are lifestyle diseases a matter of concern for elderly...
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Are Lifestyle Diseases a Matter of Concern for Elderly Women: A
Study of Older Old and Oldest Old Population of India
Abstract:
The elderly women are more vulnerable in India due to the patriarchal nature of Indian
society. The present study aims at understanding the extent of life style disease (LSDs)
among elderly women and to explore the factors associated with the selected LSDs in India.
Using IHDS, 2004-05 data we have analyzed three major LSDs namely High BP, Heart
disease and Diabetes. This study is restricted to elderly women who are 60 years and above.
The study has employed bi-variate and multivariate analysis to find out the association
between socioeconomic & demographic characteristics and selected LSDs among elderly
women. The results shows that a high proportion of elderly women (38%) suffer from high
blood pressure followed by diabetes (18%) and less than ten percent of them report heart
problems. Furthermore, the multi-nominal results show that the LSDs is equally prevalent in
urban area, high caste groups, educated and non-poor section of the society.
Introduction and Background
Advances in medical science and better living conditions have increased the life expectancy, which
consequently contributes to the higher proportion of older population. At present, one of the
emerging challenges being faced by economies of the world is the rapid increase in their
proportion of elderly population. Globally, the number of persons aged 60 or over is expected
to increase by more than triple by 2100, increasing from 784 million in 2011 to 2 billion in
2050 and 2.8 billion in 2100. Furthermore, presently 65 per cent of the world’s older persons
live in such regions where there is lack of basic infrastructure and are still struggling with
infectious diseases and it is expected that the proportion of elderly population will increase
to 79 per cent by 2050 (United Nations, 2011). The developed countries became old after
being rich but it’s the opposite in the case of developing countries which makes it difficult for
the governments to give priority to its geriatric population.
Twenty-first century is witnessing a serious health concern emerging out of this
unprecedented population ageing. Gavrilov and Gavrilova (2001) argued that biological
ageing is correlated with increased morbidity, mortality and poor health status. This, together
with changing lifestyles and urbanization, has brought a radical shift in the types of health
problems being faced by populations in the developing world giving rise to an ‘epidemic of
chronic diseases’. Shetty (2002) in his study finds that the changes in the pattern of
health, disease and mortality promote a major shift from infectious and parasitic
disease to non communicable as the major cause of morbidity and mortality. The
estimate provided by WHO (2010) support these findings that lifestyle and behaviour
are linked to 20–25% of the global burden of disease, which would be increasing rapidly
in poorer countries. Moreover, literature suggest that the share of NCDs is expected to
account for seven out of every 10 deaths in the developing regions by 2020, compared
with less than half today. These finding indicates that the rate of epidemiological
transition in developing countries is very rapid, which has made it difficult particularly
for the policymakers of these countries to address the rapid change in transition (Reddy
et al., 1998; WHO, 2003; Huynen, 2005; Karar, 2009; WHO, 2004, 2010) for which India
is not an exception.
In the context of India, its population growth rate has come down to 1.6 per cent per
annum and life expectancy has crossed 60 years, but the total fertility rate (TFR) is still
above replacement level, the mortality is not yet very low (Human development report
India 2011). All these demographic circumstances have led to a marked increase in the
older population in India both in relative and absolute terms. The United Nations
Population Division projected that India’s population aged 50 years and above will reach to
34 percent by 2050. It is expected that between 2010 and 2050, the share of older population
(65 years and above) will increase from five to 14 percent, while the share of the oldest
population (80+ age group) will be tripled (United Nations Population Division, 2006)
which is most likely to make India home to the second largest older population of the world
by the year 2050. At the same time, the country is also witnessing the gradual breakdown of
its traditional practice of multigenerational co residence which often used to provide the
much needed support and care to the elderly (Alam and Mukherji, 2005; Golandaj, et al.
2013; Rajan et al. 2000). The socioeconomic status of elderly in India is way behind many
economically advanced nations (Bloom et al., 2010). Around 33 percent of elderly are living
below the poverty line, and 90 percent of the workforce is engaged in unorganized sector
which has no social security mechanism (NSSO, 1998). In such circumstances, it becomes
essential to assess the condition of elderly women as given the patriarchal nature of Indian
society, in which women are the weaker sex. Prakash has rightly mentioned way back in
1999 that Indian elderly women suffer from triple jeopardy i.e. of being old, being woman in
the patriarchal structure and being poor.
