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The prevalence of disability in elderly in India – Analysis of 2011 census data
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Disability and Health Journal
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(2016)
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www.disabilityandhealthjnl.com
Research Paper
The prevalence of disability in elderly in India e Analysis of 2011 census data Banurekha Velayutham, M.B.B.S.a,*, Boopathi Kangusamy, M.Sc., M.B.A.b, Vasna Joshua, Ph.D.b, and Sanjay Mehendale, M.D., M.P.H.b a
National Institute for Research in Tuberculosis, Indian Council of Medical Research, No. 1 Mayor Sathyamoorthy Road, Chetput, Chennai 600 031, Tamil Nadu, India b National Institute of Epidemiology, Indian Council of Medical Research, Chennai, Tamil Nadu, India
Abstract Background: Advancing age leads to physical and sensory impairment with varying degrees of disability. There is lack of publication focusing on disability of elderly in India with a countrywide state-based analysis of all types of disabilities. Objective: To measure the prevalence of disability and describe the types of disability in the elderly Indian population by gender, advancing age, states and geographical regions. Methods: The 2011 Census cross-sectional survey data restricted to elderly in India was analyzed. ‘Elderly’ is defined as a person who is of age 60 years or above. Disability rates per 100,000 elderly population and age-adjusted disability rates were calculated. Results: A total of 5,376,205 elderly individuals were disabled in India in 2011; disability rate of 5178 per 100,000 elderly population. Movement and seeing disabilities individually accounted for 25% of total disabilities and disability in hearing was 19%. Disability rates in 17 Indian States and Union Territories were above the national average. Disability rates increased as age advanced with the highest disability rate of 8409 per 100,000 among people aged 80 yrs or above. The disability rates were higher in males than females (5314 vs. 5045 per 100,000) and in rural compared to urban areas (5593 vs. 4181 per 100,000). Currently married and working populations had lower disability rates. Conclusion: One in every twenty Indian citizens aged 60 yrs and above is either physically or mentally disabled. Identification of the underlying causes, employing effective and focused preventive strategies will help to reduce the prevalence of disability in the elderly. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Disability; Elderly; Mental; Physical; Census
The International Classification of Functioning, Disability and Health (ICF) defines disability as an umbrella term for impairments, activity limitations, and participation restrictions.1 About 15% of the world’s population (based on 2010 global population estimates) is estimated to live with some form of disability.2 As age advances, biological and physical nature of the body is likely to deteriorate which leads to physical and sensory impairment and in turn bring about varying proportions of disabilities.3 The Government of India’s ‘National Policy on Older Persons’ defines ‘elderly’ as a person who is of age 60 years or above.4 In 2011, the proportion of elderly in India was about 8.6% of the overall population. The proportion of elderly (>60 yrs) in India projected for Conflict of interest: none. * Corresponding author. Tel.: þ91 44 2836 9500. E-mail address: [email protected] (B. Velayutham). 1936-6574/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2016.04.003
2026 is about 12.17% of the overall population.5 A previous systematic review has reported lack of schooling, living in rental housing, chronic diseases, arthritis, diabetes, visual impairment, higher body mass index, poor selfperceived health, cognitive impairment, depression, slow gait, sedentary lifestyle, tiredness while performing daily activities, and limited diversity in social relations as risk factors for functional disability in the elderly.6 Article 41 of the Indian Constitution states that the State shall within the limits of its economic capacity and development; make effective provisions for securing the right to work, education and public assistance in case of unemployment, old age, sickness and disablement. People with disabilities suffer undue hardships and they continue to be marginalized, discriminated and abused.7 Access to affordable health care and rehabilitation has to be offered to the disabled persons. Disability among the elderly in India has been documented in various cross-sectional studies
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which are limited to geographical regions. However, disability of elderly in India with a focus on countrywide state-based analysis of all types of disabilities has not been reported. There is a need to quantify the prevalence of disability since this information is essential for the Government to plan policies, allocate adequate resources and implement appropriate programs for persons with disability. In India, information on physical and mental disability is captured during the census survey once in every 10 years and also during periodic surveys by National Sample Survey Organization (NSSO). The limitations of disability related data collection in census survey include only few questions on disability restricting the available information, high non-response rates and under-enumeration because of the complexity and sensitivity of the question/s. In addition, data collection is infrequent e usually every 10 years and the time between data collection and data dissemination can be considerable to understand the current prevalence rates.11 Nevertheless, the 2011 census data on disability covers the entire country and has information for all types of disability following a standard definition for each. The objective of this analysis was to measure the prevalence of disability and describe the types of disability in the elderly Indian population based on the available data on disabilities in the public domain under the Census 2011 database. We also estimated the distribution of disabilities by gender, advancing age, states, geographical regions, work and marital status in the elderly. Methodology This manuscript is based on analysis of the 2011 Census data of India. Indian census survey is conducted once in every 10 yrs following an extended de facto canvasser method. Under this approach, data is collected from every individual by visiting the household and canvassing the questionnaire all over the country, over a period of three weeks. The count is then updated to the reference date and time by conducting a Revisional Round.12 The census questionnaire had three questions pertaining to disability which captured information on 1) presence of mental or physical disability; 2) the disability type and 3) multiple disabilities [maximum of 3 disabilities] (Table 1).11
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Prior to the survey, the census enumerators were trained to obtain the information on disabilities. Considering the sensitive nature of the questions related to disabilities, they were instructed to build rapport with the respondents first and inform them about the importance of acquiring disability related information. In addition, the respondents were reassured that the individual information will be kept confidential. The question(s) on disability was asked for all persons in the household. The enumerator was instructed not to assume that just because someone looks ‘alright’ or ‘normal,’ she/he may not have disability. The enumerator was instructed to find out if any member of the household had any form of mental and/or physical disability. While the main respondent might be answering all the questions the enumerator had to make every possible effort to seek information from the disabled member of the household herself/himself, if she/he was present at the time of census taking and was able to provide correct information. The enumerator was instructed to use simple and nonderogatory language and to explain disability in terms of difficulty in doing any functions of daily living (taking care of oneself, gaining education, taking up a job) or participating in all/some spheres of life.11 The enumerator was also instructed that he/she should not avoid or rush through the question and give time for the person to respond. They were instructed not be in a hurry to write the Code of disability and ask if the person had more than one disability. The person may not ‘look’ disabled, but may have difficulty in seeing, hearing or any other disability. Hence, the census enumerators were instructed to record the person’s response as it is. The census enumerators were instructed not to try to probe on the cause, cure, treatment or rehabilitation regarding the impairment or disability reported.11 Temporary impairments like limitation of movement due to fractures or temporary illnesses were not counted as disability. The definitions used for various types of disability are provided in the Annexure 1.11 Data analysis Disability rates per 100,000 population were calculated. The numerators were number of disabled persons by type
Table 1 Questions related to disability in the Census of India 2011 questionnaire 9 (b). If, ‘‘YES’’ in 9 (a), give code Question and 9 (a). Is this person in the box against 9 (b) from the instructions mentally/physically list given below. disabled? In seeing e 1 Yes e 1/No e 2 In hearing e 2 If the person has a In speech e 3 disability please put In movement e 4 Code No. 1. If the Mental retardation e 5 person does not have a Mental illness e 6 disability, put Code Any other e 7 No. 2 Multiple disability e 8
9 (c). If ‘‘multiple disability’’ (Code 8) in 9 (b), give maximum three codes in boxes against 9 (c) from the list given below. In seeing e 1 In hearing e 2 In speech e 3 In movement e 4 Mental retardation e 5 Mental illness e 6 Any other e 7 Multiple disability e 8
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of disability and age, gender, type of residence (rural/urban) e C20 table (India and States/UTs District level).13 The denominators were extracted from C14 Table of census 2011.14 This table provides information on the number of people in the Indian population in various age groups with a 5 yearly interval starting from 0 to 4 years, upto 75e79 years and 85þ years. In addition, information on residence (rural/urban) and gender was used. The following data from the census 2011 namely DDW-0000B-01 [Workers and non-workers classified by age and sex], DDW-0000C-02fer3-MDDS [Marital status by age and sex], DDW0000C-21 [Disabled population by type of disability, marital status, age and sex], DDW-0000C-23 [Disabled population among workers and non-workers by type of disability, age and sex] were used to calculate disability rates according to marital and work status.15 Data were obtained for age groups 60 yrs and above for the analysis from all the above mentioned tables. Age-adjusted disability rates by direct standardization method using 2011 population of India aged >60 years as standard population were used for comparison and ranking of the Indian states and Union Territories with respect to each type of disability. The data was analyzed using Microsoft excel windows 2007. The representation of geographical distribution of disability rates in the different states of India was done
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using ArcGIS Desktop: Release 10. Redlands, CA: ESRI, Inc. 2011. Results A total of 5,376,205 elderly individuals were disabled in India in 2011 accounting for a disability rate of 5178 per 100,000 elderly population (5.1%) [2011 Indian elderly population 103,836,714]. The disability rates in movement and seeing [1309 per 100,000 each], hearing [984 per 100,000] and multiple disabilities [613 per 100,000] were high. Disability rates associated with speech, mental illness and mental retardation was 196, 88 and 87 per 100,000 elderly population respectively. Movement and seeing disabilities individually accounted for nearly 25% of total disabilities and hearing contributed 19% disability burden in the elderly. In addition, multiple disability and disability in speech constituted 12% and 4% respectively, whereas mental retardation and mental illness were responsible for 2% of the total disability individually. The remaining 11% of the disability was due to other causes. Disability rates in the Indian States and Union territories The disability rates in the Indian States and Union territories are shown in Fig. 1. Of the total of 35 states and
Fig. 1. Age standardized disability rates per 100,000 among elderly in the Indian states and Union territories, 2011.
