Psychological Medicine, 2001, 31, 29–38.

Printed in the United Kingdom

" 2001 Cambridge University Press

Ageing and mental health in a developing country :

who cares ? Qualitative studies from Goa, India
V I K R A M P A T E L"    M A R T I N P R I N C E
From the Sangath Society, Goa, India ; and Institute of Psychiatry and London School of Hygiene
and Tropical Medicine, London

ABSTRACT
Background. While there is a growing body of epidemiological evidence on the prevalence of mental
illnesses in late-life in developing countries, there is limited data on cultural perceptions of mental
illnesses and care arrangement for older people.
Method. This qualitative study used focus group discussions with older people and key informants
to investigate the status of older people and concepts of late-life mental health conditions,
particularly dementia and depression, in Goa, India.
Results. Vignettes of depression and dementia were widely recognized. However, neither condition
was thought to constitute a health condition. Dementia was construed as a normal part of ageing
and was not perceived as requiring medical care. Thus, primary health physicians rarely saw this
condition in their clinical work, but community health workers frequently recognized individuals
with dementia. Depression was a common presentation in primary care, but infrequently diagnosed.
Both late-life mental disorders were attributed to abuse, neglect, or lack of love on the part of
children towards a parent. There was evidence that the system of family care and support for older
persons was less reliable than has been claimed. Care was often conditional upon the child’s
expectation of inheriting the parent’s property. Care for those with dependency needs was almost
entirely family-based with little or no formal services. Unsurprisingly, fear for the future, and in
particular ‘ dependency anxiety ’ was commonplace among older Goans.
Conclusions. There is a need to raise awareness about mental disorders in late-life in the community
and among health professionals, and to improve access to appropriate health care for the elderly
with mental illness. The study suggests directions for the future development of locally appropriate
support services, such as involving the comprehensive network of community health workers.

life. For older, as with younger people, mental

INTRODUCTION
health conditions are an important cause of
By 1990, a clear majority (58 %) of the world’s morbidity and premature mortality. Among the
population aged 60 years and over were already neuropsychiatric conditions, dementia and
to be found living in developing countries. By major depression were the two leading con-
2020 this proportion will have risen to 67 %. tributors accounting respectively for one-quarter
Over these 30 years this oldest sector of the and one-sixth of all disability adjusted life years
population will have increased in number by (DALYs) in this group (Murray & Lopez, 1996).
200 % in developing countries as compared to If the age-specific prevalence of dementia in
68 % in the developed world (Murray & Lopez, developing countries matches that observed in
1996). This demographic transition will be developed countries, then by 2025 nearly three-
accompanied by economic growth and quarters of all cases would be living in the
industrialization, and by profound changes in developing world, a total of 24 million people
social organization and in the pattern of family out of the estimated 32 millions living with
" Address for correspondence : Dr Vikram Patel, Sangath Centre, dementia worldwide (Prince, 1997).
841\1 Alto Porvorim, Goa 403521, India. Studies from India have demonstrated a
29
30 V. Patel and M. Prince