In this backdrop, let us first understand the life style diseases. The trend point to the direction
where an individual will become increasingly more responsible for ensuring own well being
in the age when a person should free from all the responsibilities. The issue of ageing is more
grave for India because.
In India, Non-communical diseases (NCDs) were responsible for 53% of deaths and 44% of
disability adjusted life years lost (Srinath R. K, at al, 2005.) These findings are in
consistancy with the study, by WHO (2003) which estimated that the proportion of NCDs in
developing countries was 36% in 1990 which is expected to increase to 57% by 2020.
Developing countries, like India, are likely to face an enormous burden of NCDs in future
(Fuentes R, 2000) and of these diseases, abnormal blood pressure (BP), Hearth disease and
Diabeties are some of the most frequently reported long-term illness that causes mortality and
morbidity in the elderly population (Desai et al, 2010). Women experience proportionately
higher rates of chronic illness and disability in later life than men, and also experience lower
social and mental health status, especially if they are single and/or widowed1.
Need for the study
While these diseases present a challenge for health policy for people at all stages of life
course, they are particularly more evident among older population where their effect is
obvious. A study done by Sharma (2003) argued that elderly have limited regenerative ability
and are more prone to disease, syndromes and sickness. The average number of diseases
reported by older population is 2.6 per person, which suggest that, multiple diseases are very
common in this age group. This is so because on the one hand the elderly population are not
much aware about the newly discovered morbid conditions and hence their ignorance leads to
underreporting; secondly, the biological capacity also goes down with the increase in the age
and so the effect of these lifestyle disease could be fatal in worst cases. The increase in the
vulnerability because of biological factors cannot be controlled; however increasing
susceptibility due to man-made factors, lifestyle changes etc should be controlled if not
eradicated completely. The growing proportion of elderly population and the reducing
resistance capacity with the age gives enough reasons to understand the importance of
addressing these health problems (WHO, 2003).
1 Over 50% of women aged 80 and above are widows (Government of India, 2011).
The area of graying population is being explored at length; however there is a virtual vacuum
of studies that have attempted to explore the effect of lifestyle diseases on the elderly women.
Such diseases are termed as disease of longevity which itself points to the direction of
rejecting the assumption of elderly being immune from such diseases. The present study aims
at understanding the extent of life style disease (LSDs) among elderly women its relationship
with advancement of age and other variables and to understand the factors associated with
selected diseases in India.
Materials and Methods
Data source and sample size
The present research has used the data of India Human Development Survey (IHDS) 2005
which is a collaborative research project of the University of Maryland, USA and National
Council of Applied Economic Research, New Delhi. IHDS is conducted across the states and
union territories with the exception of Andaman and Nicobar and Lakshadweep islands
covering 99.9 percent of India’s population. It is a multi-topic survey which has collected a
vast range of information on health, education, employment, economic status, marriage,
fertility, gender relations, and social capital. In addition to socio-economic and demographic
characteristics information have been collected about each and every individual in the
household regarding social network, diseases and disabilities, etc. In the present study,
information on the socioeconomic characteristics and major morbidity of population aged 60
and above is used. The following table gives the sample selection for the present study.
Population Number
Total Households 41,554
Total sample size 215,754
Elderly person 17,904
Elderly women 8,941*
*Hence, the present study is restricted to only elderly women who are aged 60 and above (for more details on sampling see
also Desai et al. (2010)).
Definition of variables
Health variable Predictor variables
Life style disease: Age of the sample of older women population was
a. High Blood Pressure (BP)
b. Heart disease and
c. Diabetes
categorized into two group, 60-69 years and 70 years above
of age.
The place of residence is coded as rural and urban.
Caste: Identification of the social group in modern India is
broadly classified into four groups: Scheduled Castes (SCs),
Scheduled Tribes (STs), Other Backward Castes (OBCs) and
other castes (Srinivas, 1957).
