Demographic and clinical profiles of residents in long-term care facilities in South Africa: A cross-sectional survey

Background The demand for long-term care facilities (LTCFs) amongst older people in South Africa (SA) is growing and there is insufficient information on the profile and healthcare needs of this population. Aim This study was conducted to describe the demographic and clinical characteristics of residents in LTFCs in SA. Setting Three LTCFs in eThekwini district. Methods A cross-sectional design was used to collect data from a purposive sample of 102 (N = 204) residents. A structured questionnaire was used to collect demographic and clinical data. The data were entered into Microsoft Excel and analysed descriptively and inferentially using R version 3.5.1 software. Results The majority of the residents (59.8%) were between 65 and 80 years (78.9 ± 8.1 years) and 74.5% were women. The residents were white people (91.1%), SA born (82.4%) and widowed (54.9%). English was the primary language (91.1%), with the majority being christian (52.0%). Some residents had a university education, were previously employed and are financially independent. Ninety-three percent had clinical conditions, each suffering from at least three clinical conditions. Hypertension (63.7%), high cholesterol (53.9%), arthritis (38.2%), depression (37.3%) were the most prevalent clinical conditions recorded amongst the residents. Most residents were assessed to be intermediately frail, at risk of malnutrition and had mild depression as based on the respective mean frailty-, nutrition-, and geriatric depression scores. Conc lusion Residents in LTCFs in the eThekwini district are more likely to be white people; women, christian, widowed, intermediately frail and at risk of malnutrition.

Introduction and psychiatric conditions. 8,9,10,11 Comorbid conditions such as hypertension, diabetes mellitus, arthritis and renal failure were also reported amongst LTCF residents. 8 The diverse SA population represents many cultures; however, there are trends towards greater urbanisation and neglect of previous cultural norms and practices, such as home-based care for the elderly in one's family. The SA apartheid policies also saw many indigenous people being forcefully removed from prime areas and further divided along racial categories which made access (after the development of prime land) in urban areas mostly unaffordable to persons from lower socio-economic groups (from whom the land had been confiscated in the first place).
The clinical and demographic profiles of residents from LTCFs in SA have not been well reported. A 2016 study conducted in Bloemfontein (SA) revealed that 72.1% of the 104 residents in the nursing home were women with an average age of 77 years. 12 That study identified hypertension, joint disease, heart disease, cancer, psychological disorders and pain as the primary clinical conditions amongst elderly residents. 12 A recent scoping review that explored the evidence on standards and quality of care for the elderly in LTCFs on the African continent found no published literature on this topic. 13 However, the previously published literature relating to residents from LTCFs in SA reported on pathological long-bone fractures in residents with cerebral palsy 11 , social capital and mental well-being 12 , and costeffective utilisation of nursing personnel in old age homes. 13 To this end, this study provides a benchmark to report current evidence on the residential profile of people from LTCFs in 2021 in SA's largest rural province, and the data can inform planning of healthcare services for older persons in similar settings. Therefore, this study described the demographic and clinical profiles of elderly residents from three LTCFs in the eThekwini district of KwaZulu-Natal (KZN) province.

Study design and setting
This study was a cross-sectional survey conducted amongst older residents of LTCFs in the eThekwini district, a Metropolitan health district and one of 54 municipalities in the KZN province. 14 eThekwini has a developing population of about 3 548 512. 15 The economically active group represents 64% of the total population, with children (< 15 years) and the elderly (> 60 years) accounting for 28% and 8%, respectively. 15 The epidemiological disease profile of residents in eThekwini shows that the leading causes of death in the district include death due to injury or trauma, non-communicable disease (NCDs), human immunodeficiency virus (HIV) and tuberculosis (TB) and communicable diseases together with perinatal, maternal and nutritional conditions. 15 The district service delivery platform in eThekwini is managed by municipal and provincial authorities. 15 It consists of hospital level services provided by 17 hospitals, including one central hospital, one tertiary hospital, five regional hospitals, two district hospitals, one state-aided hospital, one eye specialist hospital, two specialised TB hospitals, one psychiatric hospital, two chronic hospitals and one hospital complex (inclusive of TB, dental, psychiatric and district services). 15 There are eight community health centres (CHCs) and 103 primary health care (PHC) clinics. The PHC services are governed by different authorities (provincial and local government). 15 Formally, there are 21 old age homes in eThekwini municipality. 16

