Background
The majority of the total population of Bangladesh resides in rural areas, and they still live below the poverty line [
1]. Rural older people cannot meet their fundamental needs and access to healthcare facilities that may significantly increase the risk of malnutrition and geriatric depression (GD) [
2,
3].
The older population of Bangladesh is susceptible to poor health as there are diverse risk factors encountered in providing good health. The household’s food insecurity, inadequate knowledge due to illiteracy, poor appetite, weight loss, lack of awareness predispose illnesses like malnutrition. Limited access of older adults to health facilities could be considered as another underlying cause that could lead to poor health and illness [
4]. Besides these, the rural people confront an unhealthy environment, inadequate social supports, and poor health amenities, which intensify their health risks, cause malnutrition, and invite various communicable and non-communicable diseases, where the older people are worse victims [
5,
6].
Some existing literature from the developing countries reported that the rural people suffered from different health risks due to poverty, unemployment, insufficient health facilities, and absence of social security, where the risk is severe in the older community [
7‐
9]. A community-based study conducted among the population of Kalapara Upazila (one of our sampling areas) of Patuakhali district showed that for every 8000 people there is only one health facility [
10]. These lacking; basic humanitarian needs, socio-economic insecurity, and limited access to health facilities create a burden of poor health among the rural older adults.
According to the World Health Organization (WHO), 80% of older people will be living in low- and middle-income countries in 2050. GD is a common health condition in rural communities of developing countries. Older people are constantly at threat of this health problem due to socio-economic, physical, and social environment, and factors related to aging [
11‐
13]. Rural older people of the developing countries are the most vulnerable group for various physical and mental health consequences, and diverse age-specific sufferings [
12‐
14]. Their quality of life deteriorates and needs comprehensive health care, and increases healthcare utilization costs [
15,
16]. As a consequence, a remarkable segment of older adults suffers from major depression and commit suicide, although multiple other reasons can also be involved in most cases [
17].
Several risk factors (i.e., biological, social, psychological, environmental, etc.) have been suggested in the development of GD such as being female, older, single or widow, smoker, drug user, and multiple medication users, and having lower educational status [
18,
19]. Low income, being unemployed, financial insecurity, poor physical health like malnutrition, co-morbidities, sleeping disorders, frailty, loneliness, lack of social support, stressful life events, poverty, and cognitive impairment are also established as determinants of GD [
20,
21]. Most of these determinants are identified through descriptive cross-sectional studies and association of risk factors with geriatric depression through analytical studies is very scarce. Comparative study based on two groups of rural older adult participants to find an association between GD and malnutrition is not evident in the remote costal context of a developing country like Bangladesh.
Malnutrition and depression are interrelated geriatric medical disorders and diverse studies revealed an interdependent relationship between these two geriatric health issues. Globally, the depression status of older adults has been well researched but still, it is an unfinished agenda [
8]. A previous study conducted in Bangladesh examined the issue and reported a 24% prevalence of malnutrition among Bangladeshi hospital-attending older patients [
22]. In developing a public-health response to GD and malnutrition, it is imperative to devise strategies, which may reinforce recovery, adaptation, and sound health in the older population. But, most of the developing countries confront challenges to ensure that their health and social systems are ready to address these major geriatric health issues.
Research has demonstrated that earlier diagnosis and treatment of malnutrition can lead to improved outcomes and better quality of life as well as reduced health consequences among older adults. However, studies especially community-based case-control studies concerning GD and malnutrition especially in a rural setting are scarce in Bangladesh. In this context, the present community-based case-control study investigated GD as the dependent variable while malnutrition and associated risk factors as independent variables among the rural older adults in Bangladesh. The study intended to explore the relationship between GD with malnutrition and identify risk factors associated with GD. The study findings could contribute to devising effective interventions and approaches to prevent these leading geriatric medical disorders in the country.
Results
A total of 600 rural older adults (300 depressed as cases and 300 non-depressed as controls) participated in this comparative cross-sectional study. The study found no significant differences in gender and age between cases and controls. Females shared 54.0% cases and 56.0% controls while males shared 46.0% cases and 44.0% controls. Regarding marital status, the majority of the cases (61.7%) were single, while the majority of the controls (76.0%) were married, and this difference was statistically significant (
p < 0.01). In respect of social class (based on monthly family income), lower and middle class (having monthly family income ≤20,000 BDT) was significantly (
p < 0.01) higher in cases (81.3%) than in controls (50.7%) while upper class (having monthly family income > 20,000 BDT) was significantly higher in the controls (49.3%) than in the cases (18.7%). In respect of educational status, higher education (Graduation and above) was significantly (
p < 0.05) higher in the controls (56.4%)) than in the cases (43.6%). Concerning employment status, the majority of the cases (82.7%) were unemployed, while the majority of the controls (60.7%) were employed, and this difference was statistically significant (
p < 0.01) (Table
1).
