|Year : 2014 | Volume
| Issue : 1 | Page : 11-16
Functional disability among elderly persons in a rural area of Haryana
Priti Gupta1, Kalaivani Mani2, Sanjay Kumar Rai3, Baridalyne Nongkynrih3, Sanjeev Kumar Gupta4
1 Junior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Scientist, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
3 Additional Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||5-Mar-2014|
Sanjeev Kumar Gupta
Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The number and proportion of elderly persons is increasing, in India, as well as the world. Disability is an important indicator to measure disease burden in this group. While some chronic conditions may not be amenable to complete cure, their functional disabilities can be improved with timely and appropriate management. Objectives: The objective of the following study is to estimate the prevalence of functional disability and study its association with socio-demographic variables and self-reported chronic conditions among elderly persons in a rural area of Haryana. Materials and Methods: All persons aged 60 years and above in the randomly selected six clusters were included in this community-based cross-sectional study. Information was collected on socio-demographic variables and self-reported chronic conditions. Functional disability was defined as having disability in activities of daily living, or blindness or hearing impairment, or a combination of these. In multivariate analysis, backward stepwise logistic regression was carried out to study the association between the independent and dependent variables, after adjusting for confounding variables. Results: Among the 836 participants studied, the prevalence of functional disability was estimated to be 37.4% (95% confidence interval: 34.2, 40.7). The prevalence was less among men (35.9%) than women (38.8%). The prevalence increased with age, was more common among persons who were not currently married, had diabetes and chronic obstructive pulmonary disease. Conclusion: Functional disability is common among elderly persons in the rural area. Community-based interventions are needed to address them. Management of chronic conditions should include prevention and control of associated disability.
Keywords: Activities of daily living, Disability, Elderly, Functional disability, Older persons, Rural
|How to cite this article:|
Gupta P, Mani K, Rai SK, Nongkynrih B, Gupta SK. Functional disability among elderly persons in a rural area of Haryana. Indian J Public Health 2014;58:11-6
|How to cite this URL:|
Gupta P, Mani K, Rai SK, Nongkynrih B, Gupta SK. Functional disability among elderly persons in a rural area of Haryana. Indian J Public Health [serial online] 2014 [cited 2018 Aug 16];58:11-6. Available from: http://www.ijph.in/text.asp?2014/58/1/11/128155
| Introduction|| |
Elderly population, in India as well as world-wide, is increasing rapidly over the years. The proportion of world's elderly population will double from 11% to 22%, between 2000 and 2050. The number of people aged 60 years and above is expected to increase from 605 million in the year 2000, to 2 billion in 2050.  In India, the proportion of elderly was 8% in 2012, which is expected to increase to 19% in 2050. 
Elderly persons, being one of the most vulnerable groups of the society have more chances of chronic disease, infections, as well as disabilities. Disability has been defined as a restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being.  It reflects how well an individual is able to function in general areas of life. Disability in elderly can be grouped in three large groups. First - who can manage in their daily activities with the help of mechanical devices. Second - who have multiple health problems and severe limitations in mental and/or physical functioning who require very intensive levels of care. Third-in between above two groups, they are functionally disabled in one or two ADLs, or have mild cognitive impairments.  Magnitude of disability has become an important indicator in measuring disease burden along with morbidity and mortality rates.
Although elderly persons may have chronic diseases that may not be amenable to cure, their functional disabilities, if recognized at an early stage, can often be improved greatly. Planning and delivery of health care services in this area would require information on the magnitude of the problem in the community. Hence, it would be useful to estimate the burden of functional disability among the elderly persons in a rural area.
This study was carried out to estimate the prevalence of functional disability and study its association with various socio-demographic variables and self-reported chronic conditions among elderly persons in a rural area of Haryana.
| Materials and Methods|| |
This community-based cross-sectional study was conducted among persons aged 60 years and above, in rural area of Ballabgarh, District Faridabad, Haryana, which is the rural field practice area of the institute. There are 28 villages under our intensive rural field practice area. These villages are nearly 50 km away from Delhi and represent a typical rural community of Haryana. There are two primary health centers in this area, each with 6 sub centers. The health management information system is a computerized database of all individuals residing in these villages which is regularly updated with birth, death and migration record. The total population of study area is nearly 90,000. The study was conducted in November 2011 to January 2012.
The interview schedule was developed in English, translated into Hindi and then back-translated into English to check the correctness of translation. It was administered to participants in Hindi, by a single trained investigator. Information on age, marital status, education, occupation and economic dependence was recorded. A participant was considered economically independent, if his/her source of personal income or any monetary benefit from social scheme was perceived to be sufficient to maintain himself/herself. The participant was considered partially dependent if he/she had some personal income or any monetary benefit from social scheme, but which was not perceived to be sufficient to maintain himself/herself. The person was classified as economically dependent, if there was no personal income or monetary benefit from any social scheme and was totally dependent on other family members. The information on self-reported chronic conditions was recorded. Self-reported chronic condition was recorded if the participant had a doctor's prescription or medicines for the condition, viz., hypertension, diabetes, chronic obstructive pulmonary disease (COPD). Information on joint pains was recorded based on the history.
