|Year : 2020 | Volume
| Issue : 4 | Page : 160-164
Impact of socioeconomic status on morbidities, disabilities, activity limitation, and participation restriction in the geriatric population living in urban area: A comparative study
Vivek Aggarwal1, VK Sashindran2, Puja Dudeja3, V Vasdev1, Anuj Singhal4
1 Department of Geriatrics, AFMC, Pune, Maharashtra, India
2 Commandant, Air Force Hospital, Kanpur, Uttar Pradesh, India
3 O/o DGMS, Ministry of Defence, New Delhi, India
4 Department of Medicine, AH R and R, New Delhi, India
|Date of Submission||21-Oct-2020|
|Date of Decision||09-Jan-2021|
|Date of Acceptance||10-Jan-2021|
|Date of Web Publication||23-Feb-2021|
Dr. Vivek Aggarwal
Department of Geriatrics, AFMC, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Socioeconomic inequalities have been considered as an important factor for disparity in the prevalence of disabilities among geriatric population belonging to different socioeconomic strata with significantly increased of disability in elderly population belonging to lower socioeconomic status. The impact of socioeconomic status on the morbidity and disability profile of elderly in India is very scarce. This study would help in planning geriatric health care services for different communities depending upon their socioeconomic status. Aim: The aim of this study was to compare the morbidity profile, disability profile, and perceived health care needs in Indian elderly population belonging to two different socioeconomic strata residing in city of western India. Methodology: This was a cross sectional qualitative comparative study done in Aug 2016 to Dec 2016. In this study two geriatric cohorts one belonging to high income group staying in a gated community and other belonging to low income group staying in a urban slum were compared. House to house survey was done based on prevalidated WHO DAS scale predesigned questionnaire to assess the activity limitation and participation restriction of the elderly population in city dwellers in Western India. After initial sensitisation workshops to sensitise and train the medical students, paramedics and the social workers, the house to house survey was on holidays. Results: Total 406 elderly patients were interviewed in HIG and 409 were interviewed in LIG. Females outnumbered the males in both the cohorts with 53.7% in HIG and 63.8% in LIG. It was noted that 14.5% of the elderly were staying alone in HIG where as against 10.2% in LIG. It was also noted that 14.5% of elderly in HIG required help of outside caregiver from doing the activities of daily living (ADLs) where as 28.9% in LIG required outside help to do ADLs. It was noted that there was a significant difference in the activity limitation score in both the cohorts with 64% of elderly in HIG having a good score (0-18) as against 13.9 % in LIG. in participation restriction score with 77% of elderly belonging to HIG having a good participation score as against 40.6% in the elderly belonging to LIG. Conclusion: The morbidity profile, disability profile, and perceived health care needs in Indian elderly population belonging to two different socioeconomic strata residing in city of western India are different. Public health care penetration was poor in the elderly living in LIG as most of them visited the doctor only during emergencies and that too majority of them had access to alternative medicine system. Dedicated geriatric services along with provision of medicines, ambulance and geriatric helpline was the most felt needs in the society.