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Union territories, the disability rates in 17 States and Union Territories were above the national average of 5178 per 100,000 population and ranged from 5211 to 10,926 per 100,000 population. Sikkim, Rajasthan and Chhattisgarh states reported the highest disability rates of 10,926, 10,689 and 8883 per 100,000 population respectively. Tamil Nadu and the Union Territory of Dadra and Nagar Haveli had the lowest disability rates of 2542 and 3232 per 100,000 population respectively. The prevalence of disability rates in majority of the remaining Indian states ranged between 3500 and 8800 per 100,000 population. Data in all and in top ten States and Union Territories according to the type of disability are shown in Tables 2 and 3. Disability in seeing (2626 per 100,000), movement (3359 per 100,000) and multiple disability (2260 per 100,000) were highest in Rajasthan. Disability in hearing, speech, mental retardation and mental illness was highest in Sikkim (3398 per 100,000), Maharashtra (524 per
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100,000), Mizoram (214 per 100,000) and Kerala (335 per 100,000) respectively.
Disability rates by basic demographic variables Disability rates increased as age advanced with the highest disability rate of 8409 per 100,000 among people aged >80 yrs (Table 4). The disability rates were higher in males compared to females (5314 vs. 5045 per 100,000) and higher in rural areas compared to urban areas (5593 vs. 4181 per 100,000) (Table 4). The disability rates in men and women in the rural areas of India were 5714 vs. 5476 per 100,000 respectively compared to 4361 vs. 4007 per 100,000 in the urban areas. Disability rates were higher in males in the age group 60e69 yrs (4407 vs. 3891 per 100,000) and 70e79 years (6258 vs. 6186 per 100,000) compared to females. Beyond 80 yrs of age there was a female preponderance in disability rates (8570 vs. 8226 per 100,000). There was
Table 2 Age-standardized disability rates per 100,000 in the Indian states and Union territories according to type of disability among the elderly, 2011 Disability rate per 100,000 S. no.
State/Union Territory
Seeing
Hearing
Speech
Movement
Mental retardation
Mental illness
Multiple disability
Overall
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Jammu and Kashmir Himachal Pradesh Punjab Chandigarh Uttarakhand Haryana Delhi Rajasthan Uttar Pradesh Bihar Sikkim Arunachal Pradesh Nagaland Manipur Mizoram Tripura Meghalaya Assam West Bengal Jharkhand Odisha Chhattisgarh Madhya Pradesh Gujarat Daman and Diu Dadra and Nagar Haveli Maharashtra Andhra Pradesh Karnataka Goa Lakshadweep Kerala Tamil Nadu Puducherry Andaman and Nicobar India
2174 1550 862 580 1280 1474 743 2626 1110 1137 2404 2122 1226 1208 651 1209 1014 1166 1299 1548 2146 2103 1417 1029 715 679 1129 1718 1159 1116 1799 1247 446 966 1508 1309
1748 1417 902 655 1108 1113 695 1497 945 939 3398 2250 2495 1169 1451 890 1152 1158 799 1327 1584 1639 997 979 786 1064 858 936 692 1072 850 872 610 1491 1339 984
184 185 104 132 157 110 119 137 163 192 355 190 217 147 178 110 95 143 159 154 171 129 115 111 70 51 524 286 125 477 128 153 97 152 171 196
1596 1542 936 1227 1014 1283 1734 3359 875 1009 1528 1193 992 728 574 955 541 1069 972 1870 2229 2804 1724 909 1281 783 1120 1668 840 1507 1918 1326 715 1793 1555 1309
165 95 116 49 81 92 66 102 70 82 120 119 120 213 214 123 83 109 140 100 124 84 84 55 26 42 63 96 88 91 56 87 51 97 69 87
241 107 142 109 86 90 94 98 44 49 144 130 104 114 142 138 110 146 122 82 136 91 63 98 114 79 71 58 45 187 217 335 56 92 136 88
1567 981 294 396 689 719 635 2260 391 312 1775 1113 1021 466 605 590 425 819 641 843 1234 1486 748 346 396 335 309 574 316 563 823 665 156 357 896 613
8813 6511 4176 3572 4877 5598 4466 10,689 4265 4318 10,926 7668 6723 4500 4137 4452 3930 5170 4711 6502 8267 8883 5766 3970 3554 3232 4613 6028 3795 5715 6174 5211 2542 5433 5993 5178
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2260 1775 1567 1486 1234 1113 1021 981 896 843 Rajasthan Sikkim Jammu & Kashmir Chhattisgarh Odisha Arunachal Pradesh Nagaland Himachal Pradesh Andaman & Nicobar Jharkhand 335 241 217 187 146 144 142 142 138 136 Kerala Jammu & Kashmir Lakshadweep Goa Assam Sikkim Punjab Mizoram Tripura Odisha 214 213 165 140 124 123 120 120 119 116 Mizoram Manipur Jammu & Kashmir West Bengal Odisha Tripura Sikkim Nagaland Arunachal Pradesh Punjab 3359 2804 2229 1918 1870 1793 1734 1724 1668 1596 Rajasthan Chhattisgarh Odisha Lakshadweep Jharkhand Puducherry Delhi Madhya Pradesh Andhra Pradesh Jammu & Kashmir 524 477 355 286 217 192 190 185 184 178 Maharashtra Goa Sikkim Andhra Pradesh Nagaland Bihar Arunachal Pradesh Himachal Pradesh Jammu & Kashmir Mizoram 3398 2495 2250 1748 1639 1584 1497 1491 1451 1417 Sikkim Nagaland Arunachal Pradesh Jammu & Kashmir Chhattisgarh Odisha Rajasthan Puducherry Mizoram Himachal Pradesh 2626 2404 2174 2146 2122 2103 1799 1718 1550 1548 Rajasthan Sikkim Jammu & Kashmir Odisha Arunachal Pradesh Chhattisgarh Lakshadweep Andhra Pradesh Himachal Pradesh Jharkhand 1 2 3 4 5 6 7 8 9 10
Rank State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate
Table 3 The top 10 Indian states and Union territories according to type of disability among the elderly (age-standardized disability rates per 100,000), 2011 Seeing Hearing Speech Movement Mental retardation Mental illness
Multiple disability
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Table 4 Disability rates by basic demographic variables in the elderly in India, 2011 Demographic Total Total Disability rate characteristics population disabled per 100,000 Age in years 60e69 70e79 80 and above Gender Male Female Location of residence Rural Urban Marital status Never married Currently married Others [widowed separated divorced] Work status Working Non-working
64,110,397 28,438,544 11,287,773
2,657,679 1,769,370 949,156
4145 6222 8409
51,065,214 52,771,500
2,713,757 2,662,448
5314 5045
73,281,496 30,555,218
4,098,613 1,277,592
5593 4181
2,550,602 68,103,262 33,195,176
188,799 3,086,602 2,101,218
7402 4532 6330
43,193,342 65,180,096
1,521,732 3,854,887
3523 5914
a rural preponderance in the disability rates across the different age groups. The disability rates were higher in the non-working population compared to working population (5914 vs. 3523 per 100,000) (Table 4). Never married and widowed/separated/ divorced populations had higher disability rates (7402 and 6330 per 100,000 respectively) compared to currently married population (4532 per 100,000) (Table 4). There was a male and rural predominance in the disability rates in the working, non-working populations and in different subgroups of marital status. Types of disability by age, gender and location of residence Disability rates associated with movement, seeing, hearing and multiple disability increased as age advanced (Fig. 2). Age group above 80 yrs had a two-fold increase in the disability rates for movement, seeing and hearing and more than five-fold increase in multiple disability rates as compared to age group 60e69 yrs. Speech, mental retardation and mental illness related disability rates remained stationery with advancing age. Disability associated with movement was high in the 60e69 yrs and above 80 yrs age group (1062 and 1999 per 100,000 respectively) and that associated with seeing was high in 70e79 yrs age group (1637 per 100,000). In the elderly population, there was a rural predominance for disability associated with movement (1426 vs. 1029 per 100,000), seeing (1467 vs. 931 per 100,000), hearing (1043 vs. 844 per 100,000) and multiple disability (708 vs. 386 per 100,000) compared to urban. Urban predominance was observed in disability associated with speech (230 vs. 182 per 100,000), mental retardation (89 vs. 86 per 100,000) and mental illness (93 vs. 86 per
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Fig. 2. Age differences in the disability rates according to the type of disability in the elderly in India, 2011.