Functional disability was defined as having disability in activities of daily living (ADL) or blindness or bilateral hearing impairment, or a combination of these.
ADL were assessed by using Barthel "ADL" questionnaire. ,, The ten ADL items assessed were feeding, bathing, dressing, grooming, toileting, bladder control, bowel control, transferring from bed to chair, walking and stair climbing. The participant was considered as having ADL disability if she\he had at least one of these ten ADL disabilities.
Presenting visual acuity was assessed by using Snellen's distance vision chart. The vision was recorded at a distance of 6 meters separately for each eye; with distant glasses, if any; the participants were categorized as having vision <6/60 or ≥6/60. Blindness was defined as presenting visual acuity of <6/60 in the better eye. 
For hearing assessment, all participants were first administered the whisper test. Those participants who failed the whisper test were examined with Rinne's test and Weber's test for hearing status, using a 512 Hz tuning fork. Based on these tests, it was determined if bilateral hearing impairment was present or not.
Sample size was calculated using a prevalence of 21.5%.  The relative precision was taken as 20% and alpha error as 5%. With a design effect of 2, the estimated sample size was 730. However, taking a response rate of 80%, the final sample size was calculated to be 913, say 920 elderly persons aged 60 years and above. The villages of the study area were either segmented or merged to yield 30 clusters, the population of which ranged from 2385 to 3420. Cluster random sampling was carried out and six clusters were randomly selected to yield the desired sample. All elderly persons in the selected clusters were recruited to the study. Elderly persons who had been residing in the area for at least last 6 months were included. Those who were unable to understand or answer the questions were excluded from the study. House-to-house visits were conducted in the selected clusters to collect the data. Three house visits were made in case the eligible participant was not available on the first visit. Participants who refused to participate or who could not be contacted despite three house visits were taken as non-responders.
Data was entered in Microsoft Excel 2007 and transferred to STATA version 9 (StataCorp, College Station., Texas, USA) for statistical analysis. All socio-demographic variables and self-reported chronic conditions, i.e., hypertension, diabetes, chronic obstructive airway disease (COPD) and joint pains were taken as predictor variables for functional disability. The prevalence of functional disability was estimated and reported as prevalence (95% confidence interval [CI]). Odds ratios were computed for bivariate analysis to find association between outcome and predictor variables. All the predictor variables which were significant at the level of P < 0.10 were included as a factor in the multivariate model for logistic regression. In multivariate analysis, backward stepwise logistic regression was done and all the predictor variables significant at the level of P < 0.10 were included in the model. All the variables retained in the final model were reported to be independent predictor variable for the dependent variables after adjusting for confounding variables. Results of bivariate and multivariate analysis are presented as unadjusted odds ratio and adjusted odds ratio respectively. P < 0.05 was considered to be statistically significant.
Approval for this study was taken from the Ethics Committee of the All India Institute of Medical Sciences, New Delhi, India. Written informed consent was obtained from the participants.
| Results|| |
Of the 932 enumerated elderly participants in the six selected clusters, 927 were eligible for the study. Out of these 927, 836 (90.1%) participated in the study. Of the remaining 91 elderly participants, 80 (45 men and 35 women) could not be contacted despite three visits to their homes and 11 (4 men and 7 women) refused to participate. Response rate was more among women (90.8%) than men (88.4%). It was maximum in age group 70-74 years (94.9%) and minimum in age group 60-64 years (84.1%). The cluster-wise response rate ranged from 84.2% to 97.1% respectively.
Out of 836 participants, 46.7% were men. The youngest age-group, viz., 60-64 years had the largest number of participants, viz., 39.3%. Mean age of the participants was 67.8 years (SD = 7.41). The mean age of men and women was 68 years (SD = 7.41) and 67.6 years (SD = 7.5), respectively. Five hundred and seventy-six (68.9%) participants were currently married. More men (83.1%) were currently married than women (56.5%). Others include never married, widow/widower and divorced or separated. Almost all participants (98.8%) were living either with their family or spouse. Five participants were living alone. Six hundred and eighty-four (81.8%) participants were economically dependent. Most (89.9%) participants were not working. About two-thirds (67.2%) of the study participants were illiterate.
Of the 836 participants, 172 (20.6%) reported to have hypertension, 54 (6.5%) had diabetes, 114 (13.6%) had COPD and 193 (23.1%) gave a history of joint pains.
The prevalence of functional disability was estimated to be 37.4% (95% CI: 34.2, 40.7). It was less among men (35.9%; 95% CI: 31.1, 40.7) then women (38.8%; 95% CI: 34.2, 43.3). The prevalence increased with age, from 23.7% in the youngest age-group of 60-64 years, to 63.8% in the oldest age-group of >75 years.
