Disability among elderly rural villagers: report of a survey from Gonoshasthaya Kendra, Bangladesh

  • Nicola Cherry1Email author,

    Affiliated with

    • Morshed Chowdhury2,

      Affiliated with

      • Rezaul Haque3,

        Affiliated with

        • Corbett McDonald4 and

          Affiliated with

          • Zafrullah Chowdhury5

            Affiliated with

            BMC Public Health201212:379

            DOI: 10.1186/1471-2458-12-379

            Received: 11 March 2012

            Accepted: 25 May 2012

            Published: 25 May 2012

            Abstract

            Background

            The study was set up to identify the extent and nature of difficulty with activities of daily living (disabilities) among elderly village residents of Bangladesh, to describe help currently given and to identify possible interventions. It was carried out at Gonoshasthaya Kendra (GK), a community development organization responsible for the health care of 600 villages with a population of some 1.5 million.

            Methods

            A survey card was designed and piloted using 12 questions on disability, elaborated from the Washington Group Disability questions, together with a checklist of health problems. A survey was carried out in 2010 in 535 villages under the care of GK since 2005, with village paramedics interviewing residents believed to be age 60 years or older. Respondents were matched where possible to data from the 2005 GK household census, giving data on education, occupation, socioeconomic group and smoking habit.

            Results

            Survey cards were completed for 43417 residents of which 17346 were matched to residents recorded in the GK census as born ≤ 1945. The proportion reporting ‘much difficulty’ on one or more functional capacities increased steadily with age, reaching 55% (1796/3620) among those ≥ 85 years. Difficulties most frequently reported were lifting and carrying, vision and going outside the home. At all ages women were more likely to report ‘much difficulty’ than men (OR = 1.43 (1.35 to 1.48)), with widows and the illiterate at greater risk. Health problems, particularly hemiplegia, resting tremor, urinary incontinence and depression were strongly related to the 12 disabilities assessed. Help came almost entirely from family members; of 11211 villagers with ‘much difficult’ on at least one functional capacity, only 15 reported getting help outside the family.

            Conclusions

            Disabled elderly residents were dependent on the family for help but, with family cohesiveness under threat from migration to the city, there is a pressing need for the development and critical evaluation of community-based interventions designed specifically for the elderly in poor rural societies. New approaches to training and practice will be needed to integrate such disability management into primary care.

            Background

            Bangladesh is a poor, largely rural, country with a population of more than 150 million. Although health services remain limited, much has been achieved among the young, but with little care from outside the family for the growing population of the rural elderly. The present study was designed to identify important difficulties in functional capacity in the elderly living in villages under the care of Gonoshasthaya Kendra (GK), a community development organization which provides primary health care through paramedics trained for 2 years within GK. At the time of the survey GK was responsible for the health care of 600 villages with a population of some 1.5 million. Rural health care was administered through 16 sub-centres, administering 40 health centres, from which a paramedic was assigned responsibility for each village, providing front line care.

            Our aim was to collect information that would serve to improve the management of disability in the elderly. The WHO Study on global AGEing and adult heath (SAGE) has developed interview schedules to collect data on ageing, which have been used in some less developed countries including one area of Bangladesh [1], but the schedules appeared too complex for our goal of identifying interventions that might be helpful in poor rural communities. We adopted instead the set of 6 disability questions developed by the ‘Washington Group ‘, covering vision, hearing, remembering or concentrating, walking or climbing stairs, self care (washing or dressing) and communicating [2]. We expanded these to help us better understand the circumstances in which difficulties occurred and might be managed. We then used this tool in a survey of elderly villagers living in 535 villages that had been under the care of GK since 2005, when a GK house-to-house census had been conducted by the paramedic assigned to each village.

            Methods

            Target population

            1. 1)

              Conceptual. The survey was designed to include all those still living in 2010 in the village recorded in the 2005 GK census and with a recorded census birth year of 1945 or earlier (i.e. 65 years or greater at the time of the survey).

               
            2. 2)

              Pragmatic (survey population). All residents of each village believed to be 60 years or older were identified. In the absence of any birth certification true age was difficult to ascertain, either in the census or survey; a standard protocol was used, estimating age from historic events.

               
            3. 3)

              Matched sub-population. Information from the 2005 census and 2010 survey were matched on household number and sex for all those recorded with a birth before 1945 in the census, thus approximating the initial design.

               

            Survey card

            The survey card (Additional file 1) devised was in 5 parts, demographic (age, sex, marital status, age of living spouse), difficulties with activities of daily life (disability: questions 1-12), health problems (ill-health: Q13), resting tremor, as a coarse screen for Parkinson’s disease (Q14) and help received and needed (Q15 and 16). Questions 1 and 2 on the card and the response scale for all disability questions (‘no problem’ to ‘can’t do it at all’) were taken directly from the Washington Group questions1 but the remaining 10 disability questions were elaborated to help identify barriers that might be susceptible to intervention. Respondents were asked to provide their own perception of degree of difficulty but paramedics were asked to record whether this was importantly underrated. The health problems listed were those felt by GK physicians (ZC, RH) to be the most troublesome among elderly villagers: space was left to record ‘other’ problems.

            The final English version was translated into Bangla and back-translated before being piloted for comprehension in villages that had come under the care of GK since 2005.

            Administration

            Starting in November 2009, the paramedic in each village conducted a house-to-house survey to compile a list of villagers believed to be aged 60 or greater. She then sought to interview all listed, recording the reason for any failure to do so. Supervisors re-interviewed about 10% of respondents to ensure that the interview had indeed been conducted. Cards were checked for completeness locally and returned to the GK research unit for coding and data entry. Responses to the disability and ill-health questions (Q1-14) were entered as recorded. Up to three responses were coded for open-ended items. Data collection was completed in May 2010.

            Matching to census

            Survey respondents were matched to the census data , collected by paramedics in a house-to-house survey in 2005, on village, household number and sex Where a match was achieved, census year of birth, educational level, socioeconomic status (used by GK to determine payment), occupation in 2005 and smoking habit (yes/no) were added to the survey data file.

            Statistical methods

            Three composite scores were calculated, the total number of disabilities coded as either 3 or 4 (range 0-12), a total disability score (the sum of codes 1-4 on all 12 items: range 12- 48) and the total number of boxes checked (from joints to ‘other’) at Q13 (range 0-10).

            The demographics of the 2 populations (survey and census-matched) were compared and the frequency of reporting each disability and health problem examined by age and sex. Disability was considered to be present only for those reporting that they had either ‘much difficulty’ (code 3) or ‘could not do it at all’ (code 4) on Q1-12. The relation of each disability to age, family structure (living spouse) and census information on poverty, literacy, employment and smoking was examined by logistic regression, stratified by sex. The model also included the health problems listed at Q13 (except prolapse, applicable to women only) and at Q14. In these regressions the effect of each factor (present versus absent) was calculated in a model containing all potential predictors and confounders. The relation of total disability score (range 12-48, log-transformed to reduce skew) to health problems as examined by linear regression. Help received and needed was examined by age, sex and extent of disability.

            There were very few missing values on items other than age. In analyses including age missing values were excluded: those reporting an age <60 years (but believed to be ≥60 years) were included as a distinct group. The analysis was carried out using SPSS/PASW Statistics 18.

            Results

            Participation and matching

            Survey cards were completed and entered for 43417 residents. Non-completion was recorded for 12969, with 54 recorded as refused, 5821 as died before an interview could be completed, 2006 as having moved out of the village and 1496 as still living there but never found at home. No reason was given for non-completion for 3592. In the absence of an independent nominal roll there was some uncertainty about the true size of the target population, but the response rate estimated from these figures (excluding those who had died or moved away) was 89.4% (43417/48559).

