Patterns in Elderly Care: A study Conducted in Kedah

Malaysia is estimated to become an “aging society” country by 2030 due to the increase in the number of senior citizens in the country. This is expected to lead to issues relevant to the welfare of the elderly when there is an outflow of guardians to the urban cities. Thus, this study was conducted to explain the pattern of caring for the elderly among their guardians. This qualitative study was conducted in Yan, Kedah, involving 26 respondents among the elderly. Face-to-face interviews have been conducted by researchers using semi-structured interview forms related to demographics and elderly care patterns. Moreover, a Focus Group Discussion (FGD) has also been conducted with the subjects to find out more about the issues being studied. The data obtained has been analyzed descriptively and thematically to answer the research questions. The results showed that there has been migrations of the elderly‟s guardians from rural areas to urban areas. Most respondents live with their spouse or alone in the village because of their guardian‟s job commitments. The results also demonstrated that respondents chose to live in their own homes rather than their children's homes. The study also suggested that authorities need to provide social support for the elderly who live in rural areas, especially to care for the welfare of these groups.


Introduction
Migration from rural areas to urban areas among the primary guardians of the elderly deem them no longer considered safe for the future care of the elderly. This is because at an older age many aspects of care are needed by the elderly towards the end of their lives. Care can be defined as the act of guarding, monitoring, nurturing, regulating and so forth (Kamus Dewan Bahasa dan Pustaka, 2018). The term "guardians" in this paper refers to the children or closely-related family members of the elderly. One aspect that needs to be emphasized regarding the elderly is the issue of the outflowing of guardians to the cities (Wan et al., 2015).
The issue of the outflowing of guardians, also known as care drain is a booming issue that has been discussed globally (Bettio and Villa, 2006). It has left implications that have led to abandonment of senior citizens in urban areas and consequently guardianship issues. Although this issue has yet to obtain the attention of gerontologists in Malaysia (Wan et al., 2015); the phenomenon of migration of guardians out of rural areas, which has caused many elderly people in the these areas to deal with guardianship problems, merits more attention. In Malaysia, migration to cities has become more popular since the Malaysian New Economic Policy (Dasar Ekonomi Baru) was launched in 1971, leaving an impact on how care for the elderly has evolved, especially in rural areas.
Migration of guardians to the city has become a factor to custodial problems faced by the elderly who may struggle to find alternative ways to substitute care, which may include finding a maid from Indonesia (Zakiyah et al., 2009). Therefore, before any policy on elderly care can be formulated, the extent of the outflow of the guardians should be analyzed to assist the government in identifying the true extent of the phenomenon characterized by the outflow of guardians to the city. Additionally, this phenomenon needs to be analyzed as the population of elderly members continue to grow in society. Family members, communities and governments are required to face the problems of the care system for this population. Thus, this article attempts to identify the extent of migration patterns of the senior citizens" guardians out of the area of their living quarters.

Research Problems
The migration phenomenon has long earned the attention of demographic researchers (Katiman, 2006;Mohd and Ishak, 2007;Usman and Tarmiji, 2010). However, studies on the implications of the outflow of guardians has yet to gain the attention of researchers who study senior citizens in Malaysia (Wan et al., 2015). Currently, there has been no specific study that quantitatively explores the issue of the outflow of guardians and its implications on elderly care in Malaysia. Studies conducted previously by researchers on the elderly in general (Economic Planning Unit, 2001;Husna and Jariah, 2012;Tengku and Jariah, 2010) show that there is clear evidence of the elderly being left behind in poverty and economic hardship. Therefore, the main concern behind the issue of aging population aside from poverty is the issue of elderly care (Wan et al., 2015); neglect (Noraini et al., 2015) and abuse (Jal, 2010).
The phenomenon pertaining to the outflow of the senior citizens" guardians to the cities should be given more attention by the researchers who study senior citizens.This is based on observation that has shown many senior citizens live alone in rural areas in Kedah, Kelantan and Terengganu (Wan Ibrahim Wan Ahmad, 2015). Studies conducted in Selangor, Negeri Sembilan and Melaka by (Masitah and Nazileh, 1988) also show similar findings in their areas of research. Therefore, to ascertain the extent of the impact of the outflow issue to the pattern in elderly care in the future, an in-depth study is required. Secondly, Malaysia is now facing the rapid growth of senior citizens. With an increase in the population of senior citizens, Malaysia, as well as some other countries is considered to be heading towards the direction of becoming an ageing society (Phillips, 1992). In 1970, the population of Malaysian residents who were 65 years old and above was 282,367 people. In the year of 2000, the population grew to 919,000 residents whereas the year of 2005 saw an increase to 1,1133,000 residents.
It is expected that the population in Malaysia in 2020 will amount to 2,079,000 residents. In terms of percentage, it has increased from 3. 1% (1970), to 3.9% (1995), to 4.2% (2000) and is expected to be 7.3% by 2020 (United, 1982). In 2010, there were approximately 2.3 million (8.2%) senior citizens aged 60 and above in Malaysia and the number is expected to increase to 5.5 million (14.4%) by 2030 (Faculty of Economics and Administration, University of Malaya, 2012, seen in Wan et al. (2015). There is one elderly person aged 60 years and above in every 16 Malaysians (Tengku et al., 2004). With the increase in senior citizens, family members are faced with the custody problems pertinent to elderly people. Senior citizens also face issues with alternative residency as a result of a depleting source of elderly caregivers (Wan et al., 2015). This advocates for issues relating to elderly care to merit the attention of researchers studying the elderly in Malaysia.
Thirdly, this is in response to urges from the World Assembly on Aging held in Vienna (United, 1982) which invites all countries to raise awareness on the consequences of population aging. The United Nations has also declared the year 1999 as International Year of Older Persons (Kinsella and Velkoff, 2001) in hopes to draw attention and intensify studies on the elderly in any aspect. Thus, this is a small effort towards fulfilling the urges as mentioned above. Until now, the question regarding the outflow of the guardians and to what extent the outflow can raise implications on the patterns of elderly care still has not been elaborated fully. Hence, the question of how much the extent of the outflow of the guardians have to be explained objectively.