Of the 313 participants with functional disability, more than two-thirds had only one condition, viz., either ADL disability or blindness or bilateral hearing impairment. The most common of these three, alone or in combination was bilateral hearing impairment (24.7%), followed by ADL disability (17.6%) and blindness (9.0%).
The association of functional disability with socio-demographic variables and self-reported chronic conditions is shown in [Table 1]. After adjusting for socio-demographic variables and self-reported chronic conditions, functional disability increased with age, was more common among persons who were not currently married, had diabetes and COPD. It was less common among persons with education status above 10 th .
|Table 1: Association of functional disability with socio-demographic variables and self-reported chronic conditions|
Click here to view
| Discussion|| |
This study describes the prevalence of functional disability among elderly persons in a rural area and its association with socio-demographic variables and self-reported chronic morbidity. The study population was randomly selected from geographically defined rural communities. The prevalence rate of functional disability was 37.4% and increased with age. The prevalence of functional disability was higher among elderly women than men. Functional disability was found to be positively and significantly associated with increasing age, marital status other than married, diabetes and chronic obstructive airway disease. In the present study, a participant was said to be functionally disabled if the Barthel ADL scale score was ≤19, i.e., at least one ADL disability was present, or better eye presenting vision was <6/60, or bilateral hearing impairment was present, or a combination of these.
However, published literature has used various definitions to describe functional disability. Barthel scale has been used in a large number of studies. Using the 10 items Barthel scale, this study revealed that 17.6% of elderly persons aged 60 years and above were dependent in at least one ADL disability. The prevalence of ADL disability in the present study was similar to studies carried out in developed countries such as USA (15%) and Japan (20%). , The prevalence of ADL disability in present study was less than the other countries such as Nigeria (28.3%), Brazil (40%), Malacca (24%). ,,
In a community-based study from West Bengal using the ADL scale, 16.16% elderly persons were found to be functionally disabled.  Another community-based study from rural Tamil Nadu reported a prevalence of functional disability of 22% using the same scale.  In rural Bangalore, 32.4% elderly persons were found to be facing problems completely or partially in at least one of the ADL activities.  Thus, as far as the ADL activities go, the results of the present study are somewhat less than those reported from other community-based studies from India.
In a community-based study from rural Ballabhgarh in 2002, among elderly persons aged 60 years and above, using Katz scale, blindness, hearing impairment and locomotor disability, the prevalence of functional disability was estimated to be 47.8%.  The difference in this result with the present study could be due to a difference in scales used and the inclusion of locomotor disability.
The present study included ADL, blindness and hearing impairment in the definition of functional disability. In addition to the commonly used ADL scale, blindness and hearing impairment were also included as these have the potential to limit the functions of elderly persons in a large way. Further, any community-based intervention to address the issue of functional disability among this vulnerable group must necessarily target blindness and hearing impairment. An earlier study has reported that blindness and hearing impairment are associated with mortality in this age-group.  Hence, if appropriate curative or rehabilitative measures are instituted, not only will they alleviate the suffering due to the functional disability, they shall also add years to the life of our elderly persons. Locomotor disability was not included in the present study, as it was felt that it would be reflected in the components of the ADL scale.
Five out of 932 elderly persons were excluded from the study, as they were unable to understand or answer the questions. As these persons could have been functionally disabled, this could have resulted in a slight under-estimation of the prevalence of functional disability, though this number was small. Self-reported chronic conditions were used in the present study. This may have led to an under-estimation of these conditions. However, it is difficult to comment on the effect this may have had on the results. A limitation regarding the sample size estimation needs to be mentioned here. The result of a study from Karnataka was used to estimate the sample size. However, this study had included mental disability and speech disability also.
Prevalence of functional disability among elderly persons in rural Ballabhgarh was 37.4%. Functional disability was found to be significantly associated with age, marital status, diabetes and COPD. These findings emphasize that there is a need to strengthen health care facilities for our elderly persons, in the domain of disability management. Community-based programs need to have strong components of prevention of disability and adequate treatment of chronic conditions. Management of chronic conditions, especially diabetes and chronic airway obstructive pulmonary disease, should address the accompanying functional disability as well. The concerned health care providers need to recognize the functional disability as a condition deserving of attention, as much as the primary chronic condition. Within the group of elderly persons in our community, those who are not currently married deserve special attention.
India has launched the National Program for the Health Care for the Elderly. One of the objectives of this program is to provide an easy access to promotive, preventive, curative and rehabilitative services to the elderly through a community-based primary health care approach.  At the sub-center level, the package of services includes domiciliary visits by trained health workers for attention and care to elderly persons and provision of training to the family care providers in looking after the disabled elderly persons. This step shall go a long way in addressing the serious issue of functional disability among the elderly persons in our rural areas.
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