prevalence of dementia in persons aged over 65 states (Population Research Centre et al. 1995),
years ranging from 1n8 to 4n5 % (The 10\66 41 % of the population live in urban areas,
Dementia Research Group, 2000). Prevalence compared with 26 % for India. Goa has a higher
rates for depression in a community sample of proportion of persons aged  60 (6 –7 %) than
elders has varied from 6 % in South India does the rest of India. Its declining infant
(Venkoba Rao, 1993) to
50 % in rural West mortality, fertility and adult mortality are typical
Bengal (Nandi et al. 1997). It is now widely of populations in the advanced phase of demo-
accepted that socio-cultural and regional factors graphic ageing. Goa has
1 doctor for every
modulate health perceptions, illness presen- 1000 persons, as compared with 1 doctor for
tations and interactions between the potential every 2000 persons in the rest of the country.
consumers and providers of health care services More than 90 % of all births are conducted in
(Patel, 2000). It is essential that these factors be hospitals. An extensive network of public and
taken into account in prioritizing, designing and private medical care facilities ensures that health
delivering new services. This is clearly a crucial care is relatively easily accessed by the majority
issue with respect to services for older people in of the population (Patel et al. 2000).
developing countries, where currently there is
little, if any, formal health or social welfare Procedure
provision, and where there is a heavy reliance on Data was collected in focus group discussions
informal care from families. Qualitative research (FGD). The methodology of conducting FGD is
can be used to explore in detail people’s attitudes, described elsewhere (Khan et al. 1991 ; Patel et
perceptions and experiences examining ‘ not only al. 1995). Two teams of two interviewers
what people think but how they think and why conducted the FGD. The interviewer teams
they think that way ’ (Kitzinger, 1995). Quali- were trained in the use of FGD by the first
tativeresearchcanusefullycomplementepidemio- author (V. P.). Two researchers conducted each
logical research, both by setting an appropriate FGD ; one facilitated the group while the other
agenda and by generating hypotheses for later recorded the proceedings, noting key themes
quantitative studies. and monitoring verbal and non-verbal inter-
The aims of the study described in this paper actions. All FGDs were audiotaped, allowing
were first, to investigate the understanding and the original material to be reviewed in the
opinions of Goan people, from a variety of age preparation of the record of the group pro-
groups and backgrounds, regarding the health ceedings. Nine FGD were conducted in
experiences of older people. We focused on the Konkani, one in English and three in both
two major mental health conditions of late life, languages. The FGD lasted between 45 and
dementia and depression. Since the wider conse- 90 min.
quences of deteriorating mental health in late-
life could be better understood with reference to Subjects
the family structures and broader social and Subjects were recruited from two main sources :
community context, we also wished to assess (a) older persons living in the community or in
perceptions of the status, roles and relationships old age homes ; and, (b) key informants from the
of older persons in Goan society. We anticipated community including panchayat (village govern-
that the findings of this study would inform the ment) councillors, multi-purpose health workers,
development of ecologically sensitive pro- primary care doctors, and family care-givers of
grammes of epidemiological and health service elderly persons with disability or dementia.
research into dementia and late-life depression Subjects were recruited by purposive sampling.
in Goa. The aim of the study and implications of
participation were explained to the group.
Subjects were then invited to participate on the
METHOD
basis of this information. FGD were held in a
Setting range of settings ; in north and south Goa, in
Goa is the smallest state in India. The primary rural and urban areas, and among Konkani and
language is Konkani. Goa has better health and English speakers. In all 13 groups were held as
development indices than most other Indian follows.
 Ageing and mental health in a developing country 31