            Of the 43417 interviewed, 17346 (40%) were successfully matched to a villager of the same sex at the same address in the census data of 2005, with a census birth year ≤ 1945: scrutiny of the names recorded at the census and survey in a random sample of matched records showed a very high concordance (>95%). Because of changes in household numbering no matching was possible for 70 villages. Among those in the remaining 465 villages, subjects not matched either did not appear in the census data for that village (as would happen if they had moved into the village since 2005 or had been omitted in error from the census) or appeared in the census but with a different household number or with a birth year > 1945.

            The study populations

            The age and sex reported in the survey are shown in Table 1 for all responders and for the subgroup matched to the census, together with the number of disabilities and health problems reported. The expected deficit (implied by matching on birth ≤ 1945) was evident in the age group 60 < 65 years in the census-matched subpopulation. Women were younger than men (were more often <75 years) and more likely to be widowed. The proportion with no disability or health problem was very similar in the two populations. Overall nearly three quarters of the respondents reported that they had no serious difficulty with any of the functions listed, but the proportion with difficulties increased steadily with age. In those aged 85 years of greater 55% (1796/3620) had ‘much difficulty’ with at least one functional capacity. In this elderly population as a whole <3% reported such difficulty on 6 or more capacities, but this rose to 14.6% (477/3620) in those ≥85 years. Health problems were reported more frequently than ‘much difficulty’ with functional capacities. Almost all respondents (92.7%) reported at least one health problem that made life difficult.
            Table 1

            Distributions of age, sex, marital status, disability and health problems in the survey population and census-matched subpopulation

             

            All survey respondents (N = 43417)

            Respondents matched to census (N = 17346)

            Men

            Women

            Men

            Women

             

            N

            %

            N

            %

            N

            %

            N

            %

            Age from survey

             <60

            1369

            6.2

            1653

            7.7

            593

            6.2

            670

            8.5

             60 < 65

            3836

            17.5

            5102

            23.7

            1036

            10.9

            1246

            15.8

             65 < 75

            5043

            23.0

            5628

            26.2

            2261

            23.7

            2264

            28.7

             70 < 75

            5033

            23.0

            4215

            19.6

            2307

            24.2

            1707

            21.6

             75 < 80

            2705

            12.3

            1672

            7.8

            1420

            14.9

            743

            9.4

             80 < 85

            1988

            9.1

            1608

            7.5

            971

            10.2

            650

            8.2

             85 < 90

            783

            3.6

            524

            2.4

            411

            4.3

            229

            2.9

            >90

            1024

            4.7

            929

            4.3

            483

            5.1

            331

            4.2

             Unknown

            141

            0.6

            164

            0.8

            55

            0.6

            59

            0.7

             TOTAL

            21922

            100.0

            21495

            100.0

            9537

            100.0

            7899

            100.0

            Living spouse

             No

            2776

            12.7

            12199

            56.8

            1119

            11.7

            4579

            58.0

             Yes

            19141

            87.3

            9289

            43.2

            8416

            88.2

            3316

            42.0

             Unknown

            5

            0.0

            7

            0.0

            2

            0.0

            4

            0.1

             TOTAL

            21922

            100.0

            21495

            100.0

            9537

            100.0

            7899

            100.0

            Number of disabilities (Q1-12) (much difficulty or worse)

             None

            16717

            76.3

            15489

            72.1

            7317

            76.7

            5704

            72.2

             One

            2815

            12.8

            3084

            14.3

            1161

            12.2

            1054

            13.3

             Two

            1034

            4.7

            1246

            5.8

            458

            4.8

            467

            5.9

             3-5

            779

            3.6

            973

            4.5

            348

            3.6

            390

            4.9

             6 or more

            577

            2.6

            703

            3.2

            253

            2.7

            284

            3.6

             TOTAL

            21922

            100.0

            21495

            100.0

            9537

            100.0

            7899

            100.0

            Number of health problems (Q13)

             None

            1959

            8.9

            1237

            5.8

            944

            9.9

            528

            6.7

             One

            4088

            18.6

            3466

            16.1

            1995

            20.9

            1485

            18.8

             Two

            6018

            27.5

            5781

            26.9

            2597

            27.2

            2194

            27.8

             Three

            4537

            20.7

            4985

            23.2

            1814

            19.0

            1684

            21.3

             4 or more

            5320

            24.3

            6026

            28.0

            2187

            22.9

            2008

            25.4

             TOTAL

            21922

            100.0

            21495

            100.0

            9537

            100.0

            7899

            100.0

            At the census (Table 2) some 90% of these women had been recorded as illiterate as had two thirds of men, with younger respondents being less likely to be illiterate than the very oldest. Very few women were employed at the census, with the most common job coded as a day labourer in all age groups. In men the proportion not working increased with age at census, with about a third of the oldest group of men (>75 years in 2005) being classified as ‘dependent’. Farming was by far the most common occupation among men of all ages. Classification by socioeconomic group depended on the assets of the household, with few coded as ‘very poor or destitute’. About half the men but few women were smokers at the time of the census.
            Table 2

            Distributions of education, occupation, socioeconomic group and smoking by age (from census year of birth) and sex: census-matched subpopulation (N = 17436)

             

            Men

            Women

            Age (years)

            Age (years)

             

            65-69

            70-74

            75-79

            > 80

            Total

            65-69

            70-74

            75-79

            > 80

            Total

             

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            N

            %

            Education

             Illiterate

            2287

            63.4

            1628

            66.0

            1349

            70.2

            1146

            74.3

            6410

            67.2

            2890

            87.4

            1874

            90.1

            1337

            93.6

            1029

            95.0

            7130

            90.3

             <5 years

            186

            5.2

            117

            4.7

            88

            4.6

            66

            4.3

            457

            4.8

            126

            3.8

            53

            2.5

            30

            2.1

            9

            0.8

            218

            2.8

             5 years

            533

            14.8

            340

            13.8

            218

            11.3

            170

            11.0

            1261

            13.2

            182

            5.5

            88

            4.2

            36

            2.5

            31

            2.9

            337

            4.3

             >5 years

            602

            16.7

            380

            15.4

            266

            13.8

            161

            10.4

            1409

            14.8

            110

            3.3

            64

            3.1

            26

            1.8

            14

            1.3

            214

            2.7

             TOTAL

            3608

            100.0

            2465

            100.0

            1921

            100.0

            1543

            100.0

            9537

            100.0

            3308

            100.0

            2079

            100.0

            1429

            100.0

            1083

            100.0

            7899

            100.0

            Occupation at census

             Dependent/housewife/UE

            366

            10.1

            324

            13.1

            459

            23.9

            532

            34.5

            1681

            17.6

            3221

            97.4

            2032

            97.7

            1399

            97.9

            1060

            97.9

            7712

            97.6

             Farmer

            1971

            54.6

            1394

            56.6

            966

            50.3

            710

            46.0

            5041

            52.9

            15

            0.5

            8

            0.4

            3

            0.2

            3

            0.3

            29

            0.4

             Business

            535

            14.8

            343

            13.9

            230

            12.0

            134

            8.7

            1242

            13.0

            12

            0.4

            9

            0.4

            8

            0.6

            4

            0.4

            33

            0.4

             Day labourer

            280

            7.8

            171

            6.9

            103

            5.4

            76

            4.9

            630

            6.6

            35

            1.1

            17

            0.8

            10

            0.7

            6

            0.6

            68

            0.9

             Service

            209

            5.8

            104

            4.2

            72

            3.7

            45

            2.9

            430

            4.5

            13

            0.4

            2

            0.1

            3

            0.2

            4

            0.4

            22

            0.3

             Craftsman

            66

            1.8

            36

            1.5

            22

            1.1

            13

            0.8

            137

            1.4

            0

            0.0

            2

            0.1

            0

            0.0

            0

            0.0

            2

            0.0

             Other

            181

            5.0

            93

            3.8

            69

            3.6

            33

            2.1

            376

            3.9

            12

            0.4

            9

            0.4

            6

            0.4

            6

            0.6

            33

            0.4

             TOTAL

            3608

            100.0

            2465

            100.0

            1921

            100.0

            1543

            100.0

            9537

            100.0

            3308

            100.0

            2079

            100.0

            1429

            100.0

            1083

            100.0

            7899

            100.0

            Socioeconomics group (of household)

