|Year : 2019 | Volume
| Issue : 2 | Page : 129-133
Activity limitation and participation restriction in veterans of Indian Armed Forces: A cross-sectional study
V. K. Sashindran1, Puja Dudeja2, Vivek Aggarwal3
1 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Geriatric Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||24-Jun-2019|
|Date of Decision||24-Jul-2019|
|Date of Acceptance||05-Sep-2019|
|Date of Web Publication||19-Dec-2019|
Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The armed forces provide lifelong medical benefits to all their veterans. As most of them are older, their health needs are quite different from those of serving personnel. Having led a relatively active and disciplined life in the services, their general health might also be better than that of their civilian counterparts. Unfortunately, there are no data available on the health of Indian military veterans. This study was planned to ascertain the level of activity limitation (AL) and participation restriction (PR) and determine factors affecting AL and PR.
Material and Methods: This community-based, cross-sectional study was conducted among 406 veterans and their spouses aged 60 years and above residing in an urban housing society. House-to-house surveys were conducted. The study was done over 6 months (July–December 2016). Ethical clearance and informed consent were taken. The questionnaire used in the study was designed by incorporating elements from the International Classification of Functioning, Disability, and Health questionnaire and the WHO Disability Assessment Schedule.
Results: Of the 406 veterans and their spouses surveyed, 188 (46.3%) were male and 218 (53.7%) were female. The majority of them were in the age groups of 61–70 years (175, 43.1%) and 71–80 years (173, 42.6%). Most of them were living with other family members with only 59 (14.5%) living alone. AL score was good or average in most of them (263 and 124, respectively), and it was bad or very bad in only a small number (11 and 8, respectively) Similarly, the PR score was good or average in 316 and 78 participants, respectively. Only 12 (2.8%) had a bad PR score. PR score increased significantly beyond the age of 80 years (P = 0.00). AL was more in males as compared to females. PR was more in those who were not married/divorced/single (P < 0.05). AL and PR were independent of the type of caregivers (P > 0.05). The most common ailments reported by males were body aches and pains, hearing defects, and problems related to micturition. Complaints of feeling low or depressed were significantly higher in females (P < 0.05). The top five causes of morbidity in the study population were hypertension (209, 51.5%), diabetes (125, 30.8%), defective vision (116, 28.6%), cataract (105, 25.9%), and dental problems (102, 25.1%).
Conclusion: This study provides an insight into the magnitude of disease, impairment, and disability among veterans. Hypertension was the most common morbidity. Assessment of the AL and PR is useful planning geriatric care and educating caregivers and families to improve the quality of life of the elders.
Keywords: Activity limitation, morbidity, participation restriction, veterans
|How to cite this article:|
Sashindran VK, Dudeja P, Aggarwal V. Activity limitation and participation restriction in veterans of Indian Armed Forces: A cross-sectional study. Indian J Community Fam Med 2019;5:129-33
|How to cite this URL:|
Sashindran VK, Dudeja P, Aggarwal V. Activity limitation and participation restriction in veterans of Indian Armed Forces: A cross-sectional study. Indian J Community Fam Med [serial online] 2019 [cited 2020 Apr 9];5:129-33. Available from: http://www.ijcfm.org/text.asp?2019/5/2/129/273527
| Introduction|| |
The world population is aging rapidly. Considering the elderly (>60 years age) in 2000, it is estimated that this population will double from 11% to 22%. As per the 2011 census, the elderly constituted 8.6% of the total Indian population. Their numbers are predicted to increase to 133 million by 2021 and 301 million by 2051. The present century is considered the “century of elderly” and the next one shall witness the “aging of the aged.”
The phenomenon of aging is inevitable and does not even spare armed forces veterans. Rising life expectancy will lead to a swelling of their ranks. Concerns for scaling geriatric services in India are real and urgent. Changes in societal structure with a tendency to stay as nuclear families also pose social and personal challenges to these elderly. These elderly are better off than their civilian counterparts as most of them are pensioners and thus financially secure. Access to free health care for themselves and their dependents also insulates them from the crippling costs of health care in the civil setup. The elderly abuse due to financial dependence and lack of health insurance is less common among military veterans. The health needs of the veterans are presently being taken care by the Ex-Servicemen Contributory Health Scheme which has been striving to ensure a robust health-care delivery. Compulsory annual medical examinations in the armed forces ensure early detection and good management of diseases such as hypertension, diabetes, and coronary artery disease leading to better general health of our veterans. They, however, face difficulties due to loss of social recognition, reduced mobility, chronic and terminal diseases, dementia and depression, and loneliness. Our challenge, therefore, lies in not improving the quantum of their health but the quality of their health.