Keywords: Geriatric population, High income group, low income group, activity limitations, activity restriction
|How to cite this article:|
Aggarwal V, Sashindran V K, Dudeja P, Vasdev V, Singhal A. Impact of socioeconomic status on morbidities, disabilities, activity limitation, and participation restriction in the geriatric population living in urban area: A comparative study. J Indian Acad Geriatr 2020;16:160-4
|How to cite this URL:|
Aggarwal V, Sashindran V K, Dudeja P, Vasdev V, Singhal A. Impact of socioeconomic status on morbidities, disabilities, activity limitation, and participation restriction in the geriatric population living in urban area: A comparative study. J Indian Acad Geriatr [serial online] 2020 [cited 2022 Sep 29];16:160-4. Available from: http://www.jiag.com/text.asp?2020/16/4/160/310000
| Introduction|| |
As per the National policy for the Older Adults adopted by the Government of India, a senior citizen or elderly is defined as equal to or more than 60 years of age. As per the 2011 consensus, the elderly population consists of 8.2% of the total population and is likely to rise to 19% by 2050. This will have a tremendous economic and social burden in the coming years. Rapid aging will lead to an increase in disability due to the rise in degenerative and chronic diseases. An international classification for functioning, disability, and death defines disability as an umbrella term for impairments, including activity limitations (AL) and participation restriction (PR). Disability is a significant factor that affects the quality of life and increases hospitalization and institutionalization. Disabilities also include visual impairment, hearing impairment, and gait disorders which can be reduced or cured using assistive devices, hearing aids, spectacles, cataract surgery, and other simple interventions. Addressing these common reversible disabilities play a vital role in improving the quality of life of the elderly. Socioeconomic inequalities have been considered an essential factor for the disparity in the prevalence of disabilities among geriatric populations belonging to different socioeconomic strata with significantly increased of disability in elderly population belonging to lower socioeconomic status (SES).,
On the other hand, people belonging to low SES have poor access to health-care facilities and need to work longer to earn their living forcing them to be independent which may mask few of the morbidities and disabilities. A study done by Hosseinpoor et al. noted that the median age-standardized prevalence of disability was higher in lower and low middle-income countries. SES can significantly impact the morbidity profile of the elderly population and may lead to multimorbidity and increased mortality. Even in the developed countries, it was seen that despite a significant decrease in mortality and morbidity, the SES gradient did not show much reduction. A recent study from Bangladesh shows that noncommunicable diseases were more common in higher socioeconomic strata. There is also a difference in the perception that health care may depend on the socioeconomic strata, leading to a change in morbidity and disability profile. In another recent meta-analysis, it was noted that low SES was associated with a decrease in life expectancy of around 2.1 years compared to the high SES population between 40 and 85 years. India is a country where population belongs to varied socioeconomic strata and differences in perception of health-care needs and access to health care. The impact of SES on the morbidity and disability profile of the elderly in India is very scarce. This study compared the morbidity profile, disability, and perceived health-care needs in the Indian elderly population belonging to two different socioeconomic strata residing in the city of western India. This study would help in planning geriatric health-care services for different communities depending on their SES.
| Methodology|| |
It was a cross-sectional observational, survey-based, comparative study; done in two geriatric cohorts (>60 years), one belonging to a high-income group (HIG) staying in a gated community and the other belonging to a low-income group (LIG) staying in an urban slum. House-to-house survey was done based on prevalidated World Health Organization Disability Assessment Scale to assess AL and PR of the elderly population. Morbidity profiles for the known disabilities accessed to health care and perceived health-care needs were also included in the questionnaire.
Initial sensitization workshops to sensitize and train the medical students, paramedics, and social workers were carried out to administer the survey questionnaire and minimize the administration bias. House-to-house survey in both the cohorts was carried out from August 2017 to June 2018. Data on sociodemographic profile, morbidity status, body function, AL, and PR were collected. The total attainable score for AL and PR was 70 and 45, respectively. The scoring categories for AL were as follows: 0–18 (good), 19–36 (average), 37–54 (bad), and 55–72 (very bad). Similarly, the scoring categories for PR were as follows: 0–15 (right), 16–30 (average), and 31–45 (bad). A lower score indicated good health with fewer limitations and restrictions.
Data collection was done on Sundays and gazetted holidays, and prior intimation to individuals was given through community workers, housing society office, and e-mail. The blocks of the housing society and areas of the urban slum were divided into different blocks depending on the proximity. Everyday only one block was included in the survey, and these blocks were selected randomly. This helped in prior communication to the residents of the blocks and administering the survey effectively. This ensured smooth data collection and detailed interviews were possible. The institutional ethical committee approved the study. The sample size calculation was based on the assumed prevalence of disability in the elderly as 32% and for a precision of 5% and a 95% confidence level. The sample size was computed to be 334 in both the groups. Data were analyzed in IBM statistics SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA). The Chi-square test was used to compare proportions, and the Mann–Whitney U-test was used to compare scores.