             Destitute (Aw)

            44

            1.2

            32

            1.3

            20

            1.0

            23

            1.5

            119

            1.2

            78

            2.4

            66

            3.2

            42

            2.9

            29

            2.7

            215

            2.7

             Very poor (Ah)

            6

            0.2

            2

            0.1

            7

            0.4

            3

            0.2

            18

            0.2

            30

            0.9

            16

            0.8

            20

            1.4

            20

            1.8

            86

            1.1

             Poor (Ka)

            2201

            61.0

            1439

            58.4

            1112

            59.9

            828

            53.7

            5580

            58.5

            2035

            61.5

            1237

            59.5

            866

            60.6

            625

            57.3

            4763

            60.3

             Middle class (Kha)

            1119

            31.0

            811

            32.9

            629

            32.7

            538

            34.9

            3097

            32.5

            983

            29.7

            613

            29.5

            409

            28.6

            323

            29.8

            2328

            29.5

             Wealthier (Ga)

            238

            6.6

            181

            7.3

            153

            8.0

            151

            9.8

            723

            7.6

            182

            5.5

            147

            7.1

            92

            6.4

            86

            7.9

            507

            6.4

             TOTAL

            3608

            100.0

            2465

            100.0

            1921

            100.0

            1543

            100.0

            9537

            100.0

            3308

            100.0

            2079

            100.0

            1429

            100.0

            1083

            100.0

            7899

            100.0

            Smoker

             No

            1501

            41.6

            1122

            45.5

            961

            50.0

            797

            51.7

            4381

            45.9

            3244

            98.1

            2035

            97.9

            1412

            98.8

            1068

            98.6

            7759

            98.2

             Yes

            2107

            58.4

            1343

            54.5

            960

            50.0

            746

            48.3

            5156

            54.1

            64

            1.9

            44

            2.1

            17

            1.2

            15

            1.4

            140

            1.8

             TOTAL

            3608

            100.0

            2465

            100.0

            1921

            100.0

            1543

            100.0

            9537

            100.0

            3308

            100.0

            2079

            100.0

            1429

            100.0

            1083

            100.0

            7899

            100.0

            Disability

            Reporting of difficulty (code 3 or 4) increased steadily with age for all disabilities, with women more likely than men to report disability at almost every age (Table 3). The ranking of disabilities was very similar at each age, with difficulties in lifting and carrying, seeing, and going for some distance outside the home being rated as ‘much difficulty’ or ‘can’t do at all’ by some 20% to 50% of those aged 85 or greater. The final column in Table 3 shows the number for whom the paramedic reported the difficulty underestimated. These were uniformly low.
            Table 3

            Number (n) reporting ‘much difficulty ‘or ‘can’t do it at all’ for each functional capacity (Q 1-12) by age and sex (N = 43112)

             

            <60

            60 < 65

            65 < 70

            70 < 75

            75 < 80

            80 < 85

            > 85

            TOTAL

            % under-rated

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            Q1 seeing

            men

            13

            0.9

            116

            3.0

            217

            4.3

            316

            6.3

            262

            9.7

            252

            12.7

            362

            20.0

            1538

            7.1

            1.6

             

            women

            34

            2.1

            218

            4.3

            285

            5.1

            413

            9.8

            211

            12.6

            302

            18.8

            379

            26.1

            1842

            8.6

            2.1

            Q2 hearing

            men

            2

            0.1

            61

            1.6

            75

            1.5

            142

            2.8

            116

            4.3

            151

            7.6

            204

            11.3

            751

            3.4

            0.8

             

            women

            10

            0.6

            96

            1.9

            135

            2.4

            213

            5.1

            91

            5.4

            139

            8.6

            230

            15.8

            914

            4.3

            1.1

            Q3 getting up

            men

            8

            0.6

            47

            1.2

            67

            1.3

            93

            1.8

            81

            3.0

            99

            5.0

            206

            11.4

            601

            2.8

            0.2

             

            women

            7

            0.4

            60

            1.2

            74

            1.3

            130

            3.1

            72

            4.3

            140

            8.7

            228

            15.7

            711

            3.3

            0.3

            Q4 standing

            men

            9

            0.7

            36

            0.9

            75

            1.5

            101

            2.0

            94

            3.5

            118

            5.9

            223

            12.3

            656

            3.0

            0.3

             

            women

            6

            0.4

            43

            0.8

            68

            1.2

            137

            3.3

            79

            4.7

            161

            10.0

            283

            19.5

            777

            3.6

            0.2

            Q5 walking

            men

            4

            0.3

            34

            0.9

            63

            1.2

            87

            1.7

            75

            2.8

            93

            4.7

            189

            10.4

            545

            2.5

            0.2

             

            women

            7

            0.4

            42

            0.8

            57

            1.0

            119

            2.8

            68

            4.1

            141

            8.8

            227

            15.6

            661

            3.1

            0.2

            Q6 go outside

            men

            9

            0.7

            74

            1.9

            142

            2.8

            201

            4.0

            169

            6.2

            202

            10.2

            354

            19.6

            115

            5.3

            0.3

             

            women

            12

            0.7

            101

            2.0

            191

            3.4

            303

            7.2

            174

            10.4

            293

            18.2

            426

            29.3

            1500

            7.0

            0.3

            Q7 washing

            men

            2

            0.1

            37

            1.0

            70

            1.4

            92

            1.8

            74

            2.7

            114

            5.7

            213

            11.8

            602

            2.8

            0.1

             

            women

            10

            0.6

            38

            0.7

            72

            1.3

            127

            3.0

            79

            4.7

            152

            9.4

            253

            17.4

            731

            3.4

            0.2

            Q8 lavatory

            men

            4

            0.3

            35

            0.9

            70

            1.4

            84

            1.7

            68

            2.5

            92

            4.6

            196

            10.8

            549

            2.5

            0.1

             

            women

            6

            0.4

            41

            0.8

            63

            1.1

            122

            2.9

            77

            4.6

            139

            8.6

            228

            15.7

            676

            3.2

            0.1

            Q9 understanding

            men

            11

            0.8

            65

            1.7

            123

            2.4

            153

            3.0

            127

            4.7

            161

            8.1

            259

            14.3

            899

            4.1

            0.4

             

            women

            10

            0.6

            117

            2.3

            201

            3.6

            230

            5.5

            124

            7.4

            169

            10.5

            283

            19.5

            1134

            5.3

            0.5

            Q10 remembering

            men

            4

            0.3

            43

            1.1

            92

            1.8

            110

            2.2

            95

            3.5

            112

            5.6

            179

            9.9

            635

            2.9

            0.6

             

            women

            12

            0.7

            78

            1.5

            119

            2.1

            158

            3.7

            84

            5.0

            129

            8.0

            228

            15.7

            808

            3.8

            0.6

            Q11 lifting/carrying

            men

            51

            3.7

            487

            12.7

            699

            13.9

            792

            15.7

            609

            22.5

            540

            27.2

            672

            37.2

            3850

            17.7

            1.5

             

            women

            105

            6.4

            700

            13.7

            857

            15.2

            991

            23.5

            483

            28.9

            592

            36.8

            702

            48.7

            4430

            20.8

            1.7

            Q12 getting food

            men

            22

            1.6

            81

            2.1

            83

            1.6

            108

            2.1

            75

            2.8

            73

            3.7

            87

            4.8

            529

            2.4

            1.3

             

            women

            36

            2.2

            101

            2.0

            115

            2.0

            122

            2.9

            66

            3.9

            84

            5.2

            118

            8.1

            642

            3.0

            1.6

            TOTAL N

            men

            1369

             

