Ethical issues in the care of older people in east Africa: a scoping review protocol

Background In the face of fragile health care systems in resource scarce settings, health care for the elderly faces ethical challenges that need much attention. Very little attention is given to ageing research in Sub-Saharan Africa despite the rapidly growing number of older adults and their significance in communities, for example, in taking care of younger kin and thus shaping the future generation [1]. Care needs of older people in sub-Saharan Africa are higher than those in developed countries. For example, in South Africa, more than 45% of people aged 75 and older require assistance with daily activities, while 20% of older persons in the same age group in Switzerland require assistance [2]. Although the ageing of people could be beneficial to society in general, due to, for example, the social capital of older people and the accumulated wealth across longer life-course [3], the health care needs associated with ageing bring a challenge to healthcare systems with insufficient resources. Generally speaking, old age care in east Africa is in its underdeveloped state. The growth of older population in the region, combined with the rapid change and development in terms of culture and economy, bring more complex ethical questions not only on the ways health care services are provided, but also on how administrations and policies address care issues for the older population. Although there are strong traditional family and community supports for older people, many still suffer as traditional support structures weaken mainly because of the growth of industrialisation. Family support dwindles when a supporter, for example, dies or migrates to cities or other countries [4, 5]. A pilot search conducted on 13 June 2020 shown that there were neither protocols nor finalised reports of systematic/scoping reviews on ethical issues in old age care in east Africa. The most relevant papers that we could identify after searching five databases - African-Wide Information, AgeLine, CINAHL, MEDLINE and Google Scholar – include one systematic review protocol on the effectiveness of interventions for dementia in low- and middle-income countries [6], one systematic review of qualitative studies on end of life care in sub-Saharan Africa [7], and one protocol for a scoping review of age-related health conditions among geriatric populations in sub-Saharan Africa [8]. However, none of these articles specifically focus on ethical aspects of elder care. Therefore, seeking evidence on ethical issues in old age care in east Africa warrants further exploration. The purpose of this scoping review is to explore existing evidence addressing the various ethical issues in connection with elder care in the region of east Africa, which consists the following 18 countries according to the UN Statistics Division: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Réunion, Rwanda, Seychelles, Somalia, Uganda, United Republic of Tanzania, Zambia and Zimbabwe [9]. The scoping review, as its protocol is prepared beforehand, complies with what Peters et al. state: ‘as with all systematic reviews, an apriori scoping review protocol must be developed prior to undertaking the review itself’ [10]. It is anticipated that the results of this scoping review will inform governments and policy makers of the ethical issues in old age care in east Africa. Methods We will conduct a scoping review of the literature to capture evidence about ethical issues in the care of older people in east Africa who are 60 years old and above. The United Nations agreed to refer as geriatric populations those who are 60 and above in Africa whereas age 65 will be used to define geriatric populations in high income countries [11]. Scoping reviews are conducted mainly to identify the types of available evidence on emerging topics and to analyse the knowledge base [12]. Therefore, this methodology proves suitable for this work. We will apply Arksey and O’Malley’s scoping review framework consisting of five stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing and reporting the results [13]. We will follow a transparent and rigorous search strategy with support from experienced librarians. For reviews such as ours, using the support from qualified librarians is strongly recommended as they have the skills necessary for designing and executing sensitive search strategies that researchers may not have [13]. We will pilot the search strategy to test the appropriateness of search terms and databases. Four reviewers will be involved in this scoping review to reduce error and increase reliability in the review process [10, 12]. Eligibility criteria Inclusion criteria Articles that will be included in this scoping review will have to meet the following criteria: - Written in English - Peer-reviewed journal articles - Published in any year until July 2020 - Focus on people aged 60 or older from east Africa - Address ethical issues in connection with the provision of formal and/or informal health care to older people - Focus on one, some or all of east African countries (Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Réunion, Rwanda, Seychelles, Somalia, Uganda, United Republic of Tanzania, Zambia and Zimbabwe) Exclusion criteria Articles will be excluded if they have any of the following characteristics: - If they do not exclusively focus on people/participants aged 60 and above - If they do not exclusively focus on east African countries - If they do not exclusively focus on formal or informal care of the old - If their full text cannot be obtained - If they are not available in English - If they are not peer-reviewed journal articles Literature search The approach to searching for evidence for this scoping review will follow the same three-step method recommended in standard JBI (Joanna Briggs Institute) systematic reviews [14], and the search strategy will be comprehensive in order to identify as may literature as possible [10]. First, we will undertake an initial search of selected databases and analyse index terms and text words contained in titles and abstracts. We will gather and identify the keywords by searching MeSH terms and subject headings on the databases, searching on the internet (google, Wikipedia and Google Scholar) and incorporating expert comments. We will break down our research question – what are the ethical issues in the care of older persons in east Africa – into broad keywords and Medical Subject Headings (MeSH) terms such as “older people” or “older adults” or “senior citizens” and “east Africa”. We will develop a search strategy for each database with a combination of free text and controlled vocabulary. Our strategy in developing and using search