Two important findings were revealed in this study’s in-depth analyses. First, 42% of Bangladeshi older adults, with a higher prevalence among elderly females, had some form of functional disability, including 5% with a severe/extreme form of functional disability. Furthermore, 7% of Bangladeshi older adults, with a higher prevalence among elderly females, had some form of disability in self-care, including 3% of elderly with a severe/extreme form of self-care disability. Second, elderly females had each of the six disabilities in higher percentages (with a borderline significance level [p = 0.08] for difficulty remembering) than elderly males. Compared to elderly males, elderly females had higher odds ratios of having functional disability, disability in self-care and general disability. Additionally, older age, suffering from a chronic condition, wealth status, and place of residence including divisional differences were found to be associated with both functional disability and disability in self-care among male and female older adults in Bangladesh.
To this date, no study has specifically focused on disabilities among older adults in Bangladesh. Utilizing data collected in 2003 from working-age people for the World Health Survey (WHS), a study reported that the disability prevalence for the Bangladeshi people aged 40+ years was 26% [34]. In 2005, a study based on data from individuals of all ages reported that the disability prevalence for people aged 51–64 was 13% and for people aged 65+ was 26% [22]. In 2010, in the Bogra district of Bangladesh, the disability prevalence for people aged 55+ was reported to be 25% [13]. The disability prevalence for rural people of age 60+ years was reported to be 26% in 2010 in another study [35]. A study that used the WG’s disability items found that 33% of older Ugandans of age 50 years and above were reported to be disabled in 2010 [36]. These prevalence rates are not directly comparable to the disability prevalence of the current study due to the differences in measures, cut-offs, settings and time period. For example, the WHS used 4 questions on seeing, moving around, concentrating or remembering and self-care, each with 5 response categories. Direct questioning on hearing, speech, vision, physical, and intellectual impairments were used to measure disability in the study by Titumir and Hossain [22]. In low- and middle-income countries, the disability prevalence is particularly high compared to the high-income countries [37], and disability at older ages is an important public health concern [38]. The incidence and development of disability have negative impacts on the lives of elderly people and those who assist the elderly with regular activities. This situation affects thousands of people and, consequently, constitutes a public health problem in society [11]. Bangladesh has ratified the United Nations Convention on the Rights of Persons with Disabilities and enacted the Disability Welfare Act in 2001. The Ministry of Social Welfare, Bangladesh has allocated a special amount toward the Allowance Programme for Insolvent Persons with Disabilities of all ages in its yearly budget since 2005. Although a monthly allowance of 6.25 USD (1 USD = 80 BDT) per person has been allocated to 0.4 million insolvent persons with disabilities since the 2014 fiscal year (2.5 USD in fiscal year 2005), no specific policies regarding older adults with disabilities exist [39]. As the current study revealed that 42% of older Bangladeshi had some form of functional disability and 7% of older Bangladeshi had some form of disability in self-care, programs aimed at reducing functional disability among seniors should be prioritized in Bangladesh. Among functional disabilities, seeing, walking and hearing difficulty were highly prevalent, suggesting that preventative measures could be taken by providing eyeglasses, hearing aids and assistive devices, as well as facilitating the availability of affordable and high quality cataract surgical services.
Compared to elderly males, elderly females reported having higher functional disability, disability in self-care as well as general disability. This is in line with previous studies done in different settings [12,13,14, 20, 34, 35, 40,41,42,43]. A very limited number of studies found no significant gender differences in disability [36, 44]. Gender differences in functional disability and disability in self-care might be explained by early maternal age at first birth, chronic conditions [45], greater female longevity, exposures to domestic violence [46, 47], gender inequalities in nutritional status, marital status and education [43]. Social and health related issues largely contribute to the higher prevalence of disability in women [16]. Higher prevalence of disability among elderly females could also be due to less than adequate care and services for pregnant/delivering mothers, exposures to domestic violence in early life, and the impact of gender-related life conditions. During the reproductive period, mothers encounter some long lasting health problems which remain undisclosed due to cultural reasons. In addition, intimate partner violence was found to be transmitted across generations in Bangladesh [47]. These health problems and domestic violence can cause women to fall sick with greater frequency during reproductive years as well as in later life [12]. Obstetric fistula is today largely confined to the cultures of tropical poverty [48]. This might be one reason for the higher prevalence of disability among elderly females than elderly males in Bangladesh. Patriarchy is also thought to limit women’s advancement, rights, and a cause of lower status of women in Bangladesh. It could deprive women of many necessities including food, nutrition, health care, secure life, a respectable living, mental peace, and an abuse-free life. In turn, females could have poor health as well as disability [12]. In addition, elderly females were reported to suffer from multiple disadvantages resulting from gender biases, widowhood, ill health, social isolation, and poverty when compared to elderly males [49]. Elderly females, particularly widows, who are without living sons or who live alone, have been considered to be particularly at risk of economic destitution, social isolation, poor health, and death in Bangladesh [50]. In our study, a high percentage of elderly females were widows. Due to longer life expectancy among females and differences in age at marriage between brides and grooms, there were higher percentages of elderly widowed females in Bangladesh at the time of this study. This warrants making elderly females a priority group when programs aimed at reducing disability among seniors are implemented in Bangladesh.