The religion of the older women was categorized as Hindu,
Muslim, and others (Christians, Sikh, Buddhist, Jain and
others).
The educational level of the older women was defined using
years of schooling and they were grouped into No schooling,
1-4 years, 5-9 years and 10 and above.
Wealth status, an index of economic status (wealth quintile)
for each household is constructed using the principal
components analysis (PCA) based on the household data. The
wealth quintiles are based on 30 assets and the housing
characteristics. Each of the household asset is assigned a
weight (factor score) generated through PCA. The resulting
asset scores are standardized in relation to a normal
distribution with the mean of zero and standard deviation of
one. Then, the values of the wealth index was subsequently
divided into five quintiles – poorest, poorer, middle, richer,
and richest – however, for analytical purpose the bottom two
quintiles (lower 40%) were considered as poor and remaining
three were as non-poor. This classification is consistent with
previous studies (Joe W, et al., 2009).
The marital status of the older women population is grouped
into three categories namely, currently married, widowed and
others (single, sep/div, sp. absent, no gauna).
The family type of the older women’s household is coded
into two categories, namely, nuclear family and joint family.
According to the availability of data, the study measures following three major non-
communicable diseases; High Blood Pressure (BP), Heart disease and Diabetes. A variable
has been computed combining all the diseases considered for analysis in three categories; as
“No LSD”, “One LSD” and “At least two LSD”. Socioeconomic and demographic predictors
such as age of the older women, education, place of residence, etc., have been explained in
the table.
Analytical Approach
In order to identify the factors associated with selected life style diseases among older
women, bi-variate and multivariate analyses have been carried out. Bi-variate analyses were
used to examine the nature of association between LSDs by selected socioeconomic and
demographic characteristics and were tested for statistical significance at 95 percent
confidence interval (P < 0.05) by using χ2 test.
The study has used multinomial logit regression (MLR) to estimate the adjusted effect of
socioeconomic predictors on life style diseases. Further, for better comparison of the results
the coefficients of MLR are converted to adjusted percentages by using multiple
classification analysis (MCA) conversion model.
MCA conversion model formulae:
where:
ai i = 1, 2 : constants.
bij i = 1, 2; j = 1, 2........n : multinomial regression coefficient.
P2 : estimated probability of having LSDs score of one
disease among the older women population.
P3 : estimated probability of having LSDs score of at least
two diseases among the older women population.
P1 : (no LSDs score) is the reference category.
The procedures followed are given stepwise below:
Step 1. Using the regression coefficient and the mean values of independent variables, the
probability is computed as:
where Z is the estimated value of response variables for each variable category.
Step 2. To obtain the percentage values of the estimate, the probability P is multiplied by
100.In this way, the adjusted percentages of the tables are generated.
The study has used SPSS 17 and STATA 11 software programs for all statistical analyses
undertaken.
Results
Figure 1 shows the percent of elderly women suffering from the diseases of longevity. It is
clearly visible that a high proportion of elderly women (38%) suffer from the problem of
blood pressure followed by diabetes (18%) and less than ten percent of them report heart
problems. The figure proves that even the elderly women are not immune from lifestyle
diseases. Though the percent is less than 40% but if we convert it in absolute numbers then it
seeks the attention of policy makers. This would be interesting to see who all these elderly
women are suffering from lifestyle diseases in order to understand whether there is any
influence of socioeconomic factors on the reporting of the diseases.
Table 1 presents the distribution of the study sample by the background characteristics. The
older women population is classified into two age groups: population aged 60-69 years
referred to as older old and population aged 70 years and above comprising the oldest old.
There is a larger share of older old population in the sample (63%) as compared to the oldest
old population (37 percent) With regard to the place of residence, majority (76 percent) of the
older women resides in rural areas The literacy rate in ancient India was very low as 78
percent of the older population is illiterate and only 6 percent of them have received
education for ten and more years. Since women are biologically stronger than male and early
marriage of girl child was very much prevalent in earlier days, a large proportion of women
have to live a life of widow. In our sample, 56 percent of the elderly women were widowed;
The religious compositions of the older women population mirror the distribution of the
general population of India, with the majority of the older women belonging to Hindu (84
percent), followed by Muslim (9 percent) and the rest as the others (7 percent). Similarly, the
caste composition of the older women reflects the highest proportion of OBCs (42 percent),
followed by other castes (33 percent) and SCs/STs (25 percent). The economic status of the
household of elderly women reflects that 63% of them belong to non-poor household
whereas, 37% of them belongs to poor households. The table reflects that, these descriptive
statistics are indicative of the fact that; on the whole, the distribution of sample and un-
weighted sample size for the study is enough to carry the robust statistical analysis, however
in few of the cases the sample is less therefore those variables are not considered for
sophisticated analysis.
