs of families with elders in the community.
There are different cultural traditions rep resented in Namibia and also distinct "first w orld" and "third w orld" com m uni tie s-com m unities w here ind ivid ua ls have g re a te r e d u c a tio n and w ea lth w hich gives them m ore choices and comm unities where wealth is severely lim ited, as is education and choices. This study was conducted primarily in communities where individuals choices were restricted due to poverty. It would be interesting to conduct this study in a "first w orld" community, one in which wealth and education were not limited. Also, the cultural traditions represented in this study were Nama, Damara, Col oured, Herero, and Baster. The only sub tle d ifferen ce noted was th a t w ithin Herero tradition an elder (oldest living member of a family) is expected to make decisions for the family and to be con sulted abo ut sm all and large fam ily choices. This was not apparent in other cultural traditions. What of the Afrikaner cultural tradition in Namibia?
Also, Ovambo speaking people were not rep resented in the study. This is another large cultural group in Namibia whose b eliefs and values a bo ut elder care should be explicated. As more knowl edge accumulates, the care of persons as they age should become more and more congruent with their expectations and lead to greater well-being and qual ity of life.