Health Education Research Advance Access originally published online on February 14, 2007
Health Education Research 2008 23(1):94-105; doi:10.1093/her/cym002
The impact of health education in managing self-reported arthritis-related illness among elderly persons in rural Bangladesh
1 Research and Evaluation Division, BRAC, Dhaka 1212, Bangladesh
2 Division of Geriatric Epidemiology, NVS, Karolinska Institutet, Ageing Research Centre, 9th floor, Gävlegatan 16, 113 30 Stockholm, Sweden
3 Department of Public Health Sciences, Division of International Health (IHCAR) Karolinska Institutet, Stockholm 171 77, Sweden and Nordic School of Public Health and Apoteket AB, Goteborg, Sweden
4 Department of Psychology, Stockholm University, Stockholm 106 91, Sweden
* Correspondence to: A.K.M.M. Rana. E-mail: Rana.Akm.Masud{at}ki.se
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Abstract |
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 Top Abstract IntroductionMaterials and methodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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This study examines the impact of health education on prevalence of and expenditure on treatment of self-reported arthritis-related illness among elderly persons in rural Bangladesh. An intervention study was conducted, including 1135 elderly persons (
60 years) from eight randomly selected villages, four each of an intervention and a control area. The analyses include 839 elderly persons who participated in both pre- and post-intervention surveys (intervention area: n = 425, control area: n = 414). Participants of the intervention area were further categorized as compliant (n = 315) and non-compliant (n = 110) based on adherence to the intervention instructions. The intervention that lasted for 15 months comprised home-based physical exercise, dietary instructions and other aspects of management. Results show that although there was no significant difference in self-reported arthritis-related illness between the compliant and non-compliant groups at baseline, it was significantly lower in the compliant group (71%) at post-intervention compared with the non-compliant (81%). Related monthly expenditure on treatment was significantly reduced in the compliant group (from Taka 104 to Taka 52) but not in the other two groups. Logistic regressions further showed that the control group had a higher probability of increased treatment-related expenditure compared with the compliant group (OR 2.0, 95% CI 1.4–2.8). |
Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The increasing global burden of bone and joint diseases led the United Nations and the World Health Organization to declare the first decade of the 21st century as the ‘Bone and Joint Decade 2000–2010’ [1–3]. The aims of the declaration are to raise awareness, promote prevention and empower patients through education campaigns and to advance research on prevention, diagnosis and treatment of bone and joint diseases [3].
Arthritis-related illness (e.g. joint pain, stiffness, inflammation, biting sensation, swelling and back pain) is a pervasive problem of joints, a chronic condition with high prevalence rates, which is predicted to increase with advancing age [4, 5]. Most symptoms last for life [6]. Improper and cumulative effects of decades of use lead to this degenerative transformation in the joints [7, 8]. Arthritis-related illness accounts for more visits to the doctor and more lost workdays than any other physical disorder and adversely affects the health status of individuals [8]. Furthermore, it is a major burden on the individual, the health system and the social care systems [9] and dominates the national illness burden worldwide [10]. Arthritis-related illness is common in many high-income countries [6, 8, 11, 12] with prevalence of doctor-diagnosed arthritis ranging between 18–36% in the United States [13] and prevalence of reported joint pain, a symptom of arthritis, 95% among older African Americans [14]. The quality of life of sufferers and their families is also severely affected by the condition. Yet, in many countries, it receives low priority in the health agenda [6, 15].
Bangladesh is a poor country where 45% of the population lives below the poverty line [16]. It is the seventh largest country in the world in terms of its population size with 144 million people [17], and the size of its elderly population (60 years) is close to 8.5 million [18]. Research indicates high prevalence of different types of chronic and acute illnesses among the elderly persons [19, 20]. Among these, arthritis-related illness is reported to be the leading cause of physical disability [21], the second most common illness among elderly persons and the seventh most common illness in the adult population of the country [18, 22].