Methodology
This study was conducted in Yan, Kedah using the qualitative approach. The structured interview of using questionnaire towards 26 respondents (elderly) were used to interview them, face to face. Seeing as the respondents were elders in the ages of 60 to 83 years old, they had eyesight and reading problems due to blurry eyesight and illiteracy. Hence, researchers helped the respondents in answering the questionnaire by reading the questions and choices of answers available. This greatly helped the respondents in answering the given questions. Besides that, Focus Group Discussion (FGD) was conducted to obtain the information for this research. The FGD session went on for 60 minutes headed by the lead researcher. The data obtained was recorded and transcripted. Finally, the data was analysed descriptively for demographic purposes and manually to come up with a theme for the acquired interview"s data

Results and Discussion
The results of the research were based on 26 respondents that were interviewed by the researchers.  Table 1 above shows the distribution of the respondents" demographic. The majority of the respondents" gender were female (61.5%), while the rest were male (38.5%). There were respondents aged 60 to 64 years old (61.5%), followed by 30.8% of them who were 65 to 69 years old and only 7.1% respondents who were 75 to 79 years old. From the aspect of education, as much as 92.3% respondents possessed Sijil Rendah Pelajaran (SRP, Malay for Lower Certificate of Education) and below while only 7.7% acquired the level of education up till Sijil Pelajaran Malaysia (SPM, Malay for Malaysian Certificate of Education). Most of the respondents were housewives (53.8%) where 38.5% were self-employed and 3.8% were private sector employees and pensioners. Majority of the respondents has an income of RM1 to RM500 (53.9%), followed by 11.5% earning RM501 till RM1000 and RM1000 till RM1500. Only 3.8% respondents have an income of RM1501 till RM2000 and 19.3% of the respondents have no income. As much as 53.8% of respondents have 5 to 6 children whereas only 3.8% have 9 to 10 children or no children. Meanwhile 23.2% have 3 to 4 children and 15.4% have 7 to 8 children.