100,000) compared to rural among the elderly. Disability rates by age, gender and type of residence according to the type of disability are summarized in Table 5. The disability related to movement showed a male and rural preponderance in all the age categories except in females above 80 yrs of age (1486 vs. 1449 per 100,000) in urban areas. Disability associated with seeing was higher in females and hearing higher in males with rural preponderance across all age categories. Disability in speech, mental retardation and mental illness had an urban preponderance. Males had higher disability associated with speech and mental retardation across all age categories. Mental illness was similar in males and females in the age group 60e69 yrs with a female preponderance in other age groups. Multiple disability was higher in rural areas across all age categories and was nearly double of that observed in the urban areas in the age group 70e79 yrs (939 vs. 483 per 100,000) and above 80 yrs (2000 vs. 1002 per 100,000). Female preponderance in multiple disabilities was observed across all age categories except in the age group of 60e69 yrs in the urban area which had higher males with multiple disabilities (250 vs. 213 per 100,000). Discussion Our analysis showed that one in every twenty Indian citizens aged 60 yrs and above [5178 per 100,000 persons] is either physically or mentally disabled based on the data of census survey of 2011. This is lower compared to 2002 NSSO survey which documented a disability rate of 6401 per 100,000 in those aged 60 yrs and above. In addition, the disability rates in the 2002 NSSO survey for the age group 60 yrs and above are higher compared to our analysis
of disability data of census survey 2011 for disability associated with movement, seeing, hearing and mental illness (2818 vs. 1309, 2250 vs. 1309, 1570 vs. 984 and 177 vs. 88 per 100,000) respectively.16 We have compared our results with those of NSSO 2002 which is the only large scale and authentic study reporting data on disability per 100,000 in different age groups for various types of disability. However, it is important to remember that NSSO 2002 data is more than 13 years old. In addition, the disability rates of the census survey and NSSO survey are not strictly comparable owing to the differences in the definitions of disability used. Nevertheless, this analysis has shown that a sizeable burden of disability exists in India among the elderly. Cross-sectional studies done in India have documented disability prevalence rates of more than 35% in various geographical settings.3,8e10 The purpose for which the census survey is conducted in India every 10 years is very different compared to smaller and focused research studies on disability in the populations. Hence, although it is possible that the estimations of disability through census survey might be an under-estimate, it is also possible that surveys conducted by interested stakeholders in this area might have over-estimated the disability. It might be important to critically look at case definitions as well as survey methodologies of census and various specialized surveys to find possible reasons for variations in disability prevalence.17 Disability among the elderly was more common in the rural compared to urban areas in our analysis. A study in Tamil Nadu, India among 750 persons aged 60þ yrs showed physical disability to be significantly higher in the rural (53.6%) compared to urban areas (37.3%).3 Lack of adequate facilities and health care could result in disabilities commonly occurring in the older age groups in the
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Table 5 Disability rates by age, gender and type of residence (urban/rural) according to the type of disability in age > 60 years in India, 2011 Age 60e69 yrs Age 70e79 yrs Age 80 & above Type of disability
Site
Gender
Total disabled
Rate per 100,000
Total disabled
Rate per 100,000
Total disabled
Rate per 100,000
Movement
Rural
Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female
516,690 298,806 217,884 164,338 99,371 64,967 519,552 243,923 275,629 149,640 74,983 74,657 365,332 180,738 184,594 126,357 64,621 61,736 82,342 45,312 37,030 43,331 24,719 18,612 40,416 21,257 19,159 16,965 9297 7668 3965 19,552 19,613 17,233 8632 8601 171,343 82,557 88,786 99,079 23,726 20,353
1143 1350 945 869 1045 691 1149 1102 1195 791 789 794 808 817 800 668 680 656 182 205 161 229 260 198 89 96 83 90 98 82 87 88 85 91 91 91 379 373 385 233 250 213
352,212 189,447 162,765 100,311 53,524 46,787 375,103 175,450 199,653 90,329 42,737 47,592 260,176 130,052 130,124 82,738 41,249 41,489 36,900 20,729 16,171 18,849 10,464 8385 15,843 8139 7704 6869 3469 3400 17,306 8176 9130 7757 3543 4214 189,506 85,581 103,925 29,834 18,555 21,279
1745 1878 1612 1216 1321 1114 1858 1739 1977 1095 1055 1133 1289 1289 1289 1003 1018 988 183 205 160 228 258 200 78 81 76 83 86 81 86 81 90 94 87 100 939 848 1029 483 458 507
175,798 84,568 91,230 49,876 21,993 27,883 180,170 81,091 99,079 44,491 18,898 25,593 138,941 67,489 71,452 48,728 22,588 26,140 14,215 7522 6693 7941 3995 3976 6602 3265 3337 3315 1514 1801 6767 2956 3811 3344 1343 2001 157,858 66,075 91,783 34,022 13,147 20,875
2227 2246 2210 1470 1449 1486 2282 2154 2400 1311 1245 1364 1760 1792 1731 1436 1488 1393 180 200 162 235 263 212 84 87 81 98 100 96 86 79 92 99 88 107 2000 1755 2223 1002 866 1113
Urban
Seeing
Rural
Urban
Hearing
Rural
Urban
Speech
Rural
Urban
Mental retardation
Rural
Urban
Mental illness
Rural
Urban
Multiple disability
Rural
Urban
rural areas. Low utilization of health services among the rural elderly compared to the urban elderly has been reported in a study from Assam.18 The reasons for geographical variations [urban versus rural] in the distribution of disability observed in our analysis needs to be further explored to generate evidence that would help in designing locally relevant interventions. The linkage between aging and disability is a biological fact where the risk of disability increases with increase in age.19 We observed increased disability rates with advancing age in the elderly. Studies done in both rural and urban areas among the elderly in India have documented higher disability rates in the older age group.8,10,20 Research on disability in old age has identified non-
modifiable risk factors such as age, gender and genetics, and modifiable risk factors such as age-related diseases, impairments, functional limitations, poor coping strategies, sedentary lifestyles and other unhealthy behaviors, as well as social and environmental obstacles.21 We have presented the disability rates in various states of India by type of disability. This information will be of immense help to state health managers in planning appropriate interventions and supportive care. Understanding the causes of disability is important to plan appropriate preventive strategies and research is warranted in this arena. The finding of male predominance in disabilities in age group less than 80 yrs and female in age group 80 yrs and above was observed in our analysis. A study in the United
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States among the elderly documented greater prevalence of nonfatal disabling conditions, including fractures, osteoporosis, back problems, osteoarthritis and depression, contributing substantially to greater disability and diminished quality of life among aging women compared with men.22 This certainly highlights the need to address the gender angle in disability management through appropriate strategies for the concerned groups. The main type of disability in the elderly was associated with seeing, hearing, movement and speech in our analysis. In the 2002 NSSO survey, old age, other illnesses and injury featured among the main reasons for movement, visual, hearing, speech disability.16 In about 25% and 30% cases, for rural and urban India respectively, the probable cause of hearing disability was ‘old age.’ About 49% and 57% were found to have acquired locomotor disability at the age of 60 years and above in rural and urban India respectively.16 Old age was the cause for about 241 per 1000 persons with blindness, 278 per 1000 persons with low vision, 263 per 1000 persons with hearing disability, 13 per 1000 persons with speech disability in the NSSO survey.16 Furthermore among the elderly, age at onset of blindness, low vision, hearing, speech and locomotor disability beyond 60 yrs was 673 per 1000, 717 per 1000, 571 per 1000, 369 per 1000 and 511 per 1000 respectively. The 2002 NSSO survey data on persons 60 years and above with mental retardation or mental illness by age at onset of disability revealed that manifestation of disability due to mental illness is completed within the teen-age while onset of mental illness increased as one gradually becomes older.16 We observed higher disability rates among nonworking and widowed/separated and divorced populations. According to 2002 NSSO survey, among those aged 60 yrs and above, 193 per 1000 physically disabled persons could not take self-care even with aid/appliances and 66 per 1000 disabled persons lived alone.16 A previous study identified higher level of poverty and income inequality among disabled elderly as compared to non-disabled elderly.19 The lives of disabled people are affected by poor health outcomes, lower educational achievements, less economic participation, high rates of poverty and increased dependency.2 Prevention of disability in old age is therefore a matter of great humanitarian and economic concern.21 Disability in old age is frequent and not only lowers the quality of life of the affected, but also strains family’s and society’s limited resources for assistance, care and rehabilitation.21 In India, National Programme of Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke Programme (NPCDCS), National Mental Health Programme (NMHP), National Programme for Prevention and Control of Deafness (NPPCD), National Programme for the Health Care for the Elderly (NPHCE) and National Blindness Control Programme have to play a major role in providing preventive, curative and rehabilitative services to