status of older persons and their roles and

Older persons activities, both in the family and in the wider
Five FGD were conducted with a total of 37 community. The key themes were : What is the
older people. Three FGD involved older persons position of older people within family hierarchies
resident in homes for the aged, as follows : (1) and within local society ? ; What are the im-
Missionaries of Charity, Panaji (N l 6, aged portant roles for older people who are not in
50–70) ; (2) Asilo Home for the Aged, Panaji paid work ? ; What are the extent, the nature,
(N l 6, aged 66–83) ; and, (3) Asilo Home for and the limits of the care arrangements for
the Aged, Mapusa (N l 6, aged 65–89). dependent older persons ? ; and, What resources
Two FGD were conducted with older persons are there for older persons in the community ?
living in the community : (1) Holy Spirit Church,
Margao (N l 10, aged 60–80, older members of Data analysis
the local congregation) ; and, (2) Clube Tennis M. P. and V. P. conducted the analysis. In the
de Gaspar Dias, Panaji (N l 9 ; aged 63–72, first instance this involved detailed scrutiny of
mainly relatively affluent retired professionals). the notes and records from all FGDs. The
constant comparison technique was used to
Key informants identify all data relevant to the research
A total of eight FGD were conducted with the questions posed. The task of content coding
following groups : (1) three FGD with health included ordering the data in relation to the
workers : one with primary health centre doctors objectives of the study ; categorizing answers
(N l 3), two with multi-purpose health workers that had similar characteristics ; and examining
(MPHWs) (N l 17), i.e. community-based the data for possible associations between
health workers ; (2) one FGD with village variables (Patel et al. 1995). As a reliability
councillors (who are residents of the village) check, the two samples were analysed separately,
(N l 5) ; and, (3) four FGD with caregivers one by each of the investigators, who then cross-
of older persons with disabilities or dementia checked their codings for similarities and dis-
(N l 26) ; comprising members of church crepancies in content and organization of the
groups caring for older persons living at home, data. Themes that recurred across FGD were
and caregivers of older persons admitted to a more likely to represent a broad strand of
public psychiatric hospital or to a private opinion, and were therefore of special interest.
hospital specializing in stroke rehabilitation.
RESULTS
Focus group discussions (FDG)
The health status of older persons
Group members were asked first to describe
what they felt to be common health problems Health conditions
among older people. Three case vignettes were We recorded all health conditions mentioned as
then presented to the group describing an older being prevalent among older persons, together
person with depression ; an older person with with the number of groups in which they had
early dementia ; and then the same older person been discussed (Table 1). The lists consisted
with advanced dementia. The vignettes did not almost entirely of chronic, non-communicable
mention depression or dementia by name, but diseases ; mental health conditions were fre-
described an older person with the condition as quently volunteered.
they might be encountered by a member of the Key informants cited various causes. Promi-
same family or community (see Appendix for nent among these, mentioned in six out of eight
the full case vignettes). After each vignette the key informant groups, were the gradual de-
groups were asked to consider : Is this a health generation of health as part of old age and
problem ? ; What do you call it ? ; What care does neglect, lack of care or abuse by the family.
this person need ? ; What care is available in your Other causes recorded were alcohol abuse, poor
community ? ; and, What should be done for this diet, lack of exercise and poverty. Older persons
person ? were less likely to volunteer any attributions ; the
The second section of the FGD explored commonest explanations being a natural part of
themes related to general aspects of ageing ; the growing old, heredity and ‘ God knows ’. Doctors
32 V. Patel and M. Prince

Table 1. Common health conditions among older people

FGD with carers (N l 8) FGD with elders (N l 5)

Blood pressure\hypertension (6) Blood pressure (4)

Mental health problems\tension (6) Respiratory problems, e.g. coughs, colds, panting, bronchitis (4)
Diabetes (6) Visual problems, e.g. failing vision, cataracts, blindness, glaucoma (4)
Heart disease (5) Rheumatism\aches and pains (4)
Rheumatism\aches and pains (5) Heart disease (3)
Weakness (3) Paralysis\strokes (3)
Strokes\paralysis (3) Mental health problems\worry\insomnia\excitability (2)
Sensory deficits, e.g. hearing and visual problems (2) Deafness (2)
Alcohol abuse (2) Weakness (2)
Falls and fractures (1) Breast cancer (1)
Tuberculosis (1) Diabetes (1)
Cholesterol (1) Cholesterol (1)
Anaemia (1) Incontinence (1)
Asthma (1) Forgetting things easily (1)

Figures in parentheses are the number of FGD in which the item was recorded.

said that older persons comprised a significant moral support, love and affection. Families
proportion of primary-care clinic attenders, but needed to be educated about such problems and
that they mostly presented with minor ailments taught to value and succour their seniors. Visits
and needed only attention, reassurance or time by the parish priest, prayers, medication,
to allow them to vent their feelings. These most counselling and advice on how to adjust to old
often involved worries about health, family age, going outdoors and good food were among
conflicts and property. Multi-purpose health other interventions suggested by key informants.
workers (MPHWs) were in contact with many Older persons highlighted a caring family, a
older persons in their catchment areas. One positive attitude, spiritual programmes,
MPHW said that since many older persons had ‘ laughter clubs ’, talking to others, prayer,
no one in whom to confide, it was important keeping up with varied interests, watching
that MPHWs were able to spend some time to television and seeing a psychiatrist as potentially
listen and counsel older people. Another effective interventions. All groups expressed
suggested that MPHWs should encourage older similar views regarding the limited nature of
people to be active and provide them with roles community resources. Neighbours were of less
that might give them respect, such as working help than in the past since many people in urban
with youth organizations or clubs. areas now lived in flats. There were no clubs or
societies other than those run by the Catholic
Mental health conditions Church. Church groups prayed for such people
Depression and gave advice on problem solving.
Most older participants and key informants Dementia
identified the depression vignette as being a
psychological or mental problem. Terms fre- In none of the FGD was dementia volunteered
quently used to describe the vignette were and named as a cause of ill-health during the
open discussion. However, two cases of persons
tension, mental problem, depression and worry.
The presentation was considered by participants with probable dementia were described, un-
in each FGD to be fairly common ; one prompted, in FGD with key informants. For
participant said ‘ Five out of 10 families have example, one key informant described a man
such problems ’. However, most felt that this who could not take care of himself, needed to be
was a social, rather than a health problem. fed by his wife, and was doubly incontinent. He
Common attributions were family conflict, had to be reminded of everything. If he left his
financial difficulties, worries about children, house, very often his neighbours had to get him
neglect and abuse, loneliness and boredom. The back. The key informant explained that ‘ he had
commonest remedy suggested by key informants some defect in his brain, the memory part of his
was that older people with such problems needed brain is destroyed because his diabetes has
become too high ’.
 Ageing and mental health in a developing country 33