Study population and sampling
The study population involved older persons who reside in three LTCFs (N = 204) in the eThekwini municipality of KZN province in SA. Three LTCFs were selected for this study because of lack of external funding and coronavirus disease 2019 (COVID-19) protocols that made many of these facilities completely locked in from the outside world. Both men and women aged 65 years and older (n = 102) were included. Individuals with advanced dementia, psychosis, comatose patients, medically unstable patients and residents who did not consent to the study were excluded. Firstly, three LTCFs were randomly selected from 21 LTCFs by simple random sampling. Of the 204 residents in the selected LTCFs, 102 residents met the eligibility criteria and consented. They were thus all included in the survey.

Data collection
Data were collected from November 2020 to January 2021 using a structured questionnaire, and administered during a face-to-face interview by the principal investigator and a trained research assistant. The questionnaire was developed, piloted and amended (some questions were rephrased for clarity) after feedback. The questionnaire was developed using Microsoft Excel and administered via Google forms. The questionnaire included the following sections: (1) demographic data, (2) education and occupation, (3) personal and family history, (4) health status, (5) continence, (6) falls, (7) medical history, (8) health needs, (9) end-of-life planning, (10) screening (vision using International Functional Vision Screening Questionnaire, 17 nutrition using Mini Nutritional Assessment: Nestle, 18

Data analysis
The data were entered in Microsoft Excel and cleaned before analysis. The analysis was conducted using R version 3.5.1 and Microsoft Excel with the assistance of a statistician. Firstly, we performed a descriptive analysis of the sociodemographic and clinical profile of study participants, including demographic data, previous living area, education, employment, income sources, funding types, reasons for moving to the LTCF, health status, continence, falls, medical history, end of life planning and others. The resident's vision was measured with 15 items (score ≥ 9 suggests a vision problem). Nutrition score was classified as follows: malnourished (0-7), at risk of malnutrition (8)(9)(10)(11) and normal nutritional status (12)(13)(14). Hearing score was interpreted as no hearing impairment (0-8), mild-to-moderate hearing impairment (10-24) and significant hearing handicap (26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). Activities of daily living score was classified as independent (ADL score = 6) and dependent (ADL score < 6). Instrumental activities of daily living score was interpreted as dependent (IADL score less than 8 for women and less than 5 for men) and independent (IADL score of 8 for women, and 5 for men). Frailty score was interpreted as not frail (score = 0), intermediate (score 1-2) and frail (score > 3). A geriatric depression score of 0-5 suggested mild depression, moderate depression (score > 5) and severe depression (score > 10). Cognitive impairment was categorised as follows: no cognitive impairment (MMSE score 24-30), mild cognitive impairment (MMSE score 18-23) and severe cognitive impairment (MMSE score 0-17). Subsequently, Rank sum test, Kruskal-Wallis test, Chi-square test or Fisher's exact test were conducted to evaluate score differences (vision, nutrition, hearing, ADL, IADL, frailty, geriatric depression and MMSE), and comparisons were made between female and male participants. Spearman's rank correlation was also performed to explore associations between the scores obtained. Results were statistically significant when the p-value was less than 0.05 (p < 0.05).

Demographic characteristics
According to the demographic profile of the study participants, overall, a total of 102 elderly residents participated in the study ( Table 1). The majority (82.4%) of the residents were born in SA (3.3% in KZN province) and 17.6% were born overseas. The proportion of female to male participants was at 3:1 (74.5% vs. 25.5%). The mean age of the residents was 78.9 years (standard deviation [s.d.] = 8.1 years), and most participants were aged between 65 and 80 years (59.8%). Most of the residents from the LTCFs were white (91.1%), with black residents (2.0%) being the least represented group. Christians were the majority 52.0%, whilst Hindu constituted the least (4.9%). The majority (54.9%) of them were widows or widowers, and the least 0.01% were separated.