With increasing age, many veterans have functional disabilities, necessitating assistance to manage simple chores at home. The more infirm need dedicated caregivers for performing activities of daily living such as bathing, eating, going to toilet, and also taking medicines. There are multiple tools to assess the disability status of the elderly, but the International Classification of Functioning, Disability, and Health (ICF) is the standard one. According to the ICF, activity limitation (AL) is the difficulty in performing a task and participation restriction (PR) is the problem faced in performing a social role in life situations. AL is one of the most common geriatric problems which not only affects the individuals but also has significant societal impact. The elderly with reduced AL and PR require both formal and informal care. Data on these aspects of our veterans are scarce. This study was planned to ascertain the level of AL and PR among elderly veterans and determine the factors affecting them.
| Material and Methods|| |
This was a community-based, cross-sectional study conducted in an urban area of western Maharashtra. The sample size calculation was based on the assumed prevalence of disability in the elderly as 32% and for a precision of 5% and 95% confidence level. The sample size was computed to be 334. The study was conducted over a period of 1 year from August 2016 to August 2017. All veterans residing in a housing society meant exclusively for ex-serviceman (n = 406) were included. A questionnaire was developed based on the ICF and WHO Disability Assessment Schedule with 36 items. Data on sociodemographic profile, morbidity status, body function, AL, and PR were collected. Fourteen questions were used to assess AL, and these addressed the domains of understanding and communication, getting around, self-care, and life activities. There were 9 questions to assess PR focusing on the domains of getting along with people and participation in society. The scoring for questions was as follows: 1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = extreme/cannot do, and 8 = not applicable. The total attainable score for AL and PR was 70 and 45, respectively. The scoring categories for AL were as follows: 0–18 (good), 19–36 (average), 37–54 (bad), and 55–72 (very bad). Similarly, the scoring categories for PR were as follows: 0–15 (good), 16–30 (average), and 31–45 (bad). A lower score indicated good health with less limitations and restrictions. Institutional ethical clearance was obtained before the study, and written informed consent was taken from all participants. House-to-house surveys were conducted. Data collection was done on Sundays and holidays, and prior intimation to individuals was given through E-mail, posters in the shopping complex, military canteen, and housing society office. This ensured smooth data collection and detailed interviews were possible. Data were analyzed in IBM statistics SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA). The Chi-square test was used for comparison of proportions and the Mann–Whitney U-test was used to compare scores.
| Results|| |
The demographic details of the study population are given in [Table 1]. AL and PR scores of individuals are shown in [Table 2]. PR scores increased significantly with age beyond 80 years (P: 0.006). AL was more in males as compared to females [Table 2]. PR was more in those not married/divorced/single (P < 0.05). AL and PR were independent of type of caretakers (P > 0.05). Based on ICF, the ailments that were significantly more common among males were body aches and pains, hearing defects, and problems related to micturition. Complaints of feeling low and being depressed were significantly more common among women (P < 0.05). Gender differentials in health status as per ICF are given in [Table 3]. The top five causes of morbidity in the study population were hypertension 209 (51.5%; 46.5–56.4), diabetes 125 (30.8%; 26.3–35.5), defective vision 116 (28.6%; 24.2–33.2), cataract 105 (25.9%; 21.7–30.4), and dental problems 102 (25.1%; 21.0–29.6). Physical and mental health in the past 1 month was rated “bad” by 10% and 5% of individuals, respectively. Nearly 12% had cut back their activities in the past 1 month due to health reasons. The prevalence of current smokers and regular drinkers in the population was 6.7% and 27%, respectively.
|Table 2: Association between age, gender, and activity limitation and participation restriction in the elderly|
Click here to view
|Table 3: Health status of veterans based on the International Classification of Functioning, Disability, and Health|
Click here to view
| Discussion|| |
Aging is a process of progressive decline of various physiological functions leading to loss of viability. It is very important to understand the health needs of the elderly so as to improve the existing health-care infrastructure. Majority of the studies conducted earlier have focused on morbidity profile of the elderly in rural, urban slums and urban areas. No studies have been conducted on armed forces veterans. We assessed AL and PR along with morbidity status of armed forces veterans. The International Classification of Functioning, Disability, and Health (ICF) is the highest standard for describing health and disabilities. According to ICF the difficulties faced by an individual in performing various physical tasks are covered under the heading of AL and problems faced by individuals in social interactions and engaging in real life situations are covered under PR. This is a powerful tool in guiding the assessment and referral of the elderly to restorative therapy and supportive services.