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reduce the burden of disability among the elderly in their areas of operation. According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, in India, the Chief Commissioner for Persons with Disabilities at the Centre and a Commissioner in each State are appointed to safeguard the rights of persons with disabilities and monitor the implementation of the Act.23 The program managers have to address the barriers to health care, rehabilitation, education, support and assistant services and create enabling environments.2 National Policy on Older Persons (NPOP), 1999, The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 and Central Sector Scheme of Integrated Programme for Older Persons (IPOP) are some of the acts and schemes that benefit the elderly.4 Appropriate linkages within the National Programmes and schemes that benefit the elderly have to be developed to minimize disability in this population. Strategic preventive plans at national and community levels have to be developed, training in gerontology and geriatric medicine has to be promoted and initiatives to stimulate research and development on old age disability have to be created.21 The interpretation of the analysis presented must be done with some degree of caution. The greatest strengths of the census survey include its implementation through a welloiled machinery, universal reach and use of standardized protocols in data collection. However, there are certain limitations. There could be some level of non-response. Also, the possibility of under-reporting might result due to inability to capture the complex and sensitive information related to disability in limited number (3) questions of the census questionnaire. These factors would primarily lead to underestimation of disability rates which might be actually higher. Disability measure in the census is an aggregation of the sum of different disability types and there is no measure of activity or functional limitation. Appropriate statistical modeling may have to be applied to the census data of 2011 to estimate the current burden of disability. According to official population projections, the number of elderly persons in India will rise to approximately 140 million by 2021.4 Our analysis has shown that the prevalence of disability rates in the elderly in half of the Indian states varies between 5211 and 10,926 per 100,000 and this is a matter of concern since this is likely to increase. We have estimated and presented the national level estimates of disability prevalence, urban/rural and male/female differentials in the disability rates in the elderly. To understand the reasons to explain these, additional research studies will have to be planned or additional data mining might have to be done to look for published and unpublished literature in this area. Identification of the underlying causes and employing effective and focused preventive strategies will help to reduce the burden of disability in the elderly in the years to come. Various programs should also focus on providing appropriate interventions and rehabilitation achieves to
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maximize the quality of life and improve economic conditions of the elderly. Acknowledgment The authors would like to thank the Office of the Registrar General and Census Commissioner, India for providing access to the data on disability and population enumeration which was used for the analysis. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.dhjo.2016.04.003. References 1. Towards a Common Language for Functioning, Disability and Health International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organisation; 2002. WHO/EIP/GPE/CAS/01.3. Accessed on 21.10.14. 2. World Report on Disability. World Health Organisation and World bank, http://www.who.int/disabilities/world_report/2011/report.pdf; 2011. Accessed on 21.10.14. 3. Audinarayana N, Sheela J. Physical disability among the elderly in Tamil Nadu: patterns, differentials and determinants. Health Popul Perspect Issues. 2002;25(1):26e37. 4. Situational Analysis of Elderly in India. Central Statistics Office Ministry of Statistics & Programme Implementation Government of India, http://mospi.nic.in/mospi_new/upload/elderly_in_india.pdf; 2011. Accessed on 21.10.14. 5. Ingle GK, Nath A. Geriatric health in India: concerns and solutions. Indian J Community Med. 2008;33(4):214e218. 6. Rodrigues MA, Facchini LA, Thume E, Maia F. Gender and incidence of functional disability in the elderly: a systematic review. Cad Saude Publica. 2009;25(suppl 3):S464eS476. 7. Universal Periodic Review e India. Key issues of 120 million persons with disabilities in India. National Disability Network. http://lib.ohchr. org/HRBodies/UPR/Documents/session13/IN/NDN_UPR_IND_S13_ 2012_NationalDisabilityNetwork_E.pdf; Accessed on 27.12.14. 8. Gupta P, Mani K, Rai SK, Nongkynrih B, Gupta SK. Functional disability among elderly persons in a rural area of Haryana. Indian J Public Health. 2014;58(1):11e16.
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9. Sinha SP, Shrivastava SR, Ramasamy J. Depression in an older adult rural population in India. MEDICC Rev. 2013;15(4):41e44. 10. Srinivasan K, Vaz M, Thomas T. Prevalence of health related disability among community dwelling urban elderly from middle socioeconomic strata in Bangaluru. India Indian J Med Res. 2010;131:515e521. 11. Manual on Disability Statistics. Government of India. Ministry of Statistics and Programme Implementation. CSO-MDS-2012. http://mospi. nic.in/Mospi_New/upload/Revised_Disability_Manual_20june12.pdf; Accessed on 21.02.16. 12. Overview of Census, http://censusindia.gov.in/2011-prov-results/data_ files/mp/02Introduction.pdf; 2011. Accessed on 21.12.15. 13. Census of India. Disabled Population by type of Disability, Age and Sex e C20 Table of India. http://www.censusindia.gov.in/2011census/Cseries/c-20.html; Accessed on 21.12.15. 14. Population enumeration data (Final population). Age data. Five year Age Group Data e C14 Table. http://www.censusindia.gov.in/% 28S%28esr3lm45pksguc451d45sp55%29%29/2011census/population_ enumeration.aspx; Accessed on 21.12.15. 15. Census of India 2011. Population Enumeration Data (Final Population). http://www.censusindia.gov.in/2011census/population_enumeration. html; Accessed on 21.12.15. 16. National Sample Survey Organisation. Ministry of Statistics and Programme Implementation. Government of India. Report No. 485 (58/26/1). Available at: http://mospi.nic.in/rept%20_%20pubn/485_ final.pdf; December 2003. Accessed on 21.02.16. 17. Mitra S, Sambamoorthi U. Disability estimates in India: what the census and NSS tell us. Econ Polit Wkly. September 23, 2006;41(38):4022e4026. 18. Medhi GK, Hazarika NC, Borah PK, Mahanta J. Health problems and disability of elderly individuals in two population groups from same geographical location. J Assoc Physicians India. 2006;54: 539e544. 19. Pandey Manoj K. Poverty and Disability Among Indian Elderly: Evidence from Household Survey. ASARC Working Paper; 2009/09. 20. Paul SS, Abraham VJ. How healthy is our geriatric population? A community-based cross-sectional study. J Family Med Prim Care. 2015;4(2):221e225. 21. What Are the Main Risk Factors for Disability in Old Age and How Can Disability Be Prevented? WHO Regional Office for Europe’s Health Evidence Network (HEN); September 2003. 22. Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly cohort. Am J Public Health. 2004;94:1406e1411. 23. Annual Report 2011-12. Office of the Chief Commissioner for Persons with Disabilities Ministry of Social Justice and Empowerment Government of India. http://www.ccdisabilities.nic.in/content/en/docs/ AR12E.pdf; Accessed on 21.10.14.