            3836

             

            5043

             

            5033

             

            2705

             

            1988

             

            1807

             

            21781

             

            -

             

            women

            1653

             

            5102

             

            5628

             

            4215

             

            1672

             

            1608

             

            1453

             

            21331

             

            -

            The reporting of troublesome heath conditions followed a similar pattern to that for disability (Table 4) with only uterine prolapse and sexual difficulties not showing increase with age, in women. Painful joints were by far the most common symptom, with little increase in the proportion reporting this symptom once the age of 70 years had been reached. In those ≥85 years chest pain and urinary incontinence were, for both men and women, the second and third most common condition. The recoding of ‘other’ problems was not related to age. Responses to this question had been coded to capture reports of diabetes, hypertension, digestive system problems and back pain, but the number reporting each condition was small.
            Table 4

            Number (n) reporting each health problem (Q 13-14) by age (years) and sex (N = 43,112)

             

            <60

            60 < 65

            65 < 70

            70 < 75

            75 < 80

            80 < 85

            >85

            TOTAL

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            Pain in joints

            men

            763

            55.7

            2710

            70.6

            3704

            73.4

            3811

            75.7

            2001

            74.0

            1528

            76.9

            1366

            75.6

            15883

            72.9

             

            women

            1136

            68.7

            3995

            78.3

            4573

            81.3

            3539

            84.0

            1380

            82.5

            1384

            86.1

            1211

            83.4

            17218

            80.7

            Chest pain

            men

            386

            28.2

            1466

            38.2

            2041

            40.5

            2155

            42.8

            1109

            41.0

            868

            43.7

            751

            41.6

            8776

            40.3

             

            women

            597

            36.1

            2298

            45.0

            2547

            45.3

            2007

            47.6

            789

            47.2

            824

            51.2

            705

            48.6

            9767

            45.8

            Breathing problems

            men

            122

            8.9

            591

            15.4

            883

            17.5

            1115

            22.2

            648

            24.0

            544

            27.4

            534

            29.6

            4437

            20.4

             

            women

            156

            9.4

            714

            14.0

            794

            14.1

            712

            16.9

            306

            18.3

            344

            21.4

            352

            24.2

            3378

            15.8

            Urinary incontinence

            men

            143

            10.4

            706

            18.4

            1117

            22.1

            1425

            28.3

            827

            30.6

            683

            34.4

            726

            40.2

            5627

            25.8

             

            women

            293

            17.7

            1309

            25.7

            1553

            27.6

            1426

            33.8

            597

            35.7

            653

            40.6

            637

            43.9

            6486

            30.3

            Uterine prolapse

            men

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

            -

             

            women

            99

            6.0

            247

            4.8

            352

            6.3

            255

            6.0

            120

            7.2

            109

            6.8

            101

            7.0

            1283

            6.0

            Depression

            men

            87

            6.4

            630

            16.4

            1028

            20.5

            1053

            20.9

            592

            21.9

            491

            24.7

            478

            26.5

            4359

            20.0

             

            women

            205

            12.4

            1209

            23.7

            1335

            23.7

            1084

            25.7

            426

            25.5

            475

            29.5

            403

            27.8

            5137

            24.1

            Stroke/paralysis

            men

            10

            0.7

            125

            3.3

            177

            3.5

            194

            3.9

            132

            4.9

            111

            5.6

            134

            7.4

            883

            4.1

             

            women

            19

            1.1

            162

            3.2

            183

            3.3

            186

            4.1

            93

            5.6

            102

            6.3

            117

            8.1

            862

            4.0

            Itching

            men

            183

            13.4

            696

            18.1

            1059

            21.0

            1080

            21.5

            680

            25.1

            486

            24.4

            493

            27.3

            4677

            21.5

             

            women

            310

            18.8

            1067

            20.9

            1238

            22.0

            951

            22.6

            366

            21.9

            398

            24.8

            361

            24.9

            4691

            22.0

            Sexual difficulties

            men

            84

            6.1

            174

            4.5

            308

            6.1

            394

            7.8

            262

            9.7

            202

            10.2

            264

            14.6

            1688

            7.8

             

            women

            98

            5.9

            224

            4.4

            238

            4.7

            136

            3.2

            49

            2.9

            41

            2.5

            26

            1.8

            812

            3.8

            Other problems

            men

            531

            38.8

            1393

            36.3

            1840

            36.5

            1772

            35.2

            950

            35.1

            688

            34.6

            656

            36.3

            7830

            36.0

             

            women

            688

            41.6

            2069

            40.6

            2188

            38.9

            1562

            37.1

            598

            35.8

            585

            36.4

            566

            39.0

            8258

            38.7

            Hands shaking at rest

            men

            18

            1.3

            120

            3.1

            209

            4.1

            288

            5.7

            210

            7.8

            198

            10.0

            262

            14.5

            1305

            6.0

             

            women

            36

            2.2

            193

            3.8

            253

            4.5

            300

            7.1

            133

            8.0

            191

            11.9

            223

            15.4

            1329

            6.2

            TOTAL N

            men

            1369

             

            3836

             

            5043

             

            5033

             

            2705

             

            1988

             

            1806

             

            21780

             
             

            women

            1653

             

            5102

             

            5628

             

            4215

             

            1672

             

            1608

             

            1452

             

            21330

             
            Results of 12 logistic regression analyses relating specific disability to socio-demographic and heath conditions showed each disability remained significantly related to increasing age in the full model (except for ‘getting enough to eat ‘for men) (Tables 5 and 6). Widowhood (no living spouse) was associated with the reporting of all but one disability for women and for 9 /12 disabilities for men. In contrast, the small number of ‘very poor or destitute’ were not at greater risk (compared to the wealthiest in these villages), except for not getting enough to eat. Illiteracy was most strongly related, for both men and women, with difficulties seeing and hearing, going outside and lifting and carrying heavy loads. A man not working at the census was more likely to be disabled at the time of the survey (having adjusted for age), being more at risk on 7 of the 12 functional capacities. Smoking was not related to disability.
            Table 5

            Relation of disabilities to social factors and illness (Functional capacities 1-6): multivariate logistic regression (N = 17436)

             

            Sex

            Disability

             

            Q1 seeing

            Q2 hearing

            Q3 getting up

            Q4 standing

            Q5 walking

            Q6 go outside

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            Sociodemographic

                         