The vignette on early dementia was widely

recognized in each FGD, other than by primary General issues related to ageing in Goa
care doctors who said they had rarely seen such The status of older persons in Goan society
a presentation. The commonest terms used to Key informants concurred that, in general, older
describe the vignette described nervous or people do command respect in Goan society.
psychological illness, such as nerva frak or However, many of the older participants felt
nervachem (weak-nerves) ; nervous breakdown ; that this respect was on the wane. The younger
mental problem ; brain problem ; depression ; generation did not enjoy the company of the
and absent-mindedness. In two FGD, the terms older generation in social gatherings and tended
‘ dementia ’ and amnesia were mentioned. The to avoid them. Many participants felt that older
vignette on late dementia was recognized as people were given no respect in public places.
being less common. Many key informants saw One older participant said ‘ no one has any
this as a physical health problem but one for regard or respect for us, on the contrary we have
which a doctor could do nothing. The primary to respect others ’. Some older people remarked
care doctors said that they did not encounter that nowadays their married children ‘ told them
such cases in their clinical practice. They also what to do ’.
remarked that terms like Alzheimer’s disease
and dementia were associated with stigma and Dependency
were best avoided in clinical practice, especially Some key informants noted that many older
since a person diagnosed with dementia was people did not like to be dependent on their
typically refused admission to old-age homes. children, and preferred to do as much as possible
Many participants recognized the vignettes as on their own. Older participants corroborated
typical of people known to them in their village this view ; some said that they were not happy in
or in their families. They volunteered additional their child’s home either because of a son’s
observations of characteristic behaviours, such illness (often alcohol dependency) or abuse and
as ‘ behaving like small children ’, eating food at neglect. Children were furthermore ‘ authori-
odd hours, accusing others and being un- tative ’ and wanted things done their way. One
hygienic. older participant remarked that ‘ in your own
The commonest attribution among both older home you have respect, but it is difficult to get
persons and key informants was that the the same respect in your child’s home ’.
presentation was the result of ageing. Many felt Some key informants also pointed out that
that it was a natural process, though they did some older people preferred to live indepen-
acknowledge that few became as unwell as did dently, particularly those who could afford it.
the person in the advanced dementia vignette. However, they risked becoming isolated and
Neglect by family members, abuse, tension and lonely. Some older participants expressed con-
lack of love were potential causes. Less com- cern for the future. While they were fit and able
monly mentioned causes were lack of blood to walk around they did not have trouble with
circulation ; poverty ; stress earlier in life ; par- their children ; however, they were very unsure
alysis (stroke) ; weakness ; and blood pressure. what would happen to them if they should
All participants felt that persons such as become bedridden. Then they would see them-
described in the vignette needed help, and, selves as a burden to their family and local
potentially, constant support. Better care could hospitals were ‘ horrendous ’ for older persons.
be provided if the family recognized there was a Many participants expressed the view that it was
problem. Older persons suggested continual the duty of families and, especially, younger
reminders, talking to others, watching TV and family members to look after older people. One
listening to music, brain ‘ tonics ’ and medical participant suggested that caring for older people
treatments. The family was the only source of was necessary because ‘ older people are very
care since there were no resources in the important to the family since they are a lot of
community. One key informant said that families help in the house ’.
had to be told that they ‘ will have to wait In each of the key informant FGD, partici-
patiently until they (the older person) die ’. pants described instances of older persons,
known to them, who were being neglected.
34 V. Patel and M. Prince