Table 1
Association between depression and baseline characteristics of older adults
Age group (Years) |
60–69 | 154 (51.3) | 198 (59.3) | 0.233 |
70–79 | 86 (28.7) | 82 (27.3) |
≥80 | 60 (20.0) | 40 (13.3) |
Total | 300 (100.0) | 300 (100.0) |
Gender |
Male | 138 (46.0) | 132 (44.0) | 0.481 |
Female | 162 (54.0) | 168 (56.0) |
Total | 300 (100.0) | 300 (100.0) |
Religion |
Islam | 263 (88.0) | 276 (92.0) | 0.248 |
Hinduism | 37 (12.0) | 24 (8.0) |
Total | 300 (100.0) | 300 (100.0) |
Marital Status |
Single | 184 (61.3) | 72 (24.0) | 0.001 |
Married | 116 (38.7) | 228 (76.0) |
Total | 300 (100.0) | 300 (100.0) |
Social Class (Based on monthly family income) |
Upper class (> 20,000 BDT) | 56 (18.7) | 148 (49.3) | 0.001 |
Lower and Middle class (≤20,000 BDT) | 244 (81.3) | 152 (50.7) |
Total | 300 (100.0) | 300 (100.0) |
Educational status |
Illiterate | 62 (20.7) | 30 (10.0) | 0.026 |
Non-institutional education | 52 (17.3) | 68 (22.7) |
Between class 1–5 | 44 (14.7) | 38 (12.7) |
Between class 6–10 | 54 (18.0) | 32 (10.7) |
S.S.C | 18 (6.0) | 28 (9.3) |
H.S.C | 36 (12.0) | 60 (20.0) |
Graduation and above | 34 (43.6) | 44 (56.4) |
Total | 300 (100.0) | 300 (100.0) |
Employment Status |
Employed | 52 (17.3) | 182 (60.7) | 0.001 |
Unemployed | 248 (82.7) | 118 (39.3) |
Total | 300 (100.0) | 300 (100.0) |
Family Type |
Nuclear family | 224 (74.7) | 228 (76.0) | 0.789 |
Joint family | 76 (25.3) | 72 (24.0) |
Total | 300 (100.0) | 300 (100.0) |
Regarding the association between GD with selected personal characteristics, Pearson’s chi-square test showed that the depressed (cases) had significantly (
p < 0.05) less peer group support than the non-depressed (controls) older adults (50.7% Vs. 64.0%). Active daily life was also significantly (
p < 0.01) less prevalent in the cases than the controls (46.7% Vs. 64.7%). Having a poor diet was significantly (
p < 0.01) higher in the cases than in the controls (37.3% Vs. 77.3%). Tobacco use (both smoking and smokeless tobacco) was significantly (
p < 0.01) higher in the cases than in the controls (55.7% Vs. 37.3%). The study didn’t find any significant differences in chronic diseases between cases and controls (Table
2).
Table 2
Association between depression and personal characteristics of older adults
History of chronic disease |
Having history | 176 (58.7) | 146 (45.3) | 0.132 |
No History | 124 (41.3) | 154 (54.7) |
Total | 300 (100.0) | 300 (100.0) | |
Peer group support |
Yes | 152 (50.7) | 192 (64.0) | 0.020 |
No | 148 (49.3) | 108 (36.0) |
Total | 300 (100.0) | 300 (100.0) | |
Active in daily life |
Yes | 140 (46.7) | 194 (64.7) | 0.002 |
No | 160 (53.3) | 106 (35.3) |
Total | 300 (100.0) | 300 (100.0) | |
Tobacco use (Smoking and SLT) |
Yes | 167 (55.7) | 112 (37.3) | 0.003 |
No | 133 (44.3) | 188 (62.7) |
Total | 300 (100.0) | 300 (100.0) |
Having a poor diet |
Yes | 188 (62.7) | 68 (22.7) | 0.001 |
No | 112 (37.3) | 232 (77.3) |
Total | 300 (100.0) | 300 (100.0) | |
The study found a significant (
p < 0.01) association between malnutrition and GD, where 56.0% of the cases and 18.0% of the controls had malnutrition. The study also found that 82.0% of the controls and 34.0% of the cases had no malnutrition (Table
3).