Table 2 reflects the distribution of elderly women who reports to suffer from any of the
disease considered for the analysis. In consistency with the above figure, the table shows that
a larger proportion of older women suffers from the problem of blood pressure followed by
diabetes and heart disease. The table depicts that with the increase in the age of women there
is decline in the reporting of blood pressure and this is true for other two diseases as well i.e.
heart disease and diabetes. There is higher percent of elderly women suffering from blood
pressure and diabetes living in rural areas; however it is the other way around for heart
diseases as higher percent of elderly women with heart problems are living in urban areas.
This reflects the influence of living in urban and rural areas as these are the life style diseases.
Among the social and religious groups higher percent of women with blood pressure belongs
to other caste group and Hindu religion which is consistent for other two diseases as well. A
higher percent of women suffering from any of the three ailments belong to illiterate section
of the society. As per the expectation, there is larger concentration of elderly women
suffering from the disease in the economically better off section of the society and this
difference is quite huge as it is 68% and 32% for non-poor and poor women suffering from
blood pressure; 70% and 30% for heart disease and 83% and 17% for diabetic elderly women
in non-poor and poor women respectively. There is higher concentration of women suffering
from blood pressure (65%), heart disease (65%) and diabetes (61%) in joint family. Therefore
the results shows that women suffering from any of the disease under study belong to older
old age group, rural areas, better off section, illiterate and living in joint family.
Table 3 reflects the distribution of elderly women by life style diseases considered for the
analysis (BP, Heart disease and Diabetes). The table shows that the majority of older women
suffer more from at least two diseases; this means the incidence of multiple diseases is quite
common among the elderly women. . The table depicts that with the increase in the age of
women there is decline in the reporting of these diseases of longevity; it may be because of
other health complications that come up as age increases and so the attention is deviated from
these diseases to other complicated morbidities.
Data shows that, rural elderly women are more likely to suffer from lifestyle diseases as
compare to urban counterpart, which is striking because rural people are more physically
active than urban people. Among the social groups, elderly women belonging to other caste
group have reported atleast two LSDs which remains true when we consider any one of the
LSDs. Among religion groups it is the Hindu women who are suffering more from any of
one diseases and this is true in case of at least two diseases. A higher percent of women
suffering from any of the three ailments belong to illiterate section of the society and it is true
in case of elderly women who are suffering with at least two diseases. As per the expectation
there is larger concentration of elderly women suffering from the disease in the economically
better off the society and this difference is quite huge as it is 24 and 22 per cent for poor and
where as it is 76 and 78 per cent for non-poor women suffering from one disease and at least
two diseases respectively. There is higher concentration of women living in joint family for
one disease (56 per cent) and at least two diseases (67 per cent) respectively then their
counterparts. Therefore the results shows that elderly women who belong to older old age
group, rural areas, better off section, illiterate and living in joint family are most sufferers of
these diseases.
Table 4 presents the adjusted percentages (multinomial regression estimates) of the elderly
women by the disease scores and their background characteristics. The score is allotted based
on a person is suffering from LSD or not, and if yes, number of diseases a person is suffering
from out of three LSDs considered for the analysis (High BP, Heart disease and Diabetes).