Participants acknowledged that it was difficult dential care. In a few cases chronic deteriorating
to generalize since the position of older persons health or acute episodes of illness were
varied considerably according to family cir- mentioned as reasons for admission. However,
cumstances. The main reason that was cited was in many cases the older persons were in good
for neglect was the breakdown of family ties. health, and ‘ approaching age ’ or worries about
The younger generation was seen as having less ability to look after oneself in the future
time to care for older people ; sometimes both underpinned the move. Many of the residents
husband and wife were in full-time employment, had no family to look after them. Some had
sometimes children had to leave their family family who were either unwilling or unable to
homes to seek employment out of the area. support them. This theme was reflected in the
many residents who complained that their family
Economic factors in family care and support never visited them after their admission to the
Children’s support of their parents was reported home. Several reasons were cited for the with-
to be contingent upon an expectation of in- drawal of family support. In some cases children
heritance. Older participants reported that chil- had migrated abroad. In several cases the
dren often fight for their share of property, and resident had quarrelled with family members.
that parents were caught in the middle of these Others reported that families did not want to
disputes. Many older participants and key care for older persons because of the ‘ financial
informants highlighted that care for the parent burden ’ of doing so. Residents had experienced
often deteriorated once the property rights had being ‘ shuffled from family to family ’ ; at least in
been transferred. One commented ‘ very often the old-age home they had security. Many
the children throw their parents out of the house residents expressed bewilderment that their
once they have become a burden to them ’ and families seemed to have forgotten them after
another that under these circumstances ‘ most their admission.
often the parents are not looked after by the
children ’. One key informant, describing a sick Roles and activities
older person, said ‘ the parent was shifted from In the community, elders were involved in
a private room to a general ward in the hospital ’. household work (e.g. cooking), economic pro-
Older participants knew of cases where children duction (e.g. farming), caregiving (e.g. looking
had ill-treated or harassed parents and even after grand-children) and recreational pursuits
thrown them out of their own homes to gain (e.g. fishing and watching TV). Many older
control of the property. Children were also persons were clearly very busy and active around
reported sometimes to resent the expense of the home. Housework was spoken of as ‘ end-
medical care and treatments for parents, es- less ’. This could be a source of family conflict.
pecially when some of the children felt they were The commonest theme related to the ‘ modern ’
shouldering more than their fair share of the daughters-in-law who resented housework in
cost. Costs of care were often high ; due to lack favour of holding down jobs outside the home,
of adequate public health care for older persons, with the result that older parents were often
many families resorted to private medical care, left with the domestic chores. Key informants
which was expensive in the long-run. described older people being reduced to
‘ servants ’ in their own homes. In contrast to
Admission to old-age homes older persons living in the community, residents
It was becoming more common for older people of old-age homes, while comfortable, identified
to move into residential care homes, referred to boredom and lack of activity as a concern. One
in Goa as ‘ old-age homes ’. However, this option older person said ‘ mostly we are just sitting
was mainly available to those who were in good around ’. Another commented that ‘ it would be
health and had the means to pay. The majority nice if we were allowed to go out sometimes ’.
of old-age homes did not accept individuals who The lack of visitors and the minimal contact
were ‘ destitute ’ or who were suffering from any with the outside world was often mentioned as a
health condition likely to limit their capacity for cause of unhappiness. As with the community
self care. The residents of old-age homes residents, those institutional-based activities that
described their reasons for moving into resi- were listed were mostly non-recreational.
 Ageing and mental health in a developing country 35