Aging is characterized by a progressive loss of physiological integrity, leading to impaired function and higher vulnerability to death [51]. The current study also revealed that disability prevalence increased at older ages. This result has been found in numerous studies [11,12,13, 20,21,22,23, 26, 34,35,36, 52]. This research underscores the need to prioritize older adults in reducing disability in Bangladesh. Older adults with a chronic condition had higher rates of functional disability and disability in self-care in the current study. This has also been found in other settings [43]. This study thus also underscores the urgency in reducing the impact of chronic conditions in older adults by providing necessary health care services.
As in the current study, wealth inequality, rural-urban disparities and divisional differences in disability among older adults were also found in other studies [12, 13, 22]. Compared to people from poor households, people from middle income and rich households reported suffering lower functional disability, but higher disability in self-care in the current study. In developed countries as well as developing countries including Bangladesh, people from higher socioeconomic status experience less disability [12, 20, 26, 34, 53,54,55,56]. The short set of WG’s questions on disability had been previously combined in a study on Bangladesh [12], but for this research were grouped into two categories- functional and self-care disability. In Bangladesh, rich people have more access to health care services than poor people. They use health care services more than the poor [57], and consequently could have reduced functional disabilities. For instance, the rich could have had cataract surgery and bought glasses to relieve their problems with eye-sight. They may use assistive devices for hearing and walking as well. The rich thus have fewer functional disabilities, which should translate into less self-care disability. But this is not the case. One possible reason might be that wealthy individuals exercise less and engage in less physical work than the poor. Particularly, in rich households, women may perform less physical or weight-bearing labor as they have hired help to do so. We also found that functional limitations had not necessarily introduced self-care disability among the Bangladeshi elderly. This could be due to reporting heterogeneity between the poor and the rich; the rich may consider moderate self-care disability as a disability, while the poor may not. Further, cross-tabulations among disability, sex and age groups from the data used in this study demonstrated that a higher proportion of older than younger and females than males reported having self-care disability rather than functional disability. These results should be interpreted in light of the fact that our sample consists of more women than men of age 80 years and over. This may be the primary reason why people from rich households have higher disability in self-care than people from poor households.
Rural elderly reported suffering higher functional, self-care as well as general disability in the current study. Rural elderly were also found to have greater disability and poor health than urban elderly in other studies [22, 24]. The higher rate of disability in rural areas than urban areas might be due to poorer living conditions, less education, poverty, fewer health care services and facilities, which are essential for consideration in reducing disability and formulating new policy. As was the case in other studies [12, 22], divisional differences in disability were also found in the current study, though not in one specific direction. Compared with older adults from Barisal division, the older adults from Chittagong and Sylhet divisions had lower odds of having functional disability and the older adults from Rajshahi division had higher odds of having functional disability. The economic conditions of the divisions might explain the fact; Chittagong is comprised of industrialized areas, Sylhet receives remittances from working abroad, and both are wealthier than Rajshahi. Older adults from Rajshai division may need additional support to reduce functional disability.
Strengths and limitations
This study has some limitations. First, we were not able to assess causality among the variables used as the data came from a cross-sectional survey. Second, the data are self-reported. This could be a possible source of bias. However, studies have shown that self-reported disability is consistent with medical diagnoses [15]. We advocate caution in explaining the relationship between wealth and disability in self-care, as we only had a few elderly with self-care disability; a data set concentrating on self-care disability is necessary for a deep investigation on this matter. The main strength of this study is that the data came from a large, valid and reliable, nationally representative data set. This study examined two kinds of disability- functional and self-care disability- a fact which also sets it apart from previous studies. However, a longitudinal study is certainly needed to address health and disability transitions, and the causal relationships between variables.