              Age from census (continuous variable)

            men

            1.04

            1.03-1.05

            1.04

            1.02-1.05

            1.06

            1.04-1.07

            1.06

            1.05-1.08

            1.05

            1.03-1.07

            1.05

            1.04-1.63

             

            women

            1.03

            1.02-1.04

            1.04

            1.03-1.73

            1.04

            1.03-1.06

            1.05

            1.03-1.06

            1.04

            1.02-1.06

            1.04

            1.03-1.06

              No living spouse

            men

            1.37

            1.14-1.64

            1.28

            1.02-1.61

            1.21

            0.91-1.60

            1.21

            0.93-1.57

            1.21

            0.90-1.62

            1.51

            1.24-1.85

             

            women

            1.42

            1.23-1.65

            1.45

            1.21-1.73

            1.51

            1.24-1.85

            1.61

            1.32-1.98

            1.48

            1.21-1.82

            1.68

            1.41-2.00

              Very poor/destitute*

            men

            1.20

            0.65-2.22

            1.84

            0.82-4.11

            0.37

            0.09-1.54

            0.64

            0.21-1.95

            0.39

            0.09-1.65

            0.42

            0.16-1.93

             

            women

            1.34

            0.83-2.18

            1.00

            0.50-2.00

            1.29

            0.58-2.85

            1.17

            0.54-2.52

            1.02

            0.43-2.42

            0.81

            0.46-1.43

              Illiterate

            men

            1.34

            1.11-1.62

            1.31

            1.01-1.72

            1.10

            0.80-1.49

            1.31

            0.85-1.53

            1.18

            0.85-1.63

            1.23

            0.99-1.54

             

            women

            1.70

            1.20-2.40

            1.42

            0.89-2.29

            0.97

            0.60-1.57

            1.45

            0.86-2.48

            1.27

            0.74-2.16

            1.75

            1.18-2.61

              No job at census

            men

            1.33

            1.10-1.61

            1.62

            1.24-2.10

            1.29

            0.94-1.77

            1.31

            0.97-1.77

            1.46

            1.06-2.01

            1.35

            1.08-1.70

             

            women

            1.29

            0.74-2.22

            0.83

            0.42-1.64

            1.38

            0.52-3.32

            1.45

            0.57-3.65

            1.13

            0.45-2.55

            1.61

            0.80-3.22

              Smoker at census

            men

            0.88

            0.75-1.03

            1.00

            0.80-1.25

            0.84

            0.64-1.10

            0.95

            0.73-1.23

            0.86

            0.65-1.14

            1.03

            0.85-1.25

             

            women

            0.50

            0.23-1.09

            0.49

            0.15-1.56

            0.61

            0.18-2.07

            0.57

            0.17-1.96

            0.67

            0.20-2.31

            0.70

            0.31-1.57

            Disease/condition

                         

              Pain in joints

            men

            1.13

            0.93-1.37

            1.17

            0.89-1.55

            1.00

            0.73-1.37

            1.06

            0.79-1.44

            1.21

            0.87-1.70

            1.20

            0.95-1.51

             

            women

            1.30

            1.04-1.63

            1.02

            0.75-1.38

            1.05

            0.75-1.47

            0.84

            0.61-1.15

            0.81

            0.58-1.13

            1.26

            0.99-1.61

              Chest pain

            men

            1.25

            1.05-1.47

            1.46

            1.15-1.85

            1.00

            0.75-1.33

            0.86

            0.65-1.13

            0.88

            0.66-1.19

            0.97

            0.90-1.19

             

            women

            1.28

            1.08-1.51

            1.31

            1.03-1.66

            0.64

            0.48-0.85

            0.68

            0.52-0.89

            0.73

            0.54-0.97

            0.85

            0.71-1.03

              Breathing problem

            men

            1.48

            1.24-1.77

            1.31

            1.02-1.68

            1.50

            1.12-2.01

            1.73

            1.32-2.28

            1.46

            1.08-1.97

            1.45

            1.18-1.79

             

            women

            1.30

            1.06-1.58

            1.15

            0.87-1.51

            1.32

            0.96-1.81

            1.29

            0.95-1.75

            1.26

            0.91-1.74

            1.23

            0.98-1.53

              Incontinence

            men

            1.52

            1.28-1.81

            1.69

            1.32-2.15

            1.61

            1.21-2.15

            1.58

            1.20-2.08

            1.58

            1.17-2.12

            1.87

            1.52-2.29

             

            women

            1.41

            1.19-1.67

            1.54

            1.21-1.95

            1.81

            1.37-2.39

            2.06

            1.58-2.69

            1.83

            1.38-2.44

            1.80

            1.49-2.18

              Depression

            men

            1.56

            1.30-1.88

            1.32

            1.02-1.72

            1.60

            1.18-2.16

            1.46

            1.09-1.95

            1.69

            1.24-2.29

            1.63

            1.31-2.01

             

            women

            1.53

            1.28-1.83

            1.26

            0.98-1.62

            1.38

            1.03-1.85

            1.42

            1.08-1.87

            1.29

            0.96-1.74

            1.48

            1.21-1.80

              Paralysis

            men

            1.09

            0.78-1.53

            1.33

            0.87-2.04

            9.06

            6.61-12.41

            8.53

            6.28-11.58

            10.20

            7.42-14.02

            4.90

            3.75-6.41

             

            women

            1.79

            1.33-2.41

            0.98

            0.62-1.54

            13.68

            10.10-18.53

            11.56

            8.56-15.60

            13.67

            10.04-18.61

            6.10

            4.68-7.95

              Itching

            men

            0.99

            0.83-1.19

            0.87

            0.67-1.14

            0.77

            0.56-1.06

            0.75

            0.55-1.01

            0.71

            0.51-0.99

            0.91

            0.73-1.13

             

            women

            0.91

            0.75-1.10

            1.33

            1.04-1.70

            0.78

            0.57-1.07

            0.92

            0.68-1.24

            0.88

            0.64-1.22

            0.96

            0.78-1.19

              Other

            men

            1.57

            1.34-1.84

            1.37

            1.09-1.72

            1.38

            1.05-1.82

            1.44

            1.11-1.86

            1.46

            1.11-1.94

            1.42

            1.17-1.72

             

            women

            1.62

            1.38-1.90

            1.52

            1.22-1.89

            1.53

            1.18-1.98

            1.59

            1.24-2.04

            1.50

            1.15-1.96

            1.51

            1.26-1.80

              Shaking at rest

            men

            1.97

            1.53-2.53

            2.59

            1.90-3.55

            3.92

            2.84-5.41

            3.89

            2.85-5.30

            4.4

            3.21-6.14

            2.89

            2.23-3.74

             

            women

            2.58

            2.05-3.25

            3.17

            2.36-4.25

            3.14

            2.26-4.35

            3.57

            2.62-4.86

            3.51

            2.53-4.88

            2.53

            1.97-3.25

            · Relative to wealthier.