deterioration, but crucially, also as a normal

Community resources feature of ageing. Advanced dementia, while
Village panchayats can provide a monthly sum being seen as a physical health problem, was one
of Rs 100 for welfare for ‘ needy elders ’. Put in for which it was felt that the doctor could do
context, this would be sufficient to buy 5 kilos of nothing. Other authors have commented on the
rice or sugar. However, the process is long- Hindi phrase sathiyana, customarily translated
winded and few older persons avail themselves as senility, but more literally ‘ sixtyish ’ (Cohen,
of the scheme. There is also a scheme for 1995). Other regional languages have similar
financial support for widows though the constructs, simultaneously conveying the con-
amounts are again insufficient to meet basic cept of advanced chronological age and in-
needs. Some villages have clubs but few older tellectual decline. Unsurprisingly, given the
people use them because they tend to focus on fatalistic view of ‘ brain weakness ’, primary
youth activities. There are no clubs organized health care doctors in Goa had little first hand
exclusively or mainly for older people. experience of managing dementia. An important
Neighbours and relatives are the main providers finding in our study was the widespread rec-
of social support. The clergy also plays an ognition of the dementia vignette by local multi-
important role and, for those older persons who purpose health workers, who identified many of
are Catholics, the church is a focal point for their active community caseload as sufferers.
socializing and support. The market also The implication would be that MPHWs would
provides an important focus for social activity. be a useful focus for the development of a
community-based dementia support service.
They could be used to identify a target group
DISCUSSION
(not an easy task in the absence of any other
The study described in this paper is, to the best health service contact) and also to implement a
of our knowledge, the first broadly based simple intervention. Thus, they might be trained
qualitative investigation of ageing and mental to educate caregivers, and to support them,
health in India. Qualitative research has its perhaps through the medium of caregiver sup-
drawbacks, notably limited generalizability due port groups.
to the recruitment of small, convenience samples Depression was recognized as being particu-
(Khan & Manderson, 1992). However, this study larly common, but was again generally not
recruited participants from a wide range of regarded as a health condition. These findings
geographical, sociodemographic and pro- suggest that lack of awareness about psycho-
fessional contexts in Goa. The data from the 13 social causes or misattribution of symptoms are
FGD show such a convergence and commonality not the main reasons for the finding that
of themes that we believe that, taken together, depression presents with somatic symptoms.
they represent a valid perspective on the status Instead, depression is not viewed as a mental
and health experiences of older people in illness in the biomedical sense ; the somatic
contemporary Goan society. symptoms that co-exist with psychological
Mental health conditions were recognized symptoms are presented since they fit the
both by older participants and by key informants explanatory model that the former are medically
as occurring commonly among older people, determined. The finding is corroborated by
and as having an important impact on their qualitative research focusing on depression and
quality of life, and on the lives of their family anxiety disorders in Goa (Patel et al. 1997). As
members. However, there were no equivalent with dementia, depression was considered to be
terms for depression or dementia in the Konkani the result of family conflict, neglect and abuse.
language. Even the English-speaking FGD only While family discord and lack of support may
once recorded the use of the term dementia. The undoubtedly play a part in the genesis of
vignettes of depression and dementia evoked depression, the prominence of these explanatory
widespread recognition but were rarely con- models may simply reflect the lack of an
ceptualized as health conditions. alternative narrative. Education of primary care
In Goa, the symptoms of early dementia doctors with regard to the clinical features and
tended to be explained as brain weakness or treatability of late-life depression is certainly
36 V. Patel and M. Prince