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Research Paper
The prevalence of disability in elderly in India e Analysis of 2011 census data Banurekha Velayutham, M.B.B.S.a,*, Boopathi Kangusamy, M.Sc., M.B.A.b, Vasna Joshua, Ph.D.b, and Sanjay Mehendale, M.D., M.P.H.b a
National Institute for Research in Tuberculosis, Indian Council of Medical Research, No. 1 Mayor Sathyamoorthy Road, Chetput, Chennai 600 031, Tamil Nadu, India b National Institute of Epidemiology, Indian Council of Medical Research, Chennai, Tamil Nadu, India
Abstract Background: Advancing age leads to physical and sensory impairment with varying degrees of disability. There is lack of publication focusing on disability of elderly in India with a countrywide state-based analysis of all types of disabilities. Objective: To measure the prevalence of disability and describe the types of disability in the elderly Indian population by gender, advancing age, states and geographical regions. Methods: The 2011 Census cross-sectional survey data restricted to elderly in India was analyzed. ‘Elderly’ is defined as a person who is of age 60 years or above. Disability rates per 100,000 elderly population and age-adjusted disability rates were calculated. Results: A total of 5,376,205 elderly individuals were disabled in India in 2011; disability rate of 5178 per 100,000 elderly population. Movement and seeing disabilities individually accounted for 25% of total disabilities and disability in hearing was 19%. Disability rates in 17 Indian States and Union Territories were above the national average. Disability rates increased as age advanced with the highest disability rate of 8409 per 100,000 among people aged 80 yrs or above. The disability rates were higher in males than females (5314 vs. 5045 per 100,000) and in rural compared to urban areas (5593 vs. 4181 per 100,000). Currently married and working populations had lower disability rates. Conclusion: One in every twenty Indian citizens aged 60 yrs and above is either physically or mentally disabled. Identification of the underlying causes, employing effective and focused preventive strategies will help to reduce the prevalence of disability in the elderly. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Disability; Elderly; Mental; Physical; Census
The International Classification of Functioning, Disability and Health (ICF) defines disability as an umbrella term for impairments, activity limitations, and participation restrictions.1 About 15% of the world’s population (based on 2010 global population estimates) is estimated to live with some form of disability.2 As age advances, biological and physical nature of the body is likely to deteriorate which leads to physical and sensory impairment and in turn bring about varying proportions of disabilities.3 The Government of India’s ‘National Policy on Older Persons’ defines ‘elderly’ as a person who is of age 60 years or above.4 In 2011, the proportion of elderly in India was about 8.6% of the overall population. The proportion of elderly (>60 yrs) in India projected for Conflict of interest: none. * Corresponding author. Tel.: þ91 44 2836 9500. E-mail address: [email protected] (B. Velayutham). 1936-6574/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2016.04.003
2026 is about 12.17% of the overall population.5 A previous systematic review has reported lack of schooling, living in rental housing, chronic diseases, arthritis, diabetes, visual impairment, higher body mass index, poor selfperceived health, cognitive impairment, depression, slow gait, sedentary lifestyle, tiredness while performing daily activities, and limited diversity in social relations as risk factors for functional disability in the elderly.6 Article 41 of the Indian Constitution states that the State shall within the limits of its economic capacity and development; make effective provisions for securing the right to work, education and public assistance in case of unemployment, old age, sickness and disablement. People with disabilities suffer undue hardships and they continue to be marginalized, discriminated and abused.7 Access to affordable health care and rehabilitation has to be offered to the disabled persons. Disability among the elderly in India has been documented in various cross-sectional studies
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which are limited to geographical regions. However, disability of elderly in India with a focus on countrywide state-based analysis of all types of disabilities has not been reported. There is a need to quantify the prevalence of disability since this information is essential for the Government to plan policies, allocate adequate resources and implement appropriate programs for persons with disability. In India, information on physical and mental disability is captured during the census survey once in every 10 years and also during periodic surveys by National Sample Survey Organization (NSSO). The limitations of disability related data collection in census survey include only few questions on disability restricting the available information, high non-response rates and under-enumeration because of the complexity and sensitivity of the question/s. In addition, data collection is infrequent e usually every 10 years and the time between data collection and data dissemination can be considerable to understand the current prevalence rates.11 Nevertheless, the 2011 census data on disability covers the entire country and has information for all types of disability following a standard definition for each. The objective of this analysis was to measure the prevalence of disability and describe the types of disability in the elderly Indian population based on the available data on disabilities in the public domain under the Census 2011 database. We also estimated the distribution of disabilities by gender, advancing age, states, geographical regions, work and marital status in the elderly. Methodology This manuscript is based on analysis of the 2011 Census data of India. Indian census survey is conducted once in every 10 yrs following an extended de facto canvasser method. Under this approach, data is collected from every individual by visiting the household and canvassing the questionnaire all over the country, over a period of three weeks. The count is then updated to the reference date and time by conducting a Revisional Round.12 The census questionnaire had three questions pertaining to disability which captured information on 1) presence of mental or physical disability; 2) the disability type and 3) multiple disabilities [maximum of 3 disabilities] (Table 1).11
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Prior to the survey, the census enumerators were trained to obtain the information on disabilities. Considering the sensitive nature of the questions related to disabilities, they were instructed to build rapport with the respondents first and inform them about the importance of acquiring disability related information. In addition, the respondents were reassured that the individual information will be kept confidential. The question(s) on disability was asked for all persons in the household. The enumerator was instructed not to assume that just because someone looks ‘alright’ or ‘normal,’ she/he may not have disability. The enumerator was instructed to find out if any member of the household had any form of mental and/or physical disability. While the main respondent might be answering all the questions the enumerator had to make every possible effort to seek information from the disabled member of the household herself/himself, if she/he was present at the time of census taking and was able to provide correct information. The enumerator was instructed to use simple and nonderogatory language and to explain disability in terms of difficulty in doing any functions of daily living (taking care of oneself, gaining education, taking up a job) or participating in all/some spheres of life.11 The enumerator was also instructed that he/she should not avoid or rush through the question and give time for the person to respond. They were instructed not be in a hurry to write the Code of disability and ask if the person had more than one disability. The person may not ‘look’ disabled, but may have difficulty in seeing, hearing or any other disability. Hence, the census enumerators were instructed to record the person’s response as it is. The census enumerators were instructed not to try to probe on the cause, cure, treatment or rehabilitation regarding the impairment or disability reported.11 Temporary impairments like limitation of movement due to fractures or temporary illnesses were not counted as disability. The definitions used for various types of disability are provided in the Annexure 1.11 Data analysis Disability rates per 100,000 population were calculated. The numerators were number of disabled persons by type
Table 1 Questions related to disability in the Census of India 2011 questionnaire 9 (b). If, ‘‘YES’’ in 9 (a), give code Question and 9 (a). Is this person in the box against 9 (b) from the instructions mentally/physically list given below. disabled? In seeing e 1 Yes e 1/No e 2 In hearing e 2 If the person has a In speech e 3 disability please put In movement e 4 Code No. 1. If the Mental retardation e 5 person does not have a Mental illness e 6 disability, put Code Any other e 7 No. 2 Multiple disability e 8
9 (c). If ‘‘multiple disability’’ (Code 8) in 9 (b), give maximum three codes in boxes against 9 (c) from the list given below. In seeing e 1 In hearing e 2 In speech e 3 In movement e 4 Mental retardation e 5 Mental illness e 6 Any other e 7 Multiple disability e 8
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of disability and age, gender, type of residence (rural/urban) e C20 table (India and States/UTs District level).13 The denominators were extracted from C14 Table of census 2011.14 This table provides information on the number of people in the Indian population in various age groups with a 5 yearly interval starting from 0 to 4 years, upto 75e79 years and 85þ years. In addition, information on residence (rural/urban) and gender was used. The following data from the census 2011 namely DDW-0000B-01 [Workers and non-workers classified by age and sex], DDW-0000C-02fer3-MDDS [Marital status by age and sex], DDW0000C-21 [Disabled population by type of disability, marital status, age and sex], DDW-0000C-23 [Disabled population among workers and non-workers by type of disability, age and sex] were used to calculate disability rates according to marital and work status.15 Data were obtained for age groups 60 yrs and above for the analysis from all the above mentioned tables. Age-adjusted disability rates by direct standardization method using 2011 population of India aged >60 years as standard population were used for comparison and ranking of the Indian states and Union Territories with respect to each type of disability. The data was analyzed using Microsoft excel windows 2007. The representation of geographical distribution of disability rates in the different states of India was done
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using ArcGIS Desktop: Release 10. Redlands, CA: ESRI, Inc. 2011. Results A total of 5,376,205 elderly individuals were disabled in India in 2011 accounting for a disability rate of 5178 per 100,000 elderly population (5.1%) [2011 Indian elderly population 103,836,714]. The disability rates in movement and seeing [1309 per 100,000 each], hearing [984 per 100,000] and multiple disabilities [613 per 100,000] were high. Disability rates associated with speech, mental illness and mental retardation was 196, 88 and 87 per 100,000 elderly population respectively. Movement and seeing disabilities individually accounted for nearly 25% of total disabilities and hearing contributed 19% disability burden in the elderly. In addition, multiple disability and disability in speech constituted 12% and 4% respectively, whereas mental retardation and mental illness were responsible for 2% of the total disability individually. The remaining 11% of the disability was due to other causes. Disability rates in the Indian States and Union territories The disability rates in the Indian States and Union territories are shown in Fig. 1. Of the total of 35 states and
Fig. 1. Age standardized disability rates per 100,000 among elderly in the Indian states and Union territories, 2011.