Further, for better understanding of the results, the scores are classified into three categories:
“No LSD”, “One LSD” and “Atleast two LSD”. Table depicts that in the older old age group,
a considerable percentage of elderly women (19%) are suffering from any one of the
ailments and 12% with at least two of the diseases. And this is holds true for the oldest old
age group. A high percent of elderly women suffering from any one of the diseases (30%)
and at least two diseases (21%) belongs to urban areas. Among the social groups higher
percent of women suffering with both category one LSD and At least two LSD belongs to
others category and followed by OBC. Among the religious groups there is higher percent of
elderly women suffering from at least two diseases are belongs to others category; however it
is the other way around for elderly women suffering from any one of the ailment are belongs
to Muslim category. And a considerable (20%) and (10%) of Hindu elderly women are also
suffering from any one ailment and at least two ailment of diseases respectively. Results
show that the life style diseases are equally prevalent in educated, urban and non-poor section
of the society.
Conclusion
The increase in the magnitude of elderly is so huge that the present century has been termed
as “century of the aged”. This means that there is an urgent need to look into the allocation of
resources as the needs of elderly are different which needs to be met differently. Overall,
results show that life style diseases are being reported by elderly women; however there is a
decline in the reporting of diseases with the increase in the age of elderly women. In other
words, there is less reporting by oldest old women as compared to older old women.
However we suggest two possibilities behind such results; one reason could be that there is
less understanding of various morbidities among oldest old women which often leads to
under reporting. Second, since with increase in age, it is largely believed that health
deteriorates and so there may be less attention paid to the health of the elderly population.
The results also point to the need of separate geriatric hospitals so as to ensure a good health
status to the elderly.
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Table 1: Percentage distribution of study sample by background characteristics, India,
IHDS, 2004-05
Background characteristics Percentage N
Age
Old-old(60-69) 62.61 5488
Oldest-old(70+) 37.39 3453
Residence
Rural 75.80 6320
Urban 24.20 2621
Caste1
SC/ST 25.42 2189
OBC 41.50 3574
Others 33.08 3178
Religion2
Hindu 83.94 7372
Muslim 9.32 829
Others 6.75 740
Education
No schooling 77.63 6757
1-4 Years 7.00 661
5-9 Years 9.14 899
10 and Above 6.23 624
Wealth Status
Poor 37.46 2993
Non-poor 62.54 5687
Marital Status3
Currently married 42.96 3864
Widowed 55.83 4969
Others 1.21 108
Family type
nuclear family 29.31 2682
Joint family 70.69 6259
Total 100 8941
Note: 1. For caste variable, others category includes Brahmin and others.
2. For religion variable, others category includes Christian, Sikh, Buddhist, Jain, Tribal, Others and None.
3. For marital status variable, others category includes single, sep/div, sp. absent, no gauna.
4. All percentage are taken of valid cases after excluding missing cases.
N= Un-weighted cases.
Source: IHDS, 2004-05.
Table 2: Distribution of elderly women suffering from lifestyle disease across
background characteristics, India, IHDS, 2004-05
Background characteristics BP N Heart N Diabetes N
Age
Old-old(60-69) 63.1 396 53.5 91 64.3 212
Oldest-old(70+) 36.9 274 46.5 79 35.7 121
Residence
Rural 60.7 344 45.9 71 52.2 161
Urban 39.3 326 54.1 99 47.8 172
Caste1
SC/ST 14.3 88 * 18 13.2 42
OBC 39.9 244 24.5 42 37.3 123
Others 45.7 338 63.2 110 49.5 168
Religion2
Hindu 76.9 497 78.4 128 72.4 241
Muslim 9.0 70 * 20 8.6 30
Others 14.1 103 * 22 19.0 62
Education
No schooling 58.0 346 57.8 97 45.6 153
1-4 Years 14.5 116 * 19 13.2 41
5-9 Years 19.3 144 20.0 37 27.9 96
10 and Above 8.2 64 * 17 13.3 43
Wealth Status
Poor 31.7 161 29.5 44 17.0 51
Non-poor 68.3 494 70.5 121 83.0 268
Marital Status3
Currently married 37.0 256 41.1 74 47.7 167
Widowed 62.4 406 58.3 94 51.2 162
Others * 8 * 2 * 4
Family type
Nuclear Family 34.7 217 35.2 59 39.4 135
Joint Family 65.3 453 64.8 111 60.6 198 Note: 1. For caste variable, others category includes Brahmin and others.