Recent research from Bangladesh shows that the majority of the elderly persons suffers from arthritis-related illness [19, 20]. However, knowledge regarding management of this illness is found to be very poor among elderly persons and their caregivers. Due to high illiteracy, poverty and inadequate support from the formal health services regarding health care and health education, the elderly do not receive much information concerning prevention and management of different illnesses including arthritis-related illness [23]. Furthermore, owing to inadequate services from the formal health care majority of elderly persons depends on semiqualified and unqualified health care providers such as informal paraprofessionals and untrained drug sellers [24].
Globally, health education programs have been based on the idea that provision of knowledge about causes of illness and options available for health care will go a long way in promoting change toward better health [25]. The Ottawa charter is an important milestone in health promotion worldwide, and defines health promotion as the process of enabling people to improve and increase control over their health [26]. For any medical condition, educational intervention is reported to provide an additional 15–30% improvement over and above the effects of medication alone [27]. For people with arthritis, it also shows important benefits as a useful complement to medical care [5]. Education develops both individual capacity for self-management and saves health care costs [26]. This is also an effective process to ensure an equitable development of health services such that all individuals are benefited [28]. It has even been argued that improvement of health is possible without a continually increasing health care budget provided that attention is given to individual habits [29]. However, there is relative lack of information about effects of health education among elderly persons, particularly in the area of arthritis in low-income countries where poverty and illiteracy are widespread.
'Primary Health Care in Later Life: Improving Services in Bangladesh and Vietnam' (PHILL) is an intervention study which aimed to study the effectiveness of low-cost preventive and health promotion interventions in improving primary health care services for the elderly persons in rural communities in Bangladesh and Vietnam. PHILL provided community-based health education interventions designed for elderly persons in a rural area of Bangladesh in order to improve knowledge regarding prevention and management of arthritis-related illness. The current study derives data from PHILL in Bangladesh in order to examine whether adherence to health education instructions benefit in reducing the prevalence of arthritis-related illness and related health care expenditure. Furthermore, determinants of increased expenditure on treatment of arthritis-related illness are examined.
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Materials and methods |
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Study design
As mentioned above, data for this study are derived from an intervention study aiming to improve health and quality of life of elderly persons in rural Bangladesh and Vietnam conducted under the auspices of the PHILL project. The study was carried out in Chandpur district (population 2.2 million), one of the 64 districts of Bangladesh. From the selected district, two subdistricts (one intervention and one control) were purposively chosen where either a Bangladesh Rural Advancement Committee (BRAC) (a non-government development organization) and/or a government health center offered primary health care services. Data were collected in two phases: baseline data were collected during April–June 2003, and after 18-month intervention, post-intervention information was collected during the same period of the year in 2005 (Fig. 1). Ethical approval for the study was obtained from Bangladesh Medical Research Council, Bangladesh and Karolinska Institutet, Sweden.
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Sample
Eight villages, four each in the intervention and control areas, located within 3 km from either a non-government or a government health center were selected by simple random sampling. A census was done in the selected villages to identify the households with at least one elderly person, aged 60 years or older. From this census, 1135 elderly persons were identified in 966 households. At baseline, 514 elderly persons from the intervention and 517 from the control areas were successfully interviewed totaling 1031 elderly persons. The overall response rate was 91% at baseline. At post-intervention, 425 elderly individuals from the intervention and 414 from the control areas were successfully interviewed totaling 839 elderly persons (Fig. 1). Hence, the response rate at follow-up was 81.4%. The reasons of attrition were death (11.5%), absence during data collection (4.5%), illness (2.0%) and refusals (0.6%).
Data collection
Verbal consent was obtained from the respondents prior to the interviews that were conducted at the elderly persons' homes. The respondents were explained the aims of the study and informed of their right to discontinue the interview at any point. To avoid bias in the data collection, field workers involved in the intervention activities did not participate in data collection. Using a structured questionnaire, baseline and post-intervention data were collected on socioeconomic and demographic characteristics, knowledge, attitude and practice on elderly care, morbidity and health-seeking behavior, functional ability, social network and support and health-related quality of life. To collect data on arthritis-related illness, a local Bangla word, bat, was used to identify the self-reported arthritis-related illness. Elderly individuals were specifically asked if they suffered from any form of arthritis-related illness during the preceding month. If they gave a positive response, they were asked about the most frequent form of treatment sought and the amount of money they had spent for treatment. Furthermore, at post-intervention, the elderly persons in the intervention area were asked if they followed the health education instructions that were provided, and if so which instructions (exercise, dietary or others) that were followed.