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Union territories, the disability rates in 17 States and Union Territories were above the national average of 5178 per 100,000 population and ranged from 5211 to 10,926 per 100,000 population. Sikkim, Rajasthan and Chhattisgarh states reported the highest disability rates of 10,926, 10,689 and 8883 per 100,000 population respectively. Tamil Nadu and the Union Territory of Dadra and Nagar Haveli had the lowest disability rates of 2542 and 3232 per 100,000 population respectively. The prevalence of disability rates in majority of the remaining Indian states ranged between 3500 and 8800 per 100,000 population. Data in all and in top ten States and Union Territories according to the type of disability are shown in Tables 2 and 3. Disability in seeing (2626 per 100,000), movement (3359 per 100,000) and multiple disability (2260 per 100,000) were highest in Rajasthan. Disability in hearing, speech, mental retardation and mental illness was highest in Sikkim (3398 per 100,000), Maharashtra (524 per
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100,000), Mizoram (214 per 100,000) and Kerala (335 per 100,000) respectively.
Disability rates by basic demographic variables Disability rates increased as age advanced with the highest disability rate of 8409 per 100,000 among people aged >80 yrs (Table 4). The disability rates were higher in males compared to females (5314 vs. 5045 per 100,000) and higher in rural areas compared to urban areas (5593 vs. 4181 per 100,000) (Table 4). The disability rates in men and women in the rural areas of India were 5714 vs. 5476 per 100,000 respectively compared to 4361 vs. 4007 per 100,000 in the urban areas. Disability rates were higher in males in the age group 60e69 yrs (4407 vs. 3891 per 100,000) and 70e79 years (6258 vs. 6186 per 100,000) compared to females. Beyond 80 yrs of age there was a female preponderance in disability rates (8570 vs. 8226 per 100,000). There was
Table 2 Age-standardized disability rates per 100,000 in the Indian states and Union territories according to type of disability among the elderly, 2011 Disability rate per 100,000 S. no.
State/Union Territory
Seeing
Hearing
Speech
Movement
Mental retardation
Mental illness
Multiple disability
Overall
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Jammu and Kashmir Himachal Pradesh Punjab Chandigarh Uttarakhand Haryana Delhi Rajasthan Uttar Pradesh Bihar Sikkim Arunachal Pradesh Nagaland Manipur Mizoram Tripura Meghalaya Assam West Bengal Jharkhand Odisha Chhattisgarh Madhya Pradesh Gujarat Daman and Diu Dadra and Nagar Haveli Maharashtra Andhra Pradesh Karnataka Goa Lakshadweep Kerala Tamil Nadu Puducherry Andaman and Nicobar India
2174 1550 862 580 1280 1474 743 2626 1110 1137 2404 2122 1226 1208 651 1209 1014 1166 1299 1548 2146 2103 1417 1029 715 679 1129 1718 1159 1116 1799 1247 446 966 1508 1309
1748 1417 902 655 1108 1113 695 1497 945 939 3398 2250 2495 1169 1451 890 1152 1158 799 1327 1584 1639 997 979 786 1064 858 936 692 1072 850 872 610 1491 1339 984
184 185 104 132 157 110 119 137 163 192 355 190 217 147 178 110 95 143 159 154 171 129 115 111 70 51 524 286 125 477 128 153 97 152 171 196
1596 1542 936 1227 1014 1283 1734 3359 875 1009 1528 1193 992 728 574 955 541 1069 972 1870 2229 2804 1724 909 1281 783 1120 1668 840 1507 1918 1326 715 1793 1555 1309
165 95 116 49 81 92 66 102 70 82 120 119 120 213 214 123 83 109 140 100 124 84 84 55 26 42 63 96 88 91 56 87 51 97 69 87
241 107 142 109 86 90 94 98 44 49 144 130 104 114 142 138 110 146 122 82 136 91 63 98 114 79 71 58 45 187 217 335 56 92 136 88
1567 981 294 396 689 719 635 2260 391 312 1775 1113 1021 466 605 590 425 819 641 843 1234 1486 748 346 396 335 309 574 316 563 823 665 156 357 896 613
8813 6511 4176 3572 4877 5598 4466 10,689 4265 4318 10,926 7668 6723 4500 4137 4452 3930 5170 4711 6502 8267 8883 5766 3970 3554 3232 4613 6028 3795 5715 6174 5211 2542 5433 5993 5178
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2260 1775 1567 1486 1234 1113 1021 981 896 843 Rajasthan Sikkim Jammu & Kashmir Chhattisgarh Odisha Arunachal Pradesh Nagaland Himachal Pradesh Andaman & Nicobar Jharkhand 335 241 217 187 146 144 142 142 138 136 Kerala Jammu & Kashmir Lakshadweep Goa Assam Sikkim Punjab Mizoram Tripura Odisha 214 213 165 140 124 123 120 120 119 116 Mizoram Manipur Jammu & Kashmir West Bengal Odisha Tripura Sikkim Nagaland Arunachal Pradesh Punjab 3359 2804 2229 1918 1870 1793 1734 1724 1668 1596 Rajasthan Chhattisgarh Odisha Lakshadweep Jharkhand Puducherry Delhi Madhya Pradesh Andhra Pradesh Jammu & Kashmir 524 477 355 286 217 192 190 185 184 178 Maharashtra Goa Sikkim Andhra Pradesh Nagaland Bihar Arunachal Pradesh Himachal Pradesh Jammu & Kashmir Mizoram 3398 2495 2250 1748 1639 1584 1497 1491 1451 1417 Sikkim Nagaland Arunachal Pradesh Jammu & Kashmir Chhattisgarh Odisha Rajasthan Puducherry Mizoram Himachal Pradesh 2626 2404 2174 2146 2122 2103 1799 1718 1550 1548 Rajasthan Sikkim Jammu & Kashmir Odisha Arunachal Pradesh Chhattisgarh Lakshadweep Andhra Pradesh Himachal Pradesh Jharkhand 1 2 3 4 5 6 7 8 9 10
Rank State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate State/Union Territory Rate
Table 3 The top 10 Indian states and Union territories according to type of disability among the elderly (age-standardized disability rates per 100,000), 2011 Seeing Hearing Speech Movement Mental retardation Mental illness
Multiple disability
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Table 4 Disability rates by basic demographic variables in the elderly in India, 2011 Demographic Total Total Disability rate characteristics population disabled per 100,000 Age in years 60e69 70e79 80 and above Gender Male Female Location of residence Rural Urban Marital status Never married Currently married Others [widowed separated divorced] Work status Working Non-working
64,110,397 28,438,544 11,287,773
2,657,679 1,769,370 949,156
4145 6222 8409
51,065,214 52,771,500
2,713,757 2,662,448
5314 5045
73,281,496 30,555,218
4,098,613 1,277,592
5593 4181
2,550,602 68,103,262 33,195,176
188,799 3,086,602 2,101,218
7402 4532 6330
43,193,342 65,180,096
1,521,732 3,854,887
3523 5914
a rural preponderance in the disability rates across the different age groups. The disability rates were higher in the non-working population compared to working population (5914 vs. 3523 per 100,000) (Table 4). Never married and widowed/separated/ divorced populations had higher disability rates (7402 and 6330 per 100,000 respectively) compared to currently married population (4532 per 100,000) (Table 4). There was a male and rural predominance in the disability rates in the working, non-working populations and in different subgroups of marital status. Types of disability by age, gender and location of residence Disability rates associated with movement, seeing, hearing and multiple disability increased as age advanced (Fig. 2). Age group above 80 yrs had a two-fold increase in the disability rates for movement, seeing and hearing and more than five-fold increase in multiple disability rates as compared to age group 60e69 yrs. Speech, mental retardation and mental illness related disability rates remained stationery with advancing age. Disability associated with movement was high in the 60e69 yrs and above 80 yrs age group (1062 and 1999 per 100,000 respectively) and that associated with seeing was high in 70e79 yrs age group (1637 per 100,000). In the elderly population, there was a rural predominance for disability associated with movement (1426 vs. 1029 per 100,000), seeing (1467 vs. 931 per 100,000), hearing (1043 vs. 844 per 100,000) and multiple disability (708 vs. 386 per 100,000) compared to urban. Urban predominance was observed in disability associated with speech (230 vs. 182 per 100,000), mental retardation (89 vs. 86 per 100,000) and mental illness (93 vs. 86 per
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Fig. 2. Age differences in the disability rates according to the type of disability in the elderly in India, 2011.