| Results|| |
A total of 406 elderly patients were interviewed in HIG and 409 were interviewed in LIG. Females outnumbered the males in both the cohorts with 53.7% in HIG and 63.8% in LIG. It was noted that 14.5% of the elderly stayed alone in HIG, whereas it was 10.2% in LIG. It was also noted that 14.5% of the elderly in HIG required outside caregiver help from doing daily living activities (ADL), whereas 28.9% in LIG outside needed help to do ADL. Details of socioeconomic profile in the two groups are shown in [Table 1].
|Table 1: Sociodemographic profile of elderly in high-income group and low-income group|
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It was noted that there was a statistically significant difference in the activity limitation score in both the cohorts, with 64% of the elderly in HIG having a good score (0–18) as against 13.9% in LIG. It was also seen that 79.2% of the elderly in LIG (79.2%) reported average activity limitation score (19–36) as against 30.5% in high SES. It was also noted that a bad to very bad activity limitation score (≥37) was more commonly seen in the LIG than HIG (6.9% vs. 3.67%). The difference noted was statistically significant, with P < 0.00001 [Table 2].
A similar pattern was noted in the PR score, with 77% of the elderly belonging to HIG having a good participation score against 40.6% in the elderly belonging to LIG. However, the average participation score (16–30) was better in LIG (57.5% vs. 19.2%). Poor participation score was seen in 2.8% of HIG and 2% of LIG [Table 3].
Hypertension and defective vision were more common in HIG, whereas osteoarthritis (OA), breathlessness, and sleep disorders were more common in LIG. Among geriatric syndromes, falls were more common in LIG, whereas dementia was more common in HIG. Chronic obstructive pulmonary disease, Parkinson's disease, depression, and tuberculosis were also common in LIG. Other significant morbidities noted in the geriatric population were diabetes, dental problems, constipation, and degenerative joint disease. In cardiovascular diseases, stroke was more common in LIG, whereas coronary artery disease was equally present in both the cohorts. Smoking and alcohol consumption was much less in LIG, and the difference was statistically significant [Figure 1].
|Figure 1: Type pf health facility visited by geriatric patients in High Income Group (HIG) and Low Income Group (LIG)|
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In LIG, more than 70% of the elderly did not visit the allopathic doctor but went to doctors trained in the complementary and alternative medical system (CAMS) including Homeopathic, Ayurvedic, and Unani practitioners. The elderly belonging to HIG visited public health-care facilities more often. Moreover, it was noted that the majority of the elderly in LIG visited a doctor only during an emergency and were not on a regular follow-up or health monitoring. In contrast, in HIG, majority of patients visiting health-care facilities either for a periodic follow-up. The most felt need by the elderly in both the cohorts was that of separate geriatric services and the provision of free medicines, easy and prompt access to ambulance, geriatric helpline, and physiotherapy facilities.
| Discussion|| |
This study noted that lifestyle and cardiovascular diseases were common in both the cohorts of the elderly population belonging to HIG and LIG. Hypertension and diabetes were more common in HIG, whereas stroke was more common in LIG. An increase in hypertension and Type 2 diabetes mellitus in HIG may be due to increased awareness and screening for these diseases. Moreover, increased obesity and sedentary lifestyle are other factors which may have contributed to the increasing prevalence of hypertension and diabetes in this group. Similar findings were noted in Romania's study; it was seen that increased SES was associated with diabetes with an odds ratio of 2.8. However, in a study from Thailand, it was noted that low educational attainment, female gender, and old age were associated with diabetes. In an Indian study on hypertension in an urban area, it was noted that the overall prevalence of hypertension was 32.9% with higher prevalence in HIG and the age group above 55 years. It was also seen that the stroke was twice more common in LIG than HIG. Similar findings were noted in a US study where the stroke was more common LIG. Similar results were reported in another study where stroke and its risk factors were more common in LIG and the incidence of stroke is expected to rise by 30% in the next 30 years in the elderly belonging to LIG. Recent studies from western countries and China also show the same stroke pattern in LIG., Income was also associated with increased adverse events and mortality in stroke patients. Thus, targeting the elderly population of lower SES is extremely important to decrease stroke incidence shortly. Falls are very common with aging and increases as the age progresses. In our study, it was noted that falls were more common in LIG. This may be due to the locality's environmental factors and surroundings where the elderly belonging to LIG stay. Moreover, the elderly belonging to LIG have to work until late to earn their living, making them more vulnerable to falls. Most of the falls are preventable and encouraging the elderly to participate in sports activity even once a week can reduce the fall risk by >20%. Our study also noted that OA of knees was significantly more in the elderly belonging to LIG. Similar findings were noted in a recent study from Britain. This may be attributed to the type of labor-intensive work being done by the elderly belonging to a LIG, making them susceptible to develop OA knees and too early. Educating the elderly on physical exercise may help to reduce the number of falls and reduce disability caused by OA knees.