The intervention
The active intervention period lasted for 15 months (October 2003 to December 2004) followed by a 3-month interval prior to the post-intervention data collection. The trainers were recruited through written and oral examination with preference given to those with prior experience on training. The intervention covered three broad domains: health care management, health awareness and social awareness related to elderly health. Health care management was primarily related to management of arthritis-related illness and also of other common illnesses among elderly persons, including diabetes and high blood pressure. Training was given to the elderly individuals through weekly counseling sessions and self-help group meetings, their primary caregivers and adolescent groups in the community through weekly small group meetings and to local health care providers through training workshops. In order to conduct the training sessions, a training manual was developed by a physician in consultation with different stakeholders. The manual was followed during the training and counseling sessions. Posters and leaflets providing various health messages were also distributed to the community.
The health education components included different health care messages regarding hygiene, diet and home-based physical exercises. As swimming and walking are feasible in the rural area, these activities were encouraged to promote physical exercise. The practical training on different types of home-based moderate physical exercise (e.g. pushing against the wall with hands, sitting down and standing up from the chair and rotating hands, etc.) was also provided by the trainers. Participants were followed-up to confirm that they had learnt the exercises appropriately. Some cautionary instructions were also provided such as to avoid lying down on a soft bed, carrying pitcher filled with water on the waist or working in bending position.
The dietary instructions included a list of healthy and unhealthy food items. Advice was given to avoid harmful food items such as extra salt, sugar, brain of ducks or chickens, livers and fatty foods which produce uric acid crystal and are harmful to different diseases, e.g. high blood pressure, diabetes and arthritis-related illness. Participants were instructed to eat healthy food, i.e. vegetables and fruits, and on intake of meals so as not to eat too much at a time which may result in increased weight and indigestion.
The health education instructions were given through elderly self-help groups, which were formed during the intervention period. All these instructions were compiled in a manual, copies of which were distributed to the elderly persons' self-help groups. During the intervention period, a field worker facilitated the sessions in the self-help group. Small group training sessions were regularly conducted in the study villages to raise awareness of the community people about elderly health and health care management. Furthermore, health cards were provided to all the elderly persons for recording their illness episodes and treatment for the illness. Information recorded on the health cards helped field workers to provide further relevant instructions to the elderly persons and to their caregivers for necessary health care. Finally, to make the intervention more effective and to increase adherence to the instructions provided, weekly visits were made by the field workers at the households of the elderly persons throughout the intervention phase.
Data analyses
In the present study, we utilized data from two time points: baseline and post-intervention. Before performing the analyses, the study participants were separated into three groups: (i) compliant group, those in the intervention area who reported that they followed the health education instructions; (ii) non-compliant group, those in the intervention area who reported that they did not follow the health education instructions and (iii) control group, those from the control area where intervention was not provided. The first two categories were done based on self-reports. Bivariate and multivariate analyses were performed using these three groups.
Analysis of variance (ANOVA) and chi-square tests were performed to examine potential differences between the groups and paired sample t-tests were performed to examine differences within groups. Finally, logistic regressions were performed in order to examine determinants of change in expenditure on treatment of arthritis-related illness across time. Four models were constructed for these analyses, one each for compliant, non-compliant and control group and a combined model for all the three groups together. The predictors included age, sex, literacy, economic status, self-rated poverty status, occupation, marital status and participation in intervention (i.e. presence or absence of intervention and compliance or non-compliance within the intervention area). The descriptions of independent and outcome variables follow next.
Independent variables
In addition to age and sex, the following indicators were used as independent variables.
Economic status
A household owning <0.5 acre of land including homestead and depending on labor-selling activities for more than a 100 days a year was considered as poor. This definition is applied by BRAC to determine whether or not individuals are eligible to participate in their poverty alleviation programs.
Literacy
Those who reported that they could read and write Bangla language were considered literate, otherwise illiterate.
