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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Public Health 1/2012

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

Zeitschrift:
BMC Public Health > Ausgabe 1/2012
Autoren:
Nicola Cherry, Morshed Chowdhury, Rezaul Haque, Corbett McDonald, Zafrullah Chowdhury
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1471-2458-12-379) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

NC, ZC and CMcD conceived the study, developed the design, methodology and measurement tools. RH and MC organized the field work and verification of information accuracy. NC and MC were responsible for data entry and verification. NC and CMcD .planned and executed the data analysis. NC drafted the paper and acts as guarantor. All authors commented critically on the initial draft and have agreed the final text.

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)
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)
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)
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.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

NC, ZC and CMcD conceived the study, developed the design, methodology and measurement tools. RH and MC organized the field work and verification of information accuracy. NC and MC were responsible for data entry and verification. NC and CMcD .planned and executed the data analysis. NC drafted the paper and acts as guarantor. All authors commented critically on the initial draft and have agreed the final text.
Zusatzmaterial
Additional file 1: Survey Card. (PDF 24 KB)
12889_2012_4165_MOESM1_ESM.pdf
Authors’ original file for figure 1
12889_2012_4165_MOESM2_ESM.pdf
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