Table 3
Association between depression and malnutrition in rural older adults
Yes | 168 (56.0) | 54 (18.0) | 0.001 |
No | 132 (44.0) | 246 (82.0) |
Total | 300 (100.0) | 300 (100.0) |
The logistic regression analysis showed that single older adults were more likely to experience depression (AOR = 2.368; 95% CI: 1.762–6.524;
p = 0.001). Concerning social class, the lower and middles classes were more likely to experience depression (AOR = 3.654; 95% CI: 2.266–7.767;
p = 0.001). The malnourished rural older adults had more than three times higher [AOR = 3.155, 95% CI: 1.534–6.494,
p = 0.002] risk of having depression than the well-nourished older adults. The unemployed older adults had around five times higher (AOR = 4.964; 95% CI: 2.361–10.440;
p = 0.001) risk of having depression, and older individuals having a poor diet had more than three times higher (AOR = 3.384; 95% CI: 1.764–6.703;
p = 0.001) risks of having depression. The rural older adults who were tobacco users had more than two times higher risk of having depression (AOR = 2.332; 95% CI: 1.663–5.623;
p = 0.003). The study also found a lower risk of depression among the older adults having SSC or below education than those having HSC or above education (Table
4).
Table 4
Logistic regression analysis of the factors associated with depression in older adults
Marital status |
Married | Reference | | 0.001 |
Single | 2.368 | (1.762–6.524) |
Social class (Based on monthly family income) |
Upper class (> 20,000 BDT) | Reference | | 0.001 |
Lower and Middle class (≤20,000 BDT) | 3.654 | (2.266–7.767) |
Educational status |
H.S.C and above | Reference | | 0.023 |
S.S.C and below | 0.730 | (0.556–0.957) |
Employment status |
Employed | Reference | | 0.001 |
Unemployed | 4.964 | (2.361–10.440) |
Peer group support | |
Yes | Reference | | 0.935 |
No | 0.947 | (0.484–1.807) |
Active in daily life |
Yes | Reference | | 0.266 |
No | 1.465 | (0.748–2.871) |
Having a poor diet |
Yes | 3.438 | (1.764–6.703) | 0.001 |
No | Reference | |
Tobacco use (Both smoking and SLT) |
Yes | 2.332 | (1.663–5.623) | 0.003 |
No | Reference | |
Malnutrition status |
Well-nourished | Reference | | 0.002 |
Mal-nourished | 3.155 | (1.534–6.491) |
Discussion
Diverse literature depicts that the causal relationship between malnutrition and depression in older adults is still inconclusive. Both malnutrition and depression are inherently related; depression may lead to appetite loss and undernutrition, while malnutrition may denigrate depression and apathy [
29]. We conducted this comparative or analytical cross-sectional study in the rural setting of Bangladesh to assess the association between malnutrition and geriatric depression and identify associated risk factors. A study reported that older depressed people have a greater risk of psychological disorders, which provoke suicide and suicidal behaviors [
30]. The existing health care delivery system in Bangladesh provides limited health care for older adults in urban communities, but it is scarce in rural settings. Accordingly, the rural older individuals do not get need-based health services within the rural health facilities. Robust data on these health issues and related risk factors are essential for devising an effective solution to reduce the occurrences of depression and malnutrition in the rural older population of the country.
A comprehensive literature review revealed that relevant data on GD in association with malnutrition is not available in the context of rural Bangladesh. Consequently, the present comparative cross-sectional study investigated malnutrition concerning GD and associated risk factors in rural older adults of the country. The current study is an ingenious initiative using a community-based analytical cross-sectional study design to expose the picture of geriatric depression and malnutrition in the rural context of the country. The study conserves enormous academic and policy implications because the study attempted to determine the temporality of the association between malnutrition and geriatric depression in the rural setting.
The present study showed that majority of the depressed and non-depressed (51.3 and 59.3%) older adults were aged 60–69 years. Another study conducted among the rural residents of Narail Upazila of Bangladesh reported a similar finding where 58.7% of those aged 60–69 years were suffering from depression as a psychological disorder [
31]. The current study found that single older adults, lower education, unemployment, and less monthly income were significantly associated with GD. In the context of Bangladesh, the rural older adults are mostly kept unemployed and dependent on other family members, which compel them to suffer from financial scarcity, lack of access to nutritious foods, healthy living, and need-based health care. A study conducted by Haseen et al. reported that illiteracy and unemployment aggravated economic constraints and poverty, which sequentially contributed to malnutrition and the occurrence of geriatric depression [
32].