            Table 6

            Relation of disabilities to social factors and illness (Functional capacities 7-12): multivariate logistic regression (N = 17436)

             

            Sex

            Disability

             

            Q7 bath

            Q8 lavatory

            Q9 understand

            Q10 Memory

            Q11 lifting

            Q12 food

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            OR

            95% CI

            Sociodemographic

                         

              Age from census

            men

            1.05

            1.03-1.06

            1.05

            1.03-1.07

            1.04

            1.03-1.06

            1.04

            1.03-1.06

            1.02

            1.02-1.03

            1.01

            0.99-1.06

             

            women

            1.04

            1.03-1.06

            1.05

            1.03-1.07

            1.04

            1.03-1.05

            1.05

            1.03-1.06

            1.03

            1.02-1.04

            1.03

            1.01-1.05

              No living spouse

            men

            1.42

            1.13-1.80

            1.36

            1.06-1.74

            1.50

            1.22-1.84

            1.51

            1.20-1.89

            1.41

            1.21-1.63

            1.38

            1.04-1.84

             

            women

            1.47

            1.21-1.80

            1.55

            1.27-1.91

            1.37

            0.55-2.04

            1.39

            1.15-1.68

            1.47

            1.31-1.66

            1.29

            1.02-1.62

              Very poor/destitute

            men

            0.55

            0.16-1.93

            0.39

            0.10-1.59

            0.89

            0.37-2.14

            0.56

            0.20-1.61

            0.55

            0.32-0.89

            3.86

            1.47-10.16

             

            women

            1.45

            0.67-3.13

            1.12

            0.50-2.49

            1.06

            0.55-2.04

            0.82

            0.42-1.62

            0.71

            0.50-1.03

            5.14

            2.33-11.35

              Illiterate

            men

            1.08

            0.80-1.47

            1.00

            0.73-1.36

            1.04

            0.82-1.31

            1.21

            0.91-1.62

            1.35

            1.19-1.54

            1.03

            0.71-1.49

             

            women

            1.19

            0.73-1.95

            1.35

            0.78-2.33

            1.96

            1.24-3.10

            1.91

            1.11-3.30

            1.53

            1.22-1.91

            1.39

            0.74-2.63

              No job at census

            men

            1.53

            1.12-2.07

            1.53

            1.11-2.11

            1.48

            1.16-1.89

            1.07

            0.79-1.45

            1.14

            0.98-1.32

            1.10

            0.73-1.64

             

            women

            1.00

            0.45-2.22

            1.17

            0.47-2.93

            0.78

            0.43-1.43

            0.62

            0.33-1.19

            1.18

            0.79-1.77

            0.51

            0.28-0.93

              Smoker at census

            men

            1.08

            0.83-1.41

            1.06

            0.80-1.41

            1.07

            0.87-1.32

            0.83

            0.64-1.06

            1.11

            0.99-1.24

            0.91

            0.66-1.26

             

            women

            1.57

            0.69-3.58

            0.71

            0.21-2.39

            0.79

            0.34-1.82

            0.78

            0.29-2.18

            0.60

            0.35-1.00

            0.91

            0.32-2.29

            Disease/condition

                         

              Pain in joints

            men

            1.05

            0.77-1.44

            1.21

            0.80-1.41

            1.15

            0.90-1.49

            1.08

            0.80-1.45

            1.15

            1.01-1.32

            1.25

            0.82-1.90

             

            women

            0.90

            0.65-1.23

            1.05

            0.74-1.49

            1.15

            0.88-1.51

            0.88

            0.64-1.20

            1.31

            1.12-1.53

            0.90

            0.61-1.33

              Chest pain

            men

            0.79

            0.60-1.05

            0.82

            0.61-1.11

            1.26

            1.02-1.56

            0.98

            0.75-1.27

            1.11

            0.98-1.23

            1.26

            0.90-1.76

             

            women

            0.72

            0.55-0.93

            0.68

            0.51-0.91

            1.10

            0.89-1.35

            0.99

            0.77-1.28

            1.06

            0.94-1.70

            1.17

            0.86-1.60

              Breathing problem

            men

            1.53

            1.16-2.03

            1.36

            1.01-1.84

            1.06

            0.84-1.34

            1.22

            0.93-1.62

            1.30

            1.14-1.49

            1.92

            1.37-2.67

             

            women

            1.24

            0.91-1.69

            0.99

            0.70-1.39

            1.25

            0.98-1.60

            0.82

            0.60-1.13

            1.15

            0.98-1.34

            1.66

            1.19-2.31

              Incontinence

            men

            1.66

            1.26-2.20

            1.75

            1.31-2.35

            1.55

            1.24-1.93

            1.55

            1.19-2.03

            1.71

            1.51-1.94

            1.99

            1.42-2.78

             

            women

            1.63

            1.25-2.14

            1.66

            1.25-2.21

            1.30

            1.05-1.61

            1.75

            1.36-2.24

            1.37

            1.21-1.56

            1.11

            0.81-1.52

              Depression

            men

            1.72

            1.29-2.29

            1.70

            1.26-2.31

            1.59

            1.26-2.01

            1.83

            1.39-2.42

            1.61

            1.40-1.84

            1.87

            1.32-2.64

             

            women

            1.37

            1.03-1.82

            1.44

            1.07-1.93

            1.17

            0.93-1.47

            1.58

            1.22-2.05

            1.39

            1.21-1.59

            2.19

            1.60-3.00

              Paralysis

            men

            7.97

            5.83-10.89

            8.42

            6.11-11.62

            1.74

            1.22-2.49

            2.56

            1.76-3.72

            2.47

            1.97-3.09

            2.06

            1.26-3.36

             

            women

            11.64

            8.61-15.72

            12.23

            8.94-16.74

            2.12

            1.51-2.97

            3.18

            2.23-4.52

            3.30

            2.60-4.19

            3.08

            2.01-4.72

              Itching

            men

            0.84

            0.62-1.14

            0.75

            0.55-1.04

            1.38

            1.11-1.73

            1.00

            0.76-1.33

            1.04

            0.91-1.19

            1.14

            0.81-1.61

             

            women

            0.85

            0.63-1.15

            0.93

            0.67-1.27

            1.41

            1.51-2.97

            1.13

            0.93-1.54

            1.10

            0.96-1.27

            1.45

            1.06-1.99

              Other

            men

            1.57

            1.21-2.04

            1.48

            1.12-1.95

            1.12

            0.91-1.38

            1.22

            0.95-1.57

            1.62

            1.45-1.82

            1.65

            1.20-2.26

             

            women

            1.50

            1.16-1.92

            1.44

            1.10-1.88

            1.29

            1.06-1.57

            1.21

            0.95-1.53

            1.82

            1.62-2.04

            1.48

            1.11-1.98

              Shaking at rest

            men

            5.41

            4.00-7.30

            4.64

            3.37-6.40

            2.38

            1.78-3.17

            3.97

            2.93-5.39

            2.49

            2.05-3.01

            2.21

            1.44-3.40

             

            women

            3.43

            2.51-4.69

            3.27

            2.35-4.53

            2.41

            1.83-3.18

            3.63

            2.70-4.87

            2.50

            2.06-3.06

            1.91

            1.28-2.86

            The relation between disability and troublesome health conditions varied markedly with the type of ill-health. Painful joints, although the most common complaint, were related only to difficulty lifting whereas hemiplegia and resting tremor were associated with increased risk of reporting every dimension of disability. In men, but not in women, breathing problems were commonly associated with disability. Chest pain showed little consistent relation to disability. Further analysis indicated a strong relation between depression and reports of chest pain: 55.9% (5345/9556) of those saying that depression often made life difficult reported chest pain compared to 39.3% (13307/33861) of those not reporting depression. Inclusion of depression in the model attenuated the bivariate relation between chest pain and, for example, difficulty walking in the home. Overall, the relation between depression and reported disabilities was striking (Tables 5 and 6): a subject who was ‘very often depressed’ was more likely to report difficulties on each of the disability questions (except hearing for women). The relation of disability to urinary incontinence was at least as strong, with both men and women who reported troublesome urinary incontinence being more likely to report each disability (except, for women, not getting enough food). In all age groups there was a close relation between urinary incontinence and depression, with depression reported overall in 41.0% of those who reported troublesome urinary incontinence but only 14.6% of those who did not. In a linear regression in which total disability score was the dependent variable, urinary incontinence was more strongly related to overall disability than any health problem except hemiplegia tremor and resting tremor (Table 7).
            Table 7