The number of elderly females was more as compared to those of males. In most societies, females have higher life expectancy than men. Worldwide, this ratio is 1.01. This pattern is also seen among the elderly in India.,,,
The proportion of individuals living alone in our study is comparable to that reported by Thakur et al. in another study done in the same city but in a different area. The majority of the elderly staying alone had children working outside the city/country. These people face a lot of social problems due to isolation and do not have strong bonds with their neighbors or community as is common in rural areas of India. These elderlies need support to combat loneliness. They also need a medical support system, especially in times of emergency.
Family members are expected to be key caregivers for the elderly in India. Surprisingly, 14% of our individuals relied on caregivers who were not family members. Only a few of these caregivers were trained. The role of an ideal caregiver is to provide social stimulation and adapt activities to match the recipients' physical and cognitive abilities. The range of help required by our individuals from caregivers varied from assistance during evening walks to performing activities of daily living and finally to care of the totally bedridden. Trained caretakers are more efficient as compared to untrained ones as they can operate and maintain medical equipment such as nebulizers, feeding pumps, wheelchairs, and changing dressings. However, they also come at a price which even these people cannot often afford.
PR denotes difficulties faced by individuals in different life situations. In our study, it increased significantly with age. One reason for this could be the fact that aging compounded by the impact of chronic diseases leads to a significant decline in various bodily functions resulting in loss of independence and social roles.
It has been shown that AL rises with increasing age and is higher in women than in men. However, in our study, AL was more in males as compared to females. This can be explained by differential distribution of gender in the age with a significantly higher percentage of males in the age group of 70 years and above. PR was more in those who were widowed or divorced (P = 0.002). This restriction could be due to both physical and social reasons. For example, an elderly female with bilateral osteoarthritis staying single will have more PR as compared to another female with the same physical condition but staying with her spouse. Cultural and societal factors have a strong impact on PR as individuals behave as they are expected to for their age by the society.
AL and PR were independent of the caregiver. The care given to an elder in the family depends on the composition of the family. The care here is delivered either by grown-up children and their spouse or by paid informal caregivers. The role of the family caregiver can be difficult in case the children and their spouses are both working. The elders in these families will be left to themselves for most of the day. Some elderly people can afford caregivers. They are usually informal caregivers with no professional training. Trained caregivers are expensive and are not covered under the ex-serviceman health-care scheme or for that matter any private medical insurance policy in India.
AL and PR in our study population were far better than that of the elderly in an urban area of Chandigarh. Veterans during their service have active lifestyles and lead life which is disciplined and structured. These habits of a lifetime persist even after retirement. This could explain why our veterans have lesser AL and PR as compared to civilian elders with similar morbidities.
Warbhae reported hypertension to be the major morbidity in his study on urban elders. The prevalence of hypertension in our individuals was more than that reported by Vandana Nikumb (28% in the elderly of an urban area of Navi Mumbai), Reddy et al. (49% at a rural tertiary care hospital in South India), and less than that reported by Jamkhandi and Bhattacharji (71% in those reporting to the outpatient clinic of a family practice unit of a tertiary care center in South India). Our results were comparable to that from these studies with respect to other common morbidities seen in the elderly.,,,,
The prevalence of current smokers in the present study was less (6.7%) as compared to that reported by Kaur et al. They found the prevalence to be 88.1%. This too can be attributed to service lifestyle where smoking is prohibited in unit areas and discouraged in social functions too.