100,000) compared to rural among the elderly. Disability rates by age, gender and type of residence according to the type of disability are summarized in Table 5. The disability related to movement showed a male and rural preponderance in all the age categories except in females above 80 yrs of age (1486 vs. 1449 per 100,000) in urban areas. Disability associated with seeing was higher in females and hearing higher in males with rural preponderance across all age categories. Disability in speech, mental retardation and mental illness had an urban preponderance. Males had higher disability associated with speech and mental retardation across all age categories. Mental illness was similar in males and females in the age group 60e69 yrs with a female preponderance in other age groups. Multiple disability was higher in rural areas across all age categories and was nearly double of that observed in the urban areas in the age group 70e79 yrs (939 vs. 483 per 100,000) and above 80 yrs (2000 vs. 1002 per 100,000). Female preponderance in multiple disabilities was observed across all age categories except in the age group of 60e69 yrs in the urban area which had higher males with multiple disabilities (250 vs. 213 per 100,000). Discussion Our analysis showed that one in every twenty Indian citizens aged 60 yrs and above [5178 per 100,000 persons] is either physically or mentally disabled based on the data of census survey of 2011. This is lower compared to 2002 NSSO survey which documented a disability rate of 6401 per 100,000 in those aged 60 yrs and above. In addition, the disability rates in the 2002 NSSO survey for the age group 60 yrs and above are higher compared to our analysis
of disability data of census survey 2011 for disability associated with movement, seeing, hearing and mental illness (2818 vs. 1309, 2250 vs. 1309, 1570 vs. 984 and 177 vs. 88 per 100,000) respectively.16 We have compared our results with those of NSSO 2002 which is the only large scale and authentic study reporting data on disability per 100,000 in different age groups for various types of disability. However, it is important to remember that NSSO 2002 data is more than 13 years old. In addition, the disability rates of the census survey and NSSO survey are not strictly comparable owing to the differences in the definitions of disability used. Nevertheless, this analysis has shown that a sizeable burden of disability exists in India among the elderly. Cross-sectional studies done in India have documented disability prevalence rates of more than 35% in various geographical settings.3,8e10 The purpose for which the census survey is conducted in India every 10 years is very different compared to smaller and focused research studies on disability in the populations. Hence, although it is possible that the estimations of disability through census survey might be an under-estimate, it is also possible that surveys conducted by interested stakeholders in this area might have over-estimated the disability. It might be important to critically look at case definitions as well as survey methodologies of census and various specialized surveys to find possible reasons for variations in disability prevalence.17 Disability among the elderly was more common in the rural compared to urban areas in our analysis. A study in Tamil Nadu, India among 750 persons aged 60þ yrs showed physical disability to be significantly higher in the rural (53.6%) compared to urban areas (37.3%).3 Lack of adequate facilities and health care could result in disabilities commonly occurring in the older age groups in the
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Table 5 Disability rates by age, gender and type of residence (urban/rural) according to the type of disability in age > 60 years in India, 2011 Age 60e69 yrs Age 70e79 yrs Age 80 & above Type of disability
Site
Gender
Total disabled
Rate per 100,000
Total disabled
Rate per 100,000
Total disabled
Rate per 100,000
Movement
Rural
Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female
516,690 298,806 217,884 164,338 99,371 64,967 519,552 243,923 275,629 149,640 74,983 74,657 365,332 180,738 184,594 126,357 64,621 61,736 82,342 45,312 37,030 43,331 24,719 18,612 40,416 21,257 19,159 16,965 9297 7668 3965 19,552 19,613 17,233 8632 8601 171,343 82,557 88,786 99,079 23,726 20,353
1143 1350 945 869 1045 691 1149 1102 1195 791 789 794 808 817 800 668 680 656 182 205 161 229 260 198 89 96 83 90 98 82 87 88 85 91 91 91 379 373 385 233 250 213
352,212 189,447 162,765 100,311 53,524 46,787 375,103 175,450 199,653 90,329 42,737 47,592 260,176 130,052 130,124 82,738 41,249 41,489 36,900 20,729 16,171 18,849 10,464 8385 15,843 8139 7704 6869 3469 3400 17,306 8176 9130 7757 3543 4214 189,506 85,581 103,925 29,834 18,555 21,279
1745 1878 1612 1216 1321 1114 1858 1739 1977 1095 1055 1133 1289 1289 1289 1003 1018 988 183 205 160 228 258 200 78 81 76 83 86 81 86 81 90 94 87 100 939 848 1029 483 458 507
175,798 84,568 91,230 49,876 21,993 27,883 180,170 81,091 99,079 44,491 18,898 25,593 138,941 67,489 71,452 48,728 22,588 26,140 14,215 7522 6693 7941 3995 3976 6602 3265 3337 3315 1514 1801 6767 2956 3811 3344 1343 2001 157,858 66,075 91,783 34,022 13,147 20,875
2227 2246 2210 1470 1449 1486 2282 2154 2400 1311 1245 1364 1760 1792 1731 1436 1488 1393 180 200 162 235 263 212 84 87 81 98 100 96 86 79 92 99 88 107 2000 1755 2223 1002 866 1113
Urban
Seeing
Rural
Urban
Hearing
Rural
Urban
Speech
Rural
Urban
Mental retardation
Rural
Urban
Mental illness
Rural
Urban
Multiple disability
Rural
Urban
rural areas. Low utilization of health services among the rural elderly compared to the urban elderly has been reported in a study from Assam.18 The reasons for geographical variations [urban versus rural] in the distribution of disability observed in our analysis needs to be further explored to generate evidence that would help in designing locally relevant interventions. The linkage between aging and disability is a biological fact where the risk of disability increases with increase in age.19 We observed increased disability rates with advancing age in the elderly. Studies done in both rural and urban areas among the elderly in India have documented higher disability rates in the older age group.8,10,20 Research on disability in old age has identified non-
modifiable risk factors such as age, gender and genetics, and modifiable risk factors such as age-related diseases, impairments, functional limitations, poor coping strategies, sedentary lifestyles and other unhealthy behaviors, as well as social and environmental obstacles.21 We have presented the disability rates in various states of India by type of disability. This information will be of immense help to state health managers in planning appropriate interventions and supportive care. Understanding the causes of disability is important to plan appropriate preventive strategies and research is warranted in this arena. The finding of male predominance in disabilities in age group less than 80 yrs and female in age group 80 yrs and above was observed in our analysis. A study in the United
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States among the elderly documented greater prevalence of nonfatal disabling conditions, including fractures, osteoporosis, back problems, osteoarthritis and depression, contributing substantially to greater disability and diminished quality of life among aging women compared with men.22 This certainly highlights the need to address the gender angle in disability management through appropriate strategies for the concerned groups. The main type of disability in the elderly was associated with seeing, hearing, movement and speech in our analysis. In the 2002 NSSO survey, old age, other illnesses and injury featured among the main reasons for movement, visual, hearing, speech disability.16 In about 25% and 30% cases, for rural and urban India respectively, the probable cause of hearing disability was ‘old age.’ About 49% and 57% were found to have acquired locomotor disability at the age of 60 years and above in rural and urban India respectively.16 Old age was the cause for about 241 per 1000 persons with blindness, 278 per 1000 persons with low vision, 263 per 1000 persons with hearing disability, 13 per 1000 persons with speech disability in the NSSO survey.16 Furthermore among the elderly, age at onset of blindness, low vision, hearing, speech and locomotor disability beyond 60 yrs was 673 per 1000, 717 per 1000, 571 per 1000, 369 per 1000 and 511 per 1000 respectively. The 2002 NSSO survey data on persons 60 years and above with mental retardation or mental illness by age at onset of disability revealed that manifestation of disability due to mental illness is completed within the teen-age while onset of mental illness increased as one gradually becomes older.16 We observed higher disability rates among nonworking and widowed/separated and divorced populations. According to 2002 NSSO survey, among those aged 60 yrs and above, 193 per 1000 physically disabled persons could not take self-care even with aid/appliances and 66 per 1000 disabled persons lived alone.16 A previous study identified higher level of poverty and income inequality among disabled elderly as compared to non-disabled elderly.19 The lives of disabled people are affected by poor health outcomes, lower educational achievements, less economic participation, high rates of poverty and increased dependency.2 Prevention of disability in old age is therefore a matter of great humanitarian and economic concern.21 Disability in old age is frequent and not only lowers the quality of life of the affected, but also strains family’s and society’s limited resources for assistance, care and rehabilitation.21 In India, National Programme of Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke Programme (NPCDCS), National Mental Health Programme (NMHP), National Programme for Prevention and Control of Deafness (NPPCD), National Programme for the Health Care for the Elderly (NPHCE) and National Blindness Control Programme have to play a major role in providing preventive, curative and rehabilitative services to
