Are Lifestyle Diseases a Matter of Concern for Elderly Women: A Study of Older Old and Oldest Old Population of India

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1 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, 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 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

2 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 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 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.

3 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 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 widowed 1. 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).

4 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 Life style disease: Predictor variables Age of the sample of older women population was

5 a. High Blood Pressure (BP) b. Heart disease and c. Diabetes categorized into two group, 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).

6 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 noncommunicable 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 χ 2 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:

7 a i i = 1, 2 b ij i = 1, 2; j = 1, 2...n P 2 P 3 P 1 : constants. : multinomial regression coefficient. : estimated probability of having LSDs score of one disease among the older women population. : estimated probability of having LSDs score of at least two diseases among the older women population. : (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.

8 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 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 unweighted 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

9 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.

10 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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13 Table 1: Percentage distribution of study sample by background characteristics, India, IHDS, Background characteristics Percentage N Age Old-old(60-69) Oldest-old(70+) Residence Rural Urban Caste 1 SC/ST OBC Others Religion 2 Hindu Muslim Others Education No schooling Years Years and Above Wealth Status Poor Non-poor Marital Status 3 Currently married Widowed Others Family type nuclear family Joint family Total 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,

14 Table 2: Distribution of elderly women suffering from lifestyle disease across background characteristics, India, IHDS, Background characteristics BP N Heart N Diabetes N Age Old-old(60-69) Oldest-old(70+) Residence Rural Urban Caste 1 SC/ST * OBC Others Religion 2 Hindu Muslim * Others * Education No schooling Years * Years and Above * Wealth Status Poor Non-poor Marital Status 3 Currently married Widowed Others * 8 * 2 * 4 Family type Nuclear Family Joint Family 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,

15 Table 3: Distribution of elderly women suffering from lifestyle disease across background characteristics, India, IHDS, Background characteristics No LSD N One LSD N At least two LSD Age Older(60-69) Oldest-old(70+) Residence Rural Urban Caste 1 SC/ST * 26 * 22 OBC Others Religion 2 Hindu Muslim * 25 * 16 Others * Education No schooling Years * Years and Above * 27 * 23 Wealth Status Poor Non-poor Marital Status 3 Currently married Widowed Others * 16 * 2 * 3 Family type nuclear family Joint family 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, N

16 Table 4: Multi-nominal results of life style diseases among elderly women across background characteristics, India, IHDS, Background characteristics No LSD One LSD At least two LSD Age Old-old(60-69) Oldest-old(70+) Residence Rural Urban Caste 1 SC/ST OBC Others Religion 2 Hindu Muslim Others Education No schooling Years Years and Above Wealth Status Poor Non-poor Marital Status 3 Currently married Widowed Others Family type Nuclear family Joint family 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,

17 Fig1: Disease of Longitivity and elderly women, India,