            Relation of total disability (log score) to health problems (N = 43112)

             

            Standardised βeta

            t

            p<

            Pain in joints

            0.040

            9.47

            0.000

            Chest pain

            0.058

            13.54

            0.000

            Breathing problems

            0.050

            12.02

            0.000

            Incontinence

            0.119

            27.53

            0.000

            Depression

            0.101

            23.54

            0.000

            Paralysis

            0.161

            38.90

            0.000

            Itching

            0.030

            7.20

            0.000

            Other

            0.089

            21.93

            0.000

            Shaking at rest

            0.132

            31.80

            0.000

            Sex: female

            0.062

            13.20

            0.000

            No living spouse

            0.054

            11.23

            0.000

            Age (continuous)

            0.318

            73.23

            0.000

            Help received and needed

            More than half the oldest group (over 85 years) had some help from a family member (Table 8): help from someone outside the family was mentioned by only 39: of 11211 villagers with ‘much difficult’ on at least one functional capacity, only 15 reported getting help outside the family. For women help was most commonly from a daughter-in-law, with mobility and bathing the most common assistance. In a logistic regression analysis, with any help reported (or not) as the outcome, help received was reported somewhat more frequently by women, by those with no living spouse, those who were older and those with a higher disability score (Table 9).
            Table 8

            Types of help obtained and needed (Q15 and Q16) by age (years) and sex

             

            < 60

            60 < 65

            65 < 70

            70 < 75

            75 < 80

            80 < 85

            > 85

            Total

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            n

            %

            Help Given

                             

              Some help given

            men

            96

            7.0

            824

            21.5

            1113

            22.1

            1435

            28.5

            837

            30.9

            820

            41.2

            949

            52.3

            6074

            27.9

             

            women

            216

            13.1

            1291

            25.3

            1351

            24.0

            1415

            33.6

            613

            36.7

            779

            48.4

            822

            56.6

            6487

            30.4

              By spouse

            men

            65

            4.7

            466

            12.1

            609

            12.1

            710

            14.1

            43.9

            16.2

            343

            17.2

            324

            17.9

            2955

            13.6

             

            women

            40

            2.4

            85

            1.7

            74

            1.3

            59

            1.4

            22

            1.3

            18

            1.1

            17

            1.2

            315

            1.5

              By daughter-in-law

            men

            18

            1.3

            116

            4.3

            263

            5.2

            455

            9.0

            294

            10.9

            338

            17.0

            510

            28.2

            2044

            9.1

             

            women

            90

            5.4

            721

            14.1

            838

            14.9

            877

            20.8

            387

            23.1

            496

            30.8

            548

            37.7

            3957

            18.6

              By son

            men

            17

            1.2

            186

            4.8

            253

            5.0

            282

            5.6

            127

            4.7

            145

            7.3

            146

            8.1

            1156

            5.3

             

            women

            68

            4.1

            345

            6.8

            279

            5.0

            278

            6.6

            115

            6.9

            115

            7.2

            125

            8.6

            1325

            6.2

              By daughter

            men

            16

            1.2

            82

            2.1

            123

            2.4

            104

            2.1

            71

            2.6

            56

            2.8

            69

            3.8

            521

            2.4

             

            women

            46

            2.8

            198

            3.9

            191

            3.4

            190

            4.5

            85

            5.1

            112

            7.0

            118

            8.1

            940

            4.4

              By grandchild

            men

            0

            0.0

            15

            0.4

            14

            0.3

            53

            1.1

            25

            0.9

            46

            2.3

            66

            3.7

            219

            1.0

             

            women

            6

            0.4

            58

            1.1

            91

            1.6

            124

            2.9

            65

            3.9

            110

            6.8

            124

            8.5

            578

            2.7

            Types of help

                             

              Mobility

            men

            16

            1.2

            148

            3.9

            246

            4.9

            307

            6.1

            222

            8.2

            265

            13.3

            363

            20.1

            1567

            7.2

             

            women

            39

            2.4

            225

            4.4

            330

            5.9

            401

            9.5

            203

            12.1

            299

            18.6

            371

            25.5

            1868

            8.8

              Bathing

            men

            19

            1.4

            121

            3.2

            204

            4.0

            308

            6.1

            241

            8.9

            269

            13.5

            424

            23.5

            1586

            7.3

             

            women

            21

            1.3

            163

            3.2

            234

            4.2

            373

            8.8

            203

            12.1

            294

            18.3

            422

            29.0

            1710

            8.0

              Feeding

            men

            26

            1.9

            160

            4.2

            244

            4.8

            317

            6.3

            196

            7.2

            198

            10.0

            271

            15.0

            1412

            6.5

             

            women

            41

            2.5

            224

            4.4

            258

            4.6

            321

            7.6

            143

            8.6

            191

            11.9

            258

            17.8

            1436

            6.7

              Washing clothes

            men

            14

            1.0

            73

            1.9

            121

            2.4

            196

            3.9

            147

            5.4

            139

            7.0

            228

            12.6

            918

            4.2

             

            women

            16

            1.0

            100

            2.0

            136

            2.4

            213

            5.1

            108

            6.5

            179

            11.1

            209

            14.4

            961

            4.5

            Some help needed

            men

            620

            45.3

            2382

            62.1

            3202

            63.5

            3309

            65.7

            1832

            66.7

            1397

            70.3

            1273

            70.4

            14015

            64.3

             

            women

            859

            52.0

            3504

            68.7

            3871

            68.8

            3002

            71.2

            1192

            71.3

            1189

            73.9

            1074

            73.9

            14691

            68.9

            Types of help

                             

              Treatment

            men

            373

            27.2

            1578

            41.1

            2090

            41.4

            2056

            40.9

            1231

            45.5

            838

            42.2

            834

            46.2

            9000

            41.3

             

            women

            565

            34.2

            2322

            45.5

            2424

            43.1

            1833

            43.5

            753

            45.0

            732

            45.5

            703

            48.4

            9332

            43.7

              Financial

            men

            214

            15.6

            751

            19.6

            1020

            20.2

            1081

            21.5

            518

            19.1

            459

            23.1

            364

            20.1

            4404

            20.2

             

            women

            241

            14.6

            1071

            21.0

            1329

            23.6

            1052

            25.0

            394

            23.6

            402

            25.0

            332

            22.8

            4821

            22.6

              Prosthesis

            men

            36

            2.6

            101

            2.6

            128

            2.5

            163

            3.2

            84

            3.1

            70

            3.5

            62

            3.4

            644

            3.0

             

            women

            52

            3.1

            111

            2.2

            143

            2.5

            131

            3.1

            45

            2.7

            58

            3.6

            59

            4.1

            599

            2.8

            Total N

            men

            1369

             

            3836

             

            5043

             

            5033

             

            2705

             

            1988

             

            1807

             

            21781

             
             

            women

            1653

             

            5102

             

            5628

             

            4215

             

            1672

             

            1608

             

            1453

             

            21331

             
            Table 9

            Any help received by need (logistic regression N = 43112)

             

            Odds Ratio

            95% CI

            Indication of Need

              

            No living spouse

            1.13

            1.07-1.19

            Female

            1.10

            1.04-1.15

            Age (continuous)

            1.04

            1.03-1.04

            Disabilities (much difficulty)

              

            None

            1

            -

            One

            1.71

            1.61-1.81

            Two

            2.83

            2.59-3.09

            3-5

            4.47

            4.03-4.96

            6 or more

            14.94

            12.66-17.65

            Nearly two thirds of both men and women in the survey reported that they were in need of help. The help specified was most usually treatment for a medical condition or financial aid (Table 8).