In this study, it was noted that dementia was more common in HIG, whereas depression was more in LIG. This contradicts a study done in Japan where LIG was associated with an increased incidence of dementia. This may be due to the lower age of our elderly cohort and inadequate screening for dementia. Depression is associated with LIG as shown in a study from Finland where every unit rise in SES was associated with odds of a significant reduction in depression. Similar results were seen in other studies from India and other parts of the world where LIG was associated with an increased incidence of depression.,
AL scores were better in elderly belonging to HIG as compared to LIG. Similar findings were noted in a study where the elderly belonging to HIG were more likely to live longer and healthier. In another recent study from Japan, years of education were associated with improved functional disability in older adults with a severe disability at baseline. In PR, it was noted that although the good score was more in HIG, average score was more in the LIG. Bad PR was more common in HIG. This is according to a study that also showed that PR score was better in LIG than HIG. This may be due to good social binding in LIG, and they have to work for a longer time to earn their living.
| Conclusion|| |
The morbidity profile, disability profile, and perceived health-care needs in the Indian elderly population belonging to two different socioeconomic strata residing in the city of western India are different. Lifestyle diseases such as diabetes and hypertension were more common in HIG, whereas stroke, OA, and falls were more common in LIG. Public health-care penetration was poor in the elderly belonging to LIG. Most of them visited the doctor only during emergencies, and that too the majority of them visited doctors of complementary and alternative medical system as access to allopathic doctor was either poor or non affordable. Dedicated geriatric services and the provision of medicines, ambulance, and geriatric helpline were the most felt needs in the society. There is an urgent need to encourage and promote geriatric services in the community so that this vulnerable and ever-growing population of the elderly can get a comprehensive, affordable sustainable, and universal health care.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in the aging population. Annu Rev Public Health 1996;17:25-46.
Coppin AK, Ferrucci L, Lauretani F, Phillips C, Chang M, Bandinelli S, et al
. Low socioeconomic status and disability in old age: evidence from the In Chianti study for the mediating role of physiological impairments. J Gerontol A Biol Sci Med Sci 2006;61:86-91.
Huisman M, Kunst AE, Mackenbach JP. Socioeconomic inequalities in morbidity among the elderly; a European overview. Soc Sci Med 2003;57:861-73.
Hosseinpoor AR, Stewart Williams JA, Gautam J, Posarac A, Officer A, Verdes E, et al
. Socioeconomic inequality in disability among adults: A multicountry study using the World Health Survey. Am J Public Health 2013;103:1278-86.
Lund Jensen N, Pedersen HS, Vestergaard M, Mercer SW, Glümer C, Prior A. The impact of socioeconomic status and multimorbidity on mortality: A population-based cohort study. Clin Epidemiol 2017;9:279-89.
Warren JR, Hernandez EM. Did socioeconomic inequalities in morbidity and mortality change in the United States over the course of the twentieth century? J Health Soc Behav 2007;48:335-51.
Biswas T, Townsend N, Islam MS, Islam MR, Das Gupta R, Das SK, et al
. Association between socioeconomic status and prevalence of non-communicable diseases risk factors and comorbidities in Bangladesh: Findings from a nationwide cross-sectional survey. BMJ Open 2019;9:e025538.