In our study, we found that aging is not a surrogate for disability as a large proportion of our elders were leading a good life despite their ailments. Disabilities affect the quality of life of the elderly. Most studies focus on the medical model of disability associating it with morbidity conditions neglecting various impairments and problems encountered by the elderly. AL PR studies are vital to arrive at a holistic assessment of elderly health.
| Conclusion|| |
This study provides a valuable insight into the magnitude of disease, impairment, and disability among veterans. Despite multiple ailments, our veterans have low AL and PR. Hypertension is the most common morbidity in this population. Assessment of the AL and PR is useful planning geriatric care and educating caregivers and families to improve the quality of life of the elders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. World Health Day 2012: Ageing and Health: Toolkit for Event Organizers. World Health Organization; 2012.
Government of India. Sample Registration System Statistical Report 2010. Report No. 1 of 2012. New Delhi: Office of the Registrar General and Census Commissioner India, Ministry of Home Affairs; 2012.
Verma R, Khanna P, Chawla S. Vaccines for the elderly need to be introduced into the immunization program in India. Hum Vaccin Immunother 2014;10:2468-70.
Raju SS. Studies on ageing in India: A review, New Delhi: BKPAI Working Paper No. 2, United Nations Population Citation Advice: Fund (UNFPA); 2011.
Kumar Y, Bhargava A. Elder abuse in Indian families: Problems and preventive actions. Int J Sci Res Publ 2014;4:1-8.
Vellakkal S, Juyal S, Mehdi A. Healthcare Delivery and Stakeholder's Satisfaction Under Social Health Insurance Schemes in India: An Evaluation of Central Government Health Scheme (CGHS) and Ex-servicemen Contributory Health Scheme (ECHS); 2012. Available from: https://ssrn.com/abstract=2049307
. [Last accessed on 2019 Jan 12].
World Health Organization. How to Use the ICF: A Practical Manual for Using the International Classification of Functioning, Disability and Health (ICF). Exposure draft for comment. Geneva: World Health Organization; 2013.
Levasseur M, Desrosiers J, St-Cyr Tribble D. Do quality of life, participation and environment of older adults differ according to level of activity? Health Qual Life Outcomes 2008;6:30.
Malhotra G, Sharma MK, Singh A, Dudeja P. Activity limitation and participation restriction to among the elderly in North India: Determinants and related management practices. Int J Disabil Hum Dev 2014;13:141-8.
López-Otín C, Blasco MA, Partridge L, Serrano M, Kroemer G. The hallmarks of aging. Cell 2013;153:1194-217.
Lad SB, Kumbar SM. Health status and care seeking behaviour of rural elderly of Palus in Sangli (Maharashtra). Indian J Gerontol 2014;2:1829.
Stineman MG, Henry-Sánchez JT, Kurichi JE, Pan Q, Xie D, Saliba D, et al
. Staging activity limitation and participation restriction in elderly community-dwelling persons according to difficulties in self-care and domestic life functioning. Am J Phys Med Rehabil 2012;91:126-40.
Thakur R, Banerjee A, Nikumb V. Health problems among the elderly: A cross-sectional study. Ann Med Health Sci Res 2013;3:19-25.
] [Full text]
Wilkie R, Peat G, Thomas E, Croft P. The prevalence of person-perceived participation restriction in community-dwelling older adults. Qual Life Res 2006;15:1471-9.
Sharma U, Kaur S, Singh A. Knowledge, beliefs and practices of caregivers regarding home based bedsore care in Chandigarh, North India. J Postgrad Med Edu Res 2013;47:138-43.
Warbhe PA, Rupesh W. Morbidity profile, health seeking behaviour and home environment survey for adaptive measures in geriatric population – Urban community study. Int J Med Res Health Sci 2015;4:778-82.
Nikumb V, Patankar F, Behera A. A study of morbidity profile among geriatric population in an urban area. Sch J Appl Med Sci 2015;3:1365-9.
Reddy AP, Suresh R, Krishnamurthy S, Reddy YJ. Clinical profile of geriatric patients in medical wards at rural tertiary care hospital in South India. Clin Sci Res 2016;5:101-4.
Jamkhandi DM, Bhattacharji S. Profile of elderly attending a general practice clinic in a poor urban area: A cross-sectional study from South India. J Fam Med Prim Care 2016;5:792-7.
Kaur G, Bansal R, Anand T, Kumar A, Singh J. Morbidity profile of noncommunicable diseases among elderly in a city in North India. Clin Epidemiol Glob Health 2019;7:29-34.
[Table 1], [Table 2], [Table 3]