            Discussion

            This survey of disability in some 43,000 villagers believed to be aged ≥60 years found that only a minority (26%) reported ‘much difficulty’ on any of 12 functional capacities. The proportion increased markedly with age and amongst the most elderly (≥85 years) there were widespread problems, in lifting and carrying, with eyesight and with going outside the house for any distance. It is of note that only 29% of the elderly villagers reported receiving any help from their family members and virtually none had help from outside the family. However those receiving help from the family did appear to be those with the greatest needs.

            The study was set up to find ways in which the extent and impact of disabilities could be lessened by appropriate interventions. The high disability rate among those with hemiplegia was expected but the recent introduction by GK of community physiotherapists may help to ensure that a greater proportion of survivors have rapid and appropriate rehabilitation. The comprehensive range of disability among those with a resting tremor is also of interest and would warrant a more focused inquiry: those reporting the symptom here are unlikely to have been formally assessed or treated. Further investigation is also needed of the possible contribution of high levels of manganese (commonly found in drinking water in rural Bangladesh [3]) to Parkinson-like illness [4]. If this were demonstrated, primary prevention of the disease and subsequent disability might be feasible. There is also some scope for intervention to meet the needs of the relatively small group – a total of 1243 – who reported that they would be helped by a prosthesis, mainly to aid mobility or vision. The high rate of disability reported by those with urinary incontinence is of particular interest, not least because of the possibility of intervention to improve its management [5, 6]. The direction of causality between the incontinence and the reported disability (and the relation to depression) is likely to be complex. Given that toilet facilities in Bangladeshi village homes are outside the main living quarters, the ability to hold urine may be severely challenged in an elderly person with poor mobility and vision. A program to increase mobility and to improve the management of urinary incontinence would have priority in this population.

            The strength of the study lies in the representation of functional difficulties and ill-health in an entire population of elderly rural villagers and in the completeness of the data: there were very few refusals and the paramedics were scrupulous about completing every question. The ability to match a substantial, and apparently representative, sub-group to census data collected 5 years earlier was also a strength of the study, allowing assessment of socio-demographic factors independent of current difficulties. The main weaknesses were the uncertainty about true age and the related difficulty of establishing a definitive list of eligible participants. Also, the data collected, both in the survey and census, failed to catch some elements of importance. While the survey asked about difficulties in understanding speech, for example, it did not ask about difficulties of expression: while the census asked about current smoking habit, it did not include amount smoked, or allow us to identify ex-smokers who had, perhaps, stopped smoking after developing disability, prior to the census. The pattern of causality was also uncertain for other observed relationships such as illiteracy and difficulty carrying heavy loads (where the physical demands may have been greater than for those with education) and the high levels of disability in those men who had already given up work by the time of the census, 5 years previously. Interpretation of the relation between poor functional capacity and reports of very often feeling depressed is also critical to decisions about interventions, designed to reduce both objective incapacity and also feelings of hopelessness. The study did not include objective measures of capacity, but relied on the villager’s own report of degree of difficulty with each dimension: such self-perception of incapacity may be the appropriate metric, although perhaps less so for those with cognitive impairment. It was reassuring that the paramedics very seldom recorded that the degree of disability was under-estimated. The converse – of exaggerating disability – was not explored systematically, but the low proportions reporting ‘much difficulty’, particularly in those below 70 years does not suggest that exaggeration was widespread.

            This is not the first study of disability in Bangladesh, although it is by far the largest, covering villages from 4 Divisions of the country. An earlier community based study of some of the same villages found that 50% of those >80 years had physician diagnosed disabilities, most frequently hearing, vision and movement difficulties [7]. Data from Matlab, an area to the south east of Dhaka, was included in the report of the WHO Sage studies, and showed greater disability in women, in older respondents, in people who were single, older, and less educated [1]. The study, which included some 850 subjects ≥70 years, did not report the prevalence of particular disabilities. Other reports from Matlab include an attempt to better understand the value of self-reported health status in older Bangladesh villagers which found, as in the present study, that respondents were more likely to report ill health than disability [8]. The strong relation between incontinence and depression observed here has been widely reported in other populations, including elderly people in Pakistan, with the need for cleanliness in Muslim religious observance being an additional dimension [911].

            The messages from this study are far reaching. First, at the level of primary health care providers, the results underline the urgent need for programs focusing on the elderly, to alleviate those disabilities that are amenable to intervention and to provide support and care for those with multiple disabilities. Instituting these programs will require development of training programs and health education materials, so that care of the elderly can be successfully integrated into primary health care. Such concentration on the elderly will need new funding, and cannot rely simply on the redistribution of resources away from existing programs, such as those for mothers and children. From the study reported here it is clear that funds are needed to support programs to increase mobility, enhance vision and hearing and to decrease the toll of incontinence and depression found to be so common in these elderly villagers. Alleviating these disabilities will require new approaches to care for the rural elderly, backed by demonstration projects to evaluate the viability and effectiveness of culturally appropriate interventions. Although the study reported here has shown that family support is still provided for many (though not the majority) of these elderly villagers, with rapid urbanization, and the departure of the young and healthy to the cities, family structures for the care of the elderly will surely break down, as has already been shown in China [12, 13]. Where young people leave, rural communities will be faced with the need to fill this gap with the provision of community facilities, giving help with feeding and personal care, and aids with vision and mobility to assure accessibility. With such help, the elderly can become more largely self-sufficient, as happens through comprehensive home and social care in wealthy developed counties, in which the maintenance of the elderly at home is seen as a prime goal for social programs. In Bangladesh, the government has begun to recognize the need for social welfare programs for the elderly, but the problems are still substantial, both in Bangladesh and other poor developing countries. Until recently the focus of WHO and donor agencies has been very largely on infants, children and those of reproductive age, but it is no longer defensible to assume either that the rural poor will not survive to old age – they increasingly do – or that younger women in the household will continue to be willing and available to help with basic needs. A new vision is needed in which the residual capacities of the old are nurtured, remediable deficiencies are attacked vigorously and community facilities put in place to reduce the physical, emotional and cognitive isolation of old people living out their years in discomfort and poverty.

            Conclusion

            In this study, disabled elderly residents of rural villages in Bangladesh were found to be dependent on the family for help. With family cohesiveness under threat from migration to the city, there is a pressing need for the development and critical evaluation of community-based interventions designed specifically for the elderly in poor rural societies. New approaches to training and practice will be needed to integrate such disability management into primary care.

            Ethical issues

            The proposal for this project was approved by the Health Research Ethics Board of the University of Alberta (Pro00009158 ) and by the Gonoshasthaya Kendra ethics committee. All subjects gave oral informed consent.

            Sources of funding

            The work was funded from research funds held at the National Heart and Lung Institute, London.The funding source had no role in the study design, collection, analysis or interpretation, in the writing of the report or in the decision to submit.

            Declarations

            Authors’ Affiliations

            (1)
            University of Alberta
            (2)
            Community-based Medical College, Gonoshasthaya Kendra
            (3)
            Gonoshasthaya Kendra
            (4)
            Imperial College
            (5)
            Gonoshasthaya Kendra

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            14. Pre-publication history

              1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2458/​12/​379/​prepub

            Copyright

            © Cherry et al.; licensee BioMed Central Ltd. 2012