The current study portrayed that majority (50.7%) of the cases (depressed rural older adults) had significantly (
p < 0.05) less peer group support than the controls (64%). Another study conducted by Disu TR and colleagues found that 31.3% of the older individuals having peer group support were depressed (cases in the present study), and 68.7% were non-depressed (controls in the present study) [
33]. In the local context of Bangladesh, rural older adults have poor access to peer group support due to the prevailing social structure, community design, and lifestyles of local people. The rural older people of the country confront these contextual realities and suffer from loneliness, mental stress, and depression.
The present study revealed that poor-diet consumption was significantly (
p < 0.01) higher in depressed (62.7%) than in non-depressed (22.7%) older adults. The study depicted that the rural older individuals having a poor diet had more than three times higher risk of experiencing depression. Another study conducted by Disu TR et al. found that 77% of the older persons having a poor diet were depressed (cases in the present study), and 22.6% were non-depressed (controls in the present study) [
33]. This difference could be due to the variation in methodological factors such as the sample size (small vs. large), sampling (systematic random vs. convenience), study design (comparative cross-sectional vs. descriptive cross-sectional), and study place (Rural vs. urban and rural both) between the current and former studies. It is also evident that ‘poor diet’ intake invites malnutrition in rural older populations.
Tobacco use was significantly (
p < 0.01) higher in the depressed older adults (55.7%) than in the non-depressed (37.3%) older individuals. The study revealed that older people who were tobacco users had more than two times higher risk of experiencing depression. The research conducted by Disu et al. didn’t find any significant difference, where 39.3% of the older adults who were smokers had depression [
33]. It could be claimed that our study assessed tobacco use considering both smoking and smokeless tobacco use while the other study considered smoking only. Moreover, variations in study design and places could also contribute to the differences. It is observed that rural older males use to do smoking in the form of bidi, cigarettes, hookah, and pipes. On the other hand, the rural older females use to take smokeless tobacco in the form of
Jarda, Gul, Sadapata, Nasshi, Khaini, etc. [
34]. Concerning the relation of depression with tobacco use, it is evident that tobacco stimulates the dopamine section from the pituitary gland of the human brain, which stimulates systemic functions and gradually produces neurological disorders like depression among older adult tobacco users.
The current study found that older adults engaged were engaged in sweat-producing activities like engagement in daily household activities and regular exercise had lower levels of depression. Some previous relevant studies also depicted similar observations. Depression is associated with decreased energy, increased fatigue, loss of interest in daily activities, and less concentration on daily activities [
35,
36]. Our study found that the depressed rural older adults (46.7%) were significantly less active in their everyday life in compassion to the counterpart non-depressed older individuals (64.7%). In this regard, the study of Disu and colleagues found that 29.2% depressed and 70.8% non-depressed older people were active in daily life [
33]. These differences could be due to variations in study place and population. It could be explained by the fact that active involvement in such activities mediates the release of various bodily chemicals like endorphins, norepinephrine, serotonin, etc., which help to prevent the occurrence of depression in older adults [
37].
Our study revealed that more than half of the depressed rural older adults had malnutrition, while it was only 18% in the non-depressed older individuals. The malnourished older adults had more than three times higher risk of having depression. In this concern, another study depicted that depression is significantly affected by malnutrition, which is associated with the food-intake behavior of older adults [
38]. The research carried out by German L and colleagues also found malnutrition remarkably higher in depressed than in non-depressed patients [
39]. Since malnutrition has a significant influence on appetite and eating habits, it seems that having malnutrition could be a risk factor for older people to be depressed. Furthermore, food insecurity, non-availability, and inaccessibility might have an association with depression [
38], particularly in the older adults [
40], and taking a poor diet may lead to mood disorders, depression, and poor cognitive performance among this vulnerable group [
41].
Given that rural older adults are more likely to live in an extended family with financial scarcity, poor diet, poor social support, and poor access to health care. As a result, they are more vulnerable to malnutrition, consequently suffer from mental stress and depression. Furthermore, studies indicate that diverse food elements like micronutrients, trace elements, and vitamins are also associated with the occurrence of different neurological complications like degenerative changes of the brain in late life, which could lead to depression [
42,
43].
Strength and limitations
Use of self-report and the non-representative sample from three selected rural communities of a district are few limitations to the generalizability of findings. Those who said they had a current acute illness (excluding long-term chronic conditions) were not eligible to participate in the study. Therefore, the prevalence of malnutrition was likely to be lower in both cases and controls. The study also missed some relevant risk factors like chronic diseases, comorbidities, and psycho-social factors that may affect GD. Despite these limitations, the present community-based case-control study identified crucial risk factors associated with depression in the rural context of the country where relevant data are scarce. The study findings also preserve essential policy inferences in devising effective interventions and health programs to prevent these leading geriatric health disorders in the rural older population of Bangladesh and other developing countries.
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