Occupation
Occupation held for the longest period by an individual was considered as his/her primary occupation. For the analyses, all occupations of the individuals were divided into two groups i.e. paid work and unpaid work.
Self-rated poverty status of household
Self-rated poverty status of the household was categorized into two categories such as deficit and non-deficit. The information was elicited by asking the respondent about the state of the household's annual expenditure in relation to the total income of the household.
Outcome variables
Three variables were considered as outcome variables: self-reported presence of arthritis-related illness, type of health care sought for arthritis-related illness and expenditure on treatment of arthritis-related illness.
Presence of arthritis-related illness
Reporting presence of any of the symptoms joint pain, inflammation, biting sensation, stiffness, swelling or back pain was considered as presence of arthritis-related illness and coded as positive.
Expenditure on treatment of arthritis-related illness
Both mean expenditure and change in expenditure on treatment of arthritis-related illness between baseline and post-intervention were considered as outcome variables. If the expenditure was reduced in the follow-up or remained the same in both periods, it was considered to be a positive outcome and hence merged together (coded ‘0’). An increased expenditure in the follow-up on the other hand was considered as a negative outcome (coded ‘1’).
Categorization of health care
Health care sought for arthritis-related illness was categorized into four groups, self-care/self treatment, paraprofessionals/drug-store sellers, qualified medical doctors and traditional medicines (including homeopathy) [24].
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Results |
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Sociodemographic profile of the study participants
A brief profile of the study sample is provided in Table I. The mean age of the elderly persons in the compliant group was significantly lower than in the non-compliant and the control groups (P < 0.05). Illiteracy was significantly higher among the non-compliant group, and the majority of the elderly persons was involved in unpaid work across all the three groups. The majority of the elderly men reported to be married while the majority of elderly women single (widowed, divorced or separated). Further, the proportion of poor elderly persons was significantly higher in the compliant and the non-compliant groups compared with the control group. Similarly, self-rated poverty status was distributed such that the majority of the elderly persons from the complaint and non-compliant groups reported the economic state of their household as deficit compared with the control group.
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Prevalence of self-reported arthritis-related illness
A majority of the elderly persons reported that they suffered from some form of arthritis-related illness (mostly joint pain) during the month preceding the interview at both baseline and post-intervention surveys (Table II). The prevalence was found to be significantly higher in the control area at both baseline and post-intervention periods. Further, at the post-intervention stage, the elderly persons in the compliant group reported a significantly lower prevalence of arthritis-related illness compared with the elderly persons in the non-compliant and control groups.
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Prevalence of self-reported arthritis-related illness as function of exercise and dietary instructions
Next, effects of physical exercise and dietary habits on arthritis-related illness were examined among those who reported that they had followed either exercise or dietary instructions. Bivariate analyses revealed that the elderly persons who reported performing moderate physical exercise, following dietary advice or both the instructions reported a significantly lower prevalence of arthritis-related illness compared with those who did not (Fig. 2).
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Health care sought for arthritis-related illness
Paraprofessionals and drug-store sales persons together were found to be the most commonly used health care providers in both the intervention and control areas and their dominance was pronounced both at baseline and in the post-intervention surveys across all the groups. Self-care emerged as the second most frequent form of health care for those suffering from arthritis-related illness at post-intervention (Table II).
Monthly mean expenditure of arthritis-related illness
The monthly mean expenditure incurred for treatment of arthritis-related illness was significantly reduced (P < 0.001) between baseline and post-intervention period in the compliant group only while no significant decline was noted in either the non-compliant or the control group (Table III). ANOVA also confirmed that, at baseline, there was no significant difference between the three groups in terms of mean expenditure on treatment while at the post-intervention stage the compliant group was found to have spent significantly less amount of money on treatment compared with the control group.
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Change in monthly expenditure on treatment
Change in monthly expenditure on treatment of arthritis-related illness was examined over time based on whether the expenditure increased, remained the same or decreased between baseline and post-intervention period. No significant change was noted across the three groups in the category where the expenditure remained the same (
12% in the compliant, the non-compliant and the control). However, those reporting decrease in expenditure was significantly higher in the compliant group compared with the control. In the latter, a significantly higher percentage of elderly persons reported increased expenditure compared with the compliant group (P < 0.001) (Table IV).