Socioeconomic characteristics
Of the 102 participants, 30.4% had university education, whilst 1.0% had no formal education. Per their previous employment, 46.1% of the 102 participants worked in the formal sector as a professional, whilst 44.1% worked at the informal sector. Nearly 10.0% of the participants were never employed. Of the 102 participants, 76.5% were financially independent. According to their current source of income, 61.7% earn from pension schemes (39.2% private and 22.5% government pension); however, close to 7% (7/102) did not have any source of income. Most residents (73.5%) were admitted from their own homes, whilst the least (4.9%) were admitted from other types of accommodation. About 25% (26/102) of the residents relocated to the LTCF because of physical challenges, and few (4.9%) were relocated because of mental challenges. In terms of their duration of stay in the LTCF, almost half (48.0%) had stayed between one month and one year, and approximately 10% were within one-month duration. The majority (65.7%) of the 102 participants lived independently at the LTCF, whilst 7.8% were frail. About 77.5% of the study participants had family supporting them and 22.5% were not supported. Of the 102 study participants, most of them (52.9%) said their children resided in other countries and 14.7% did not have children. Fifty-two percent of the participants had multiple funding sources, including state pension and non-governmental organisations (NGOs), and the remainder 48% were funded privately (see Appendix 1, Table 1-A1 for the socioeconomic characteristics of the study participants).

Clinical characteristics
Of the 102 participants, about 93.1% had clinical conditions, each suffering from at least three clinical conditions. Out of the 407 cumulative conditions, the most prevalent clinical   Table 3). A strong positive correlation was observed between ADL and IADL scores (r = 0.666; p ≤ 0.001), IADL and MMSE scores (r = 0.728; p ≤ 0.001), and moderate correlation between ADL and MMSE scores (r = 0.444; p ≤ 0.001). However, a negative correlation was observed between the nutrition score and frailty score (r = -0.536; p ≤ 0.001; Figure 3).

Discussion
This study reports the demographic and clinical profile of older residents from three LTCFs in the eThekwini district of SA. The demographic profile highlights that most of the residents from LTCF in the eThekwini district are white, Christian, widowed women between 65 and 80 years of age. The residents were primarily persons with tertiary education, previously employed and financially independent. The findings reveal that most residents from three LTCFs in the eThekwini district relocated because of physical challenges, safety concerns, lack of help at home, financial difficulties, death of a spouse and mental challenges. Despite these reasons, most residents (65.7%) lived independently at the LTCF.