keywords will be kept broad and flexible in order to increase the chance of getting relevant papers. Our topic is broad and we will be less specific when searching studies in order not to miss relevant information; “the whole point of scoping the field is to be as comprehensive as possible in identifying primary studies” [13]. Second, we will use all identified keywords and index terms to search the following databases: Africa-Wide Information, AgeLine, CINHAL, MEDLINE, APA PsycInfo, SCOPUS and SocINDEX. Third, the reference list of all identified papers will be searched for additional evidence. At this stage, we will also search additional web-based platforms such as Google to identify more literature. Study selection The evidence selection process will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist [15]. First, all eligible articles will be uploaded into Endnote X9 software. Then the first author (KMM) will identify and remove duplicates. Two of the authors (KMM, TW) will then perform a preliminary screening based on titles and abstracts to identify and exclude those papers that do not meet the eligibility criteria. Any disagreements regarding study eligibility of the selected articles will be discussed between the two reviewers until consensus is reached. If consensus could not be reached, a third reviewer will arbitrate. Then, two reviewers (JS, BE) will independently review the full-text articles to determine their eligibility. If there are discrepancies between the results and if the discrepancies cannot be resolved by discussion and consensus, a third reviewer will interfere to take the final decision. The degree or percentage of agreement between reviewers will be calculated and reported. At the end, references of the articles deemed eligible will be screened to identify any further relevant evidence. Data charting Data from the articles will be extracted using a proforma the first author prepared. The charting form will remain flexible and be updated as necessary throughout the charting process. The extracted data will include the following information (Table 1) Table 1: Categories of information to be extracted from the data Author/s, date and title Publication type Country/location of study Objective Design and methods Sample (study population) Main Findings Recommendations for future research (if any) REC/IRP approval Remarks by reviewers (if any) Collating, summarizing and reporting the results A table consisting of the results will be presented. A narrative report will be produced to summarise the presented data. Data will be described in connection with the research question and in relation to the objectives of the scoping review. Discussion This scoping review aims to identify and discuss ethical issues in the care of older people in east Africa. This review will be the first to identify and map ethical issues in old age care in east Africa. This scoping review will contribute to understandings of the ethical issues arising in relation to providing elderly care in the African context. It has a potential to create greater awareness into the growing complexities of geriatric care in today’s rapidly evolving and globalising world. The results of this review will also identify areas requiring further investigation. Some limitations in this scoping review are anticipated. Studies will be omitted if they include participants of all ages including older people aged 60 or above. Studies which, for example, operationally define older people as adults aged 50 years and above will be excluded. A typical example of such articles is the WHO’s study on global ageing and adult health (WHO SAGE) among selected low- and middle-income countries [16]. Similarly, studies that include all African countries including those in east Africa will be excluded. These may result in the exclusion of important articles that could bring more insight into the research inquiry. Additionally, studies will be omitted if they are not available in English. Lastly, the lack of critical appraisal of included articles will prohibit commenting on the reliability of extracted data. References 1. Aboderin, I.A.G. and J.R. Beard, Older people's health in sub-Saharan Africa. The Lancet, 2015. 385(9968): p. e9-e11. 2. WHO, Towards long-term care systems in sub-Saharan Africa: WHO series on long-term care. 2017, World Health Organisation: Geneva, Switzerland. 3. Gebremariam, K.M. and R. Sadana, On the ethics of healthy ageing: setting impermissible trade-offs relating to the health and well-being of older adults on the path to universal health coverage.(Report). International Journal for Equity in Health, 2019. 18(1). 4. Lemma, S., Experiences and practices of old age home care and support to the Elderly Living in the Institutions: Assessment at Three Selected Institutions in Addis Ababa. 2014, School of Social Work, Addis Ababa University. 5. Teka, A. and M. Adamek, “We Prefer Greeting Rather Than Eating:” Life in an Elder Care Center in Ethiopia. Journal of Cross-Cultural Gerontology, 2014. 29(4): p. 389-404. 6. Salcher-Konrad, M., et al., Effectiveness of interventions for dementia in low- and middle-income countries: protocol for a systematic review, pairwise and network meta-analysis. BMJ Open, 2019. 9(6). 7. Gysels, M., et al., End of life care in sub-Saharan Africa: a systematic review of the qualitative literature. BMC Palliat. Care, 2011. 10. 8. Naidoo, K. and J. van Wyk, Protocol for a scoping review of age-related health conditions among geriatric populations in sub-Saharan Africa. Syst. Rev., 2019. 8(1). 9. UN, United Nations Standard Country or Area Codes for statistical Use, D.O.E.a.S.A.S. Division, Editor. 1999: New York, United States of America. 10. Peters, D.J.M., et al., Guidance for conducting systematic scoping reviews. International Journal of Evidence-Based Healthcare, 2015. 13(3): p. 141-146. 11. Kowal, P., L. Wolfson, and J. Dowd, Creating a minimum data set on ageing in sub-Saharan Africa. NCD Prevention and Surveillance, 2000. 9. 12. Munn, Z., et al., Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med. Res. Methodol., 2018. 18(1). 13. Arksey, H. and L. O'Malley, Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 2005. 8(1): p. 19-32. 14. Aromataris, E. and D. Riitano, Constructing a search strategy and searching for evidence. A guide to the literature search for a systematic review. Am J Nurs, 2014. 114(5): p. 49. 15. Tricco, A.C., et al., PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of internal medicine, 2018. 169(7): p. 467-473. 16. Arokiasamy, P., et al., Chronic Noncommunicable Diseases in 6 Low- and Middle-Income Countries: Findings From Wave 1 of the World Health Organization's Study on Global Ageing and Adult Health (SAGE). Am J Epidemiol, 2017. 185(6): p. 414-428.