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reduce the burden of disability among the elderly in their areas of operation. According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, in India, the Chief Commissioner for Persons with Disabilities at the Centre and a Commissioner in each State are appointed to safeguard the rights of persons with disabilities and monitor the implementation of the Act.23 The program managers have to address the barriers to health care, rehabilitation, education, support and assistant services and create enabling environments.2 National Policy on Older Persons (NPOP), 1999, The Maintenance and Welfare of Parents and Senior Citizens Act, 2007 and Central Sector Scheme of Integrated Programme for Older Persons (IPOP) are some of the acts and schemes that benefit the elderly.4 Appropriate linkages within the National Programmes and schemes that benefit the elderly have to be developed to minimize disability in this population. Strategic preventive plans at national and community levels have to be developed, training in gerontology and geriatric medicine has to be promoted and initiatives to stimulate research and development on old age disability have to be created.21 The interpretation of the analysis presented must be done with some degree of caution. The greatest strengths of the census survey include its implementation through a welloiled machinery, universal reach and use of standardized protocols in data collection. However, there are certain limitations. There could be some level of non-response. Also, the possibility of under-reporting might result due to inability to capture the complex and sensitive information related to disability in limited number (3) questions of the census questionnaire. These factors would primarily lead to underestimation of disability rates which might be actually higher. Disability measure in the census is an aggregation of the sum of different disability types and there is no measure of activity or functional limitation. Appropriate statistical modeling may have to be applied to the census data of 2011 to estimate the current burden of disability. According to official population projections, the number of elderly persons in India will rise to approximately 140 million by 2021.4 Our analysis has shown that the prevalence of disability rates in the elderly in half of the Indian states varies between 5211 and 10,926 per 100,000 and this is a matter of concern since this is likely to increase. We have estimated and presented the national level estimates of disability prevalence, urban/rural and male/female differentials in the disability rates in the elderly. To understand the reasons to explain these, additional research studies will have to be planned or additional data mining might have to be done to look for published and unpublished literature in this area. Identification of the underlying causes and employing effective and focused preventive strategies will help to reduce the burden of disability in the elderly in the years to come. Various programs should also focus on providing appropriate interventions and rehabilitation achieves to
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maximize the quality of life and improve economic conditions of the elderly. Acknowledgment The authors would like to thank the Office of the Registrar General and Census Commissioner, India for providing access to the data on disability and population enumeration which was used for the analysis. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.dhjo.2016.04.003. References 1. Towards a Common Language for Functioning, Disability and Health International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organisation; 2002. WHO/EIP/GPE/CAS/01.3. Accessed on 21.10.14. 2. World Report on Disability. World Health Organisation and World bank, http://www.who.int/disabilities/world_report/2011/report.pdf; 2011. Accessed on 21.10.14. 3. Audinarayana N, Sheela J. Physical disability among the elderly in Tamil Nadu: patterns, differentials and determinants. Health Popul Perspect Issues. 2002;25(1):26e37. 4. Situational Analysis of Elderly in India. Central Statistics Office Ministry of Statistics & Programme Implementation Government of India, http://mospi.nic.in/mospi_new/upload/elderly_in_india.pdf; 2011. Accessed on 21.10.14. 5. Ingle GK, Nath A. Geriatric health in India: concerns and solutions. Indian J Community Med. 2008;33(4):214e218. 6. Rodrigues MA, Facchini LA, Thume E, Maia F. Gender and incidence of functional disability in the elderly: a systematic review. Cad Saude Publica. 2009;25(suppl 3):S464eS476. 7. Universal Periodic Review e India. Key issues of 120 million persons with disabilities in India. National Disability Network. http://lib.ohchr. org/HRBodies/UPR/Documents/session13/IN/NDN_UPR_IND_S13_ 2012_NationalDisabilityNetwork_E.pdf; Accessed on 27.12.14. 8. Gupta P, Mani K, Rai SK, Nongkynrih B, Gupta SK. Functional disability among elderly persons in a rural area of Haryana. Indian J Public Health. 2014;58(1):11e16.
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9. Sinha SP, Shrivastava SR, Ramasamy J. Depression in an older adult rural population in India. MEDICC Rev. 2013;15(4):41e44. 10. Srinivasan K, Vaz M, Thomas T. Prevalence of health related disability among community dwelling urban elderly from middle socioeconomic strata in Bangaluru. India Indian J Med Res. 2010;131:515e521. 11. Manual on Disability Statistics. Government of India. Ministry of Statistics and Programme Implementation. CSO-MDS-2012. http://mospi. nic.in/Mospi_New/upload/Revised_Disability_Manual_20june12.pdf; Accessed on 21.02.16. 12. Overview of Census, http://censusindia.gov.in/2011-prov-results/data_ files/mp/02Introduction.pdf; 2011. Accessed on 21.12.15. 13. Census of India. Disabled Population by type of Disability, Age and Sex e C20 Table of India. http://www.censusindia.gov.in/2011census/Cseries/c-20.html; Accessed on 21.12.15. 14. Population enumeration data (Final population). Age data. Five year Age Group Data e C14 Table. http://www.censusindia.gov.in/% 28S%28esr3lm45pksguc451d45sp55%29%29/2011census/population_ enumeration.aspx; Accessed on 21.12.15. 15. Census of India 2011. Population Enumeration Data (Final Population). http://www.censusindia.gov.in/2011census/population_enumeration. html; Accessed on 21.12.15. 16. National Sample Survey Organisation. Ministry of Statistics and Programme Implementation. Government of India. Report No. 485 (58/26/1). Available at: http://mospi.nic.in/rept%20_%20pubn/485_ final.pdf; December 2003. Accessed on 21.02.16. 17. Mitra S, Sambamoorthi U. Disability estimates in India: what the census and NSS tell us. Econ Polit Wkly. September 23, 2006;41(38):4022e4026. 18. Medhi GK, Hazarika NC, Borah PK, Mahanta J. Health problems and disability of elderly individuals in two population groups from same geographical location. J Assoc Physicians India. 2006;54: 539e544. 19. Pandey Manoj K. Poverty and Disability Among Indian Elderly: Evidence from Household Survey. ASARC Working Paper; 2009/09. 20. Paul SS, Abraham VJ. How healthy is our geriatric population? A community-based cross-sectional study. J Family Med Prim Care. 2015;4(2):221e225. 21. What Are the Main Risk Factors for Disability in Old Age and How Can Disability Be Prevented? WHO Regional Office for Europe’s Health Evidence Network (HEN); September 2003. 22. Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly cohort. Am J Public Health. 2004;94:1406e1411. 23. Annual Report 2011-12. Office of the Chief Commissioner for Persons with Disabilities Ministry of Social Justice and Empowerment Government of India. http://www.ccdisabilities.nic.in/content/en/docs/ AR12E.pdf; Accessed on 21.10.14.