Patterns in Elderly Care
The following is the patterns of elderly care analysed descriptively. It covers the level of health, cohabitation, in whose resident, number of children living nearby, the type of necessities provided by their children, and prospect of custody in the future. According to Table 2 above, 61.5% respondents stated that their health is not at the optimum level or unsatisfactory level, whereas only 38.5% respondents claimed that they have attained a satisfactory health level. A large number of the respondents live with their spouse only (65.4%), 11.5% live with their spouse and children, 7.7% respondents live with both daughter and son. Only 3.8% respondents live with their grandchildren or alone. Majority of the respondents live in their own house (92.3%) and only a small number live in their children"s house (7.7%). 34.6% respondents have at least one child living nearby and another 19.2% have two children living nearby. As much as 11.5% and 19.2% have three to four children each that live nearby and 15.4% respondents with no children living nearby. More than half of the respondents which is as much as 57.7% stated that they received necessities in the form of financial needs and groceries from their children. As much as 34.6% received food and clothes, 30.8% receive healthcare aid and travelling funds. About 15.4% respondents receives Hajj fund from their children. As much as 88.5% respondents depend on their children to assist and care for them in the future. 34.6% respondents depend on their spouse, 15.4% claimed that they are depending on themselves for future self-care while 3.8% depend on friends and others.
Meanwhile, based on the results obtained from the interview, several themes were identified. One of them was: i. Respondents couldn"t live with their children In the interview conducted, there were respondents who said that they couldn"t live in their children"s house. Some of them tried to live in the same household as their children but weren"t successful. This is based on the following statement; "…I couldn't stay. Tried staying there before… but two days at their house feels like a week…" (Respondent CL) Residential houses in the city such as houses with gardens, multi-storey residences such as apartments, flats or condominiums were also one the reasons the elderly could not live in the same house as their children. Likewise, the reason of living in the city is why the elderly don"t want to live with their children. This is based on the statement: "The thing is… the atmosphere at their house feels like a bird cage… I could only stay for a week… feels boxed in… we are used to being friends with the neighbours. They're not, they just close the doors, end of story…" (Respondent NL) Additionally, respondents also stated the difficulty of living in the same household as their children due to concerns of having conflicts with the in-laws. This is based on the following statement: "…if we have a decent in-law, it would be fine to live together… We wish for a good in-law but it is not certain yet… what if we have one who doesn't want to take care of her mother-in-law…" (Respondent GP) ii. Chose to live at their own house In facing the migration of the senior"s guardians, the strategy employed by the respondents to solve this issue is by choosing to live at their own house rather than at their children"s house.
"If it were up to me, I would stay at my own place. Living together with us… There's no way our mother should stay by herself, in the past she took care of us, shouldn't we take care of her now…" (Respondent CL) "It's comfortable to live at my own place… It's comfortable to live at my own place when the wife is here…" (Respondent ML) And if the guardians would like to take care of them, the respondents prefer to live at their own place rather than their children"s house. In other words, the children would have to live with their parents to care for them. This is based on the following statement: "But it is better if the children live with us, it's our right, whether or not they'll be comfortable, but this is our right. Let's say we live at their place, sometimes our children would not mind, but the in-law will mind… Sometimes that can happen…" (Respondent AL) "When we get old, it is our right whether to live at our own house or our in-law's house… in other words, for me it is better to live at our own house…" (Respondent DL) iii. Avoid burdening their children Respondents also would not like to burden their children if they lived together. Furthermore, most of them are still capable of making a living for themselves. This is based on some of the statements such as below; "When our son gets married, we have to consider their situation too… will it be burden if we were to live together with them… (Respondent KP) "As for now, if I still have the energy to move around, I will go to work…" (Respondent OP) "…with my children. We have to consider their situation too, if they are able to… for those who can't afford, if it is the daughter, sometimes she also depends on her husband to give clothes to us… if it's a son, that will be a whole different story…" (Respondent PP) The overall results from these 26 respondents showed that the outflow of the senior citizens" guardians do indeed occur in the area of study. The results coincide with the research conducted by Masitah and Nazileh (1988) where migration of the senior citizens" guardians happened in their area of study. Although there was a difference of 30 years, but Malaysia"s fast-growing economy caused people to migrate from rural to urban areas in search of job opportunities (Wan et al., 2015). Furthermore, respondents from the results showed that they would like to be more independent if they are still able to care for themselves. This includes living in their own house compared to living together with a guardian. This finding rejects Jal (2010) study where it stated that senior citizens need attention and care from their guardians especially when they"re sick or cannot afford it.
This research also showed that the pattern of migration of senior citizens to urban areas occur. This finding supports the study conducted by Wan et al. (2015) where the main issue concerning elderly currently is the outflow of the senior citizens" guardians to cities. This is not just a mere discussion in Malaysia, instead, it is a global issue. This coincides with a study done by Bettio and Villa (2006), in which, the issue of the outflow of guardians, or "care drain" is a hot issue discussed at the global stage and is leaving a huge implication on elderly that lives in the rural areas to face custodial issues. For third-world countries, this issue not only involves migration from rural areas to cities, but also migration to overseas countries such as to developing or developed countries. Therefore, many more custodial issues faced by elderly will arise.
Besides that, the findings of the research showed that custodial issues happen when guardians migrate to cities. However, challenges emerge when there"s conflict within their closest family to care for the elderly, one of which, is difficulty in making a living for themselves and their family. This situation forces the children to live far away from their parents because they have to work (Rahimah, 2015). This causes the issue of caring for the elderly to be a matter of great significance to related parties especially the senior citizens that reside in rural areas. This is because guardians among children are forced to live far away due to migrating to the cities for job opportunities. This scenario appears to reject several findings by other researchers that mentioned family members were the ones who dominated in the field of elderly care and support (Cantor, 1980;Horowitz and Dobrof, 1982). This is because the findings of this research showed that there are high demands in their jobs, forcing the primary guardians to migrate to cities as the career opportunities are wider there.
However, social support for abandoned senior citizens are one of the challenges for guardians. This is because guardians have the main responsibility as a son or daughter to their parents, which is the main priority in a family and in accordance with religion. However, this responsibility was put aside due to work commitments, managing their own household, the roles they play in the community, economic constraints and others (Aishah and Katiman, 2012;Khadijah, 2012). Therefore, in order to fulfil the demands of life, they had to migrate to the cities. However, guardians should provide social supports and not forget their responsibility to their elderly. Additionally, the government can provide social support to the elderly by involving trained social workers to help this group of people (Zarina, 2005).

Conclusion
The migration of the senior citizens" guardians do indeed occur in the area of study. A big portion of the respondents still live in their own houses by themselves or with a spouse. Even though the guardians have migrated to the city, they still keep in touch with the respondents. However, the respondents chose to live independently rather than to live together with their guardians. Nevertheless, in their senile age, the respondents will live with their guardians. Based on this finding, it showed that there are still many senior citizens who reside in rural areas independently without a guardian. Hence, related authorities should provide facilities and necessities for the elderly so that their lives in the rural areas can be improved.