2. For religion variable, others category includes Christian, Sikh, Buddhist, Jain, Tribal, Others and None.
3. For marital status variable, others category includes single, sep/div, sp. absent, no gauna.
4. All percentage are taken of valid cases after excluding missing cases.
*= the cases are very low so percentages are not shown.
N= Un-weighted cases.
Source: IHDS, 2004-05.
Table 3: Distribution of elderly women suffering from lifestyle disease across
background characteristics, India, IHDS, 2004-05
Background characteristics No LSD N One LSD N
At least two
LSD N
Age
Older(60-69) 58.70 466 59.97 143 61.17 109
Oldest-old(70+) 41.30 346 40.03 93 38.83 72
Residence
Rural 77.91 600 52.43 113 51.34 85
Urban 22.09 212 47.57 123 48.66 96
Caste1
SC/ST 20.03 173 * 26 * 22
OBC 43.60 328 34.79 82 31.96 54
Others 36.37 311 51.65 128 55.96 105
Religion2
Hindu 86.34 696 80.96 184 65.71 125
Muslim 7.52 66 * 25 * 16
Others 6.13 50 * 27 25.39 40
Education
No schooling 76.54 621 54.75 130 40.90 74
1-4 Years 8.00 63 * 25 18.36 30
5-9 Years 9.19 77 21.95 54 28.28 54
10 and Above 6.28 51 * 27 * 23
Wealth Status
Poor 37.58 297 23.93 49 22.45 37
Non-poor 62.42 478 76.07 179 77.55 137
Marital Status3
Currently married 40.24 319 50.23 125 38.59 72
Widowed 58.32 477 48.93 109 60.50 106
Others * 16 * 2 * 3
Family type
nuclear family 33.22 257 44.07 104 32.81 60
Joint family 66.78 555 55.93 132 67.19 121 Note: 1. For caste variable, others category includes Brahmin and others.
2. For religion variable, others category includes Christian, Sikh, Buddhist, Jain, Tribal, Others and None.
3. For marital status variable, others category includes single, sep/div, sp. absent, no gauna.
4. The variable “Life style disease” is computed by using three life style diseases namely “High BP” “Heart disease” and
“Diabetes” into three categories 1”No LSD” 2”One LSD” 3”At least two LSD”.
5. All percentage are taken of valid cases after excluding missing cases.
*= the cases are very low so percentages are not shown.
N= Un-weighted cases.
Source: IHDS, 2004-05.
Table 4: Multi-nominal results of life style diseases among elderly women across
background characteristics, India, IHDS, 2004-05
Background characteristics No LSD One LSD At least two LSD
Age
Old-old(60-69) 69.22 18.90 11.88
Oldest-old(70+) 67.61 22.39 10.00
Residence
Rural 74.80 17.19 8.01
Urban 49.25 29.71 21.04
Caste1
SC/ST 80.38 12.42 7.20
OBC 67.33 22.15 10.52
Others 61.30 23.72 14.98
Religion2
Hindu 69.46 20.46 10.08
Muslim 69.21 21.83 8.96
Others 57.32 14.89 27.79
Education
No schooling 76.49 17.34 6.17
1-4 Years 69.80 16.23 13.97
5-9 Years 58.59 23.45 17.95
10 and Above 40.05 34.55 25.40
Wealth Status
Poor 80.21 12.79 6.99
Non-poor 62.06 24.41 13.52
Marital Status3
Currently married 68.80 19.38 11.82
Widowed 68.02 21.86 10.13
Others 76.24 14.43 9.33
Family type
Nuclear family 69.58 19.43 11.00
Joint family 68.45 20.36 11.20 Note: 1. For caste variable, others category includes Brahmin and others.
2. For religion variable, others category includes Christian, Sikh, Buddhist, Jain, Tribal, Others and None.
3. For marital status variable, others category includes single, sep/div, sp. absent, no gauna.
4. The variable “Life style disease” is computed by using three life style diseases namely “High BP” “Heart
disease” and “Diabetes” into three categories 1”No LSD” 2”One LSD” 3”At least two LSD”.
5. All percentage are taken of valid cases after excluding missing cases.
Source: IHDS, 2004-05.
Fig1: Disease of Longitivity and elderly women, India, 2004-05