Dowd JB, Zajacova A. Does the predictive power of self-rated health for subsequent mortality risk vary by socioeconomic status in the US? Int J Epidemiol 2007;36:1214-21.
Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al
. Socioeconomic status and the 25×25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1·7 million men and women. Lancet 2017;389:1229-37.
Felea MG, Covrig M, Mircea I, Naghi L. Socioeconomic status and risk of type 2 diabetes mellitus among an elderly group population in Romania. Procedia Economics and Finance;2014;10:61-7.
Suwannaphant K, Laohasiriwong W, Puttanapong N, Saengsuwan J, Phajan T. Association between socioeconomic status and diabetes mellitus: The national socioeconomics survey, 2010 and 2012. J Clin Diagn Res 2017;11:LC18-22.
Singh S, Shankar R, Singh GP. Prevalence and associated risk factors of hypertension: A cross-sectional study in urban Varanasi. Int J Hypertens 2017;2017:5491838.
Avendano M, Kawachi I, Van Lenthe F, Boshuizen HC, Mackenbach JP, Van den Bos GA, et al
. Socioeconomic status and stroke incidence in the US elderly: The role of risk factors in the EPESE study. Stroke 2006;37:1368-73.
Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, et al
. Socioeconomic status and stroke: An updated review. Stroke 2012;43:1186-91.
Grimaud O, Roussel P, Schnitzler A, Demmer R, Menvielle G. Do socioeconomic disparities in stroke and its consequences decrease in older age? Eur J Public Health 2016;26:799-804.
Yan H, Liu B, Meng G, Shang B, Jie Q, Wei Y, et al
. The influence of individual socioeconomic status on the clinical outcomes in ischemic stroke patients with different neighborhood status in Shanghai, China. Int J Med Sci 2017;14:86-96.
Hayashi T, Kondo K, Suzuki K, Yamada M, Matsumoto D. Factors associated with falls in community-dwelling older people focus on participation in sport organisations: The Japan Gerontological evaluation study project. Biomed Res Int 2014;2014:537614.
Cleveland RJ, Luong ML, Knight JB, Schoster B, Renner JB, Jordan JM, et al
. Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis. BMC Musculoskelet Disord 2013;14:297.
Nakahori N, Sekine M, Yamada M, Tatsuse T, Kido H, Suzuki M. A pathway from low socioeconomic status to dementia in Japan: Results from the Toyama dementia survey. BMC Geriatr 2018;18:102.
Freeman A, Tyrovolas S, Koyanagi A, Chatterji S, Leonardi M, Ayuso-Mateos JL, et al
. The role of socio-economic status in depression: Results from the COURAGE (aging survey in Europe). BMC Public Health 2016;16:1098.
Koster A, Bosma H, Kempen GI, Penninx BW, Beekman AT, Deeg DJ, et al
. Socioeconomic differences in incident depression in older adults: The role of psychosocial factors, physical health status, and behavioral factors. J Psychosom Res 2006;61:619-27.
Udayar SE, Patil SD, Vadivel K. Study of socioeconomic factors in relation to depression among elderly people living in rural area of Andhra Pradesh. Natl J Community Med 2016;7:382-5.
Yang S, Hoshi T, Wang S, Nakayama N, Kong F. Socioeconomic status, comorbidity, activity limitation, and healthy life expectancy in older men and women: A 6-year follow-up study in Japan. J Appl Gerontol 2014;33:831-47.
Amemiya A, Kondo N, Saito J, Saito M, Takagi D, Haseda M, et al
. Socioeconomic status and improvement in functional ability among older adults in Japan: A longitudinal study. BMC Public Health 2019;19:209.
Liu JY. The severity and associated factors of participation restriction among community-dwelling frail older people: An application of the International Classification of Functioning, Disability and Health (WHO-ICF). BMC Geriatr 2017;17:43.
[Table 1], [Table 2], [Table 3]