indicated. The apparent willingness of MPHWs both family support and financial means. The
to take on a supportive counselling role suggests homes themselves were adequate in some
that with appropriate training they might be- respects but concerns must be expressed about
come effective therapists in their own right. the isolation of residents from their families and
Alzheimer’s Disease International and its from their local community, and at the lack of
member national societies have identified raising structured activities. These homes undoubtedly
awareness among the general community and represent a transitional phase in what is likely to
among health workers as a global priority become an extended network of public and
(Graham & Brodaty, 1997). In Goa there is no private sector facilities. Important priorities
awareness of dementia as a well-demarcated would include a system of registration and
clinical syndrome. This is as true of the medical inspection of homes, training of careworkers,
profession as of the wider community. In this and provision of medical services for residents.
respect Goa is probably typical of other parts of Older people are among the most vulnerable
India. This general lack of awareness has groups in the developing world, in part because
important consequences. First, there is no of the continuing myths that surround their
structured training on the recognition and place in society (Tout, 1989). Traditionally,
management of dementia at any level of the elders have been venerated in Indian society and
health service. Secondly, dementia is stigmatized, this remains the dominant theme in how families
for example sufferers are specifically excluded care for elders today (Venkoba Rao, 1993).
from residential care, and often denied admission However, this study has also demonstrated that
to hospital facilities. Thirdly, while families are care is not guaranteed for all elders ; indeed,
the main caregivers, they must do so with little instances of neglect and abuse were often
or no support or understanding from other mentioned. The assumptions that the extended
individuals or agencies. family always provides a safety net for elders
Residential care homes for older persons are risks perpetuating complacency among health
rare in developing countries ; however, in the policy makers, social welfare and health care
most rapidly developing regions, their numbers providers. Although families are the principal
are rising fast. Our study showed that older caregivers for the aged, it is also clear that this
persons enter such homes when they are rela- arrangement is not always to the benefit of
tively well, usually because they lacked a family either the family or the older relative. The
to care for them in the event of deteriorating answer to the central question for this study,
health, or because they feared becoming a ‘ who cares for older people in Goa ? ’, is clearly
burden on their relatives, feared inadequate ‘ the family ’. However, the single dominant
support, and therefore wished to maintain their theme across all focus groups has been the
independence from the family. This constellation concern that both respect for older people and
has been reported in two previous Indian the caring traditions of the extended family are
ethnographic studies (Vatuk, 1990 ; Cohen, changing, rapidly.
1995). It has been referred to as ‘ dependency In conclusion, this qualitative study has
anxiety ’ (Vatuk, 1990) and is differentiated from demonstrated two significant findings. First,
what Vatuk terms ‘ Western feelings of guilt and that although the symptoms of depression and
low self-worth associated with the shame of dementia are well recognized, they are much less
dependence upon one’s children ’. Thus, in likely to be conceptualized as illnesses, and
contrast to guilt about becoming a burden on certainly not as mental illnesses. Secondly,
younger relatives, elders in India feared being although the majority of elders continue to live
abandoned or neglected. Goan old-age homes, in their own homes and are well-cared for by
as a rule, did not admit those with permanent their families, there are growing instances of
disabilities and specifically excluded those with abuse of older people and neglect, which signal
dementia. One reason for this was because they the need for a long-term policy for the care of
do not have facilities or manpower to care for elders in India. An unconsidered imposition of
high-dependency individuals. There was, there- Western models of care would be highly in-
fore, no local continuing care provision for appropriate, and unlikely to succeed. Thus, in
those with dementia, or for those who lacked the setting of low awareness of and preparedness
 Ageing and mental health in a developing country 37

for mental health problems in the elderly in the buy food and came back with nothing, having
medically orientated primary care system, inter- forgotten what he went out for. He repeats himself
ventions may need to focus on supporting carers in conversation, and always seems to talk about the
in home-based programmes using community past. His family first noticed the problem 1 year ago.
health workers. Future priorities for research Since then it has been getting steadily worse.
are also evident. Prevalence and incidence studies
primarily directed towards describing disease
Vignette on established dementia
distributions and identifying risk factors, should
also include studies of care arrangements for Mr D’Souza is now 78-years-old. He has difficulty
older people, and estimates of the impact of in recognizing his wife and other close family
providing care on caregivers. Pilot studies members. He sits in a chair for most of the day.
describing care arrangements for elders with He never starts a conversation but will respond to
questions by smiling or saying something, but his
dementia and depression have recently been
answers do not usually make sense. Sometimes he gets
completed in Goa. Findings from these research restless and agitated, asking over and over again
studies will be disseminated to the community ‘ When are we going out ? ’. If he wanders out of
and to health professionals via local media the house he gets lost and has to be brought back
experts, lay publications, workshops and aware- by neighbours. His wandering can be a particular
ness campaigns. problem at night. Sometimes he gets short-tempered
and abusive for no reason. He needs to be reminded
The study was supported by a small grant from the to go to the toilet, but is still incontinent of urine.
Special Trustees at the Royal Free Hospital. Staff of
the Sangath Society for Child Development & Family
Guidance, Goa, conducted the fieldwork (Livia
Coutinho, Subodh Phadke and Pacienca Cardozo).
We are particularly grateful to all those who partici-
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