Min-Max
Vision score  The demographic profile of residents in this study in terms of race, gender and age is similar to other previous studies conducted in SA. 12,24 In SA, Gerber et al. study of older persons to determine health-related quality of life and functional abilities in nursing homes in Bloemfontein, similarly found that 72.1% of the 104 study participants were women with a mean age of 77 years. 12 Also, this study's findings on the sex and race of the residents were similar to those reported by Perold and Muller in their study, which investigated the composition of old age homes in SA. 24 They found many of the residents in their study were women and mostly classified as white people (83, 74%).
Moreover, this study found that hypertension, high cholesterol, arthritis, depression, GORD and heart failure were the most prevalent clinical conditions reported amongst the residents. Similarly, this study findings on the clinical characteristics of the residents support the study results of the Gerber et al. 12 Also, our findings on the clinical profile of the residents' support those of Gerber et al. in their study in Bloemfontein. 12 They reported that most of the study participants had a history of a minimum of two of the following diseases: hypertension, joint disease and heart disease. 12 This is probably because of age similarities reported by both studies, and also, because of socioeconomic similarities.
This study showed that most residents were older than 77 years. Getting older can bring senior health challenges such as heart diseases, diabetes, falls, arthritis, cancer and others. An awareness of these common chronic conditions can assist relevant stakeholders, and LTCF can take steps to stave off disease or plan and implement essential interventions to reduce mortality or disability amongst older persons. To this end, placement assessment needs to be reviewed regularly to identify needs and appropriate interventions. This study found that the residents mostly belong to the white race. This may be because of cultural, socioeconomic and historical influences that affect (the use of LTCF or nursing homes), and if so, community education targetting other ethnic groups will be needed to change the stereotypes about the use, access, or benefit of LTCF. Greater proportions of the residents are widows, and hence, we recommend elder care clubs and community engagement and outreach programmes to address social isolation among the elderly, especially that almost 14% reported not receiving help at homes as the reason for relocating to the LTCF. Aside from this reason, about 53% of older people resident in LTCFs in this sample had their family living abroad. Therefore, it is essential to regularly evaluate and provide relevant psychological, physical and social support to residents, especially those who have their families living abroad. These psychological, physical and social support if provided, as well as creating mental health awareness, will help to facilitate their physical and psychological well-being at the LTCFs, especially approximately 7% of the residents suffered dementia or depression. However, it will be essential to first understand the unmet needs of the residents in order to plan and provide the needed psychological, physical and social support interventions. Based on their medical history, we recommend implementing preventive strategies, such as early and regular screening, for the detection and timely initiation of treatment or care to prevent complications because of hypertension, cholesterol, arthritis, depression, osteoporosis and GORD. These in conjunction with structured physical exercise programmes, physical rehabilitation and occupational therapy will be essential to reduce the sequelae or complications of the clinical conditions as reported in the study findings.
Moreover, the frailty and nutrition scores of the residents in this study suggest that they were intermediately frail and at risk of malnutrition. This potentially could place them at high risks of diseases or infections. Even more worrying is that the BMI of about 69% of the study participants was over 23. People who are obese, compared with those having a healthy weight, have a higher risk for many serious diseases and health conditions, including the following: mortality, hypertension, dyslipidaemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease and osteoarthritis. 25,26,27 High BMI can additionally increase the risks of sleep apnoea and breathing problems; cancer; mental illness such as clinical depression, anxiety, 28,29 other mental disorders; body pain and difficulty with physical functioning. 30 Therefore, we recommend the education of residents, the LTCF managers, and the caregivers on diet, supplementation, and risk factors for   This study's participants were selected using a random method that allowed all eligible residents to be included in the survey. This study has provided a snapshot of the sociodemographic and clinical profile of older people residing on three LTCFs in eThekwini (SA). The results add to the body of knowledge on the demographic and clinical profile of elderly residents in SA's LTCFs. Despite these strengths, there are numerous weaknesses for this study. This study involved only three private LTCFs within one district in the KZN province, and hence, it may not be generalised for the whole of SA. Also, the data for this study are crosssectional and are subject to all limitations associated with the study design. Furthermore, this study's eligibility criterion was limited to residents aged 65 years and above, which possibly excluded younger residents from the LTCFs. Nonetheless, this study has provided research evidence useful for baseline planning or strategising improvements of care, hypothesis generation and future research to improve the quality of care and life of older residents in LTCFs in the study area and elsewhere both nationally and abroad, where the population characteristics are similar to those in the eThekwini district. Beyond establishing the demographic and clinical characteristics of the residents, it may be worthwhile to understand the lived experiences of the residents in LTCFs as well as the care providers and managers' experiences. This, together with the survey results, will provide a holistic understanding of the needs of the residents, care providers and the managers for reforms to improve the quality of life of the residents. To this end, we recommend that subsequent studies focus on the lived experiences of older persons resident in LTCFs and the experiences of caregivers and the LTCF managers using qualitative research methods.

Conclusion
This research study provides insights into the socioeconomic and clinical characteristics of older residents of LTCF and their reasons for choosing to live there. Furthermore, the study highlights residents' vulnerability to malnutrition, frailty and depression, and suggests urgent needs for clinical and non-clinical interventions to address these priority issues. A future qualitative exploration of lived experiences of residents at the LTCFs, those of the facility managers and caregivers would add great understanding of the quantitative results and their needs for necessary reforms to improve their quality of life whilst residing in the LTCF.