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Odds ratios (OR) of monthly increased expenditure on treatment of arthritis-related illness
Finally, logistic regression analyses were performed to analyze determinants of monthly increased expenditure on treatment of arthritis-related illness. In the non-compliant group, women were three times more (OR 3.3, 95% CI 1.1–10.1) likely than men to incur increased expenditure on arthritis-related illness (Table V). The combined model clearly shows that non-exposure to the intervention activities doubled the probability of increased expenditure on treatment (OR 2.0, 95% CI 1.4–2.8) among the control group compared with the compliant group. No other covariates showed any significant association in the different models.
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Discussion |
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This paper is one of the first attempts to examine the impact of a community-based health education intervention designed for elderly persons in a rural area of Bangladesh. Even though the duration of the intervention was too short to have far-reaching effects on chronic illness, other effects were detected. The study revealed that the intervention contributed in reducing prevalence of self-reported arthritis-related illness and related health care expenditure among the study participants who adhered to the given health education instructions.
The prevalence of self-reported arthritis-related illness was significantly lower in the compliant group compared with only the control group at baseline. However, at post-intervention, the prevalence was significantly lower in the compliant group compared with those who did not adhere to the intervention instructions. Further analyses revealed that in the compliant group those who reported performing physical exercises experienced significantly lower prevalence of self-reported arthritis-related illness compared with those who did not. Evidence from other research confirm this by showing that the benefit of moderate exercise can help in improving arthritis-related and other chronic illnesses such as diabetes and heart diseases [30]. Indeed, physical activity plays a central role in the prevention and management of chronic disease [31], and physical inactivity is identified as a leading cause of disability among older adults [32]. Even failure to walk for exercise, for example, is shown to be an important risk factor for illness in old age [33]. Similarly, those who followed the dietary instructions also reported lower prevalence of arthritis-related illness. Other research shows that high intakes of meat and protein and low intakes of fruits, vegetables and vitamin C are associated with increased inflammatory arthritis-related illnesses such as polyarthritis or rheumatoid [34]. Gout, an arthritis-related problem, is also aggravated by certain diets such as meat, liver, brain of ducks and chicken, which produce uric acid crystal in the joint [35].
Monthly expenditure on treatment of arthritis-related illness revealed that it was significantly reduced in the compliant group between baseline and post-intervention period. This expenditure declined significantly across all the socioeconomic and demographic strata e.g. poor, better off, literate, illiterate, men and women, implying that all the groups benefited from the intervention. The reasons behind the reductions of expenditure on treatment may be either that elderly persons paid less visits to health care providers due to less problems experienced or that they successfully managed the health problems by better-informed self-care. Research have shown that adherence to health education has the potential to increase perceptions of self-efficacy, decrease pain, reduce depressed mood and result in fewer visits to physicians [5, 36]. Moreover, self-help programs show effectiveness in reducing the burden of illness, improving health-related quality of life and reducing health care costs [36]. It might be argued that since the elderly persons in the control area were relatively better off than those from the intervention area, higher expenditure might be the norm. However, at baseline, no significant difference was noted between the compliant and control groups in terms of expenditure on treatment of arthritis-related illness. The benefits of declining health care expenditure in the compliant group may have substantial implications for household economy, especially among the poor, since health care costs make poor people even more vulnerable [37].
With regard to health-seeking behavior, findings from the present study show that, in general, treatment from informal paraprofessionals and unqualified health care providers together was a more frequent form of management along with self-care as also found in other studies [24]. The role of informal health care providers is profound in primary health care services in Bangladesh [38]. As elderly persons in Bangladesh do not receive adequate help from the formal health care services, they mostly depend on informal local health care providers [39]. However, the majority of these health care providers do not possess any formal training [24].
The analysis of non-compliance in this study aimed to examine the profile of the non-compliant group, i.e. those who did not comply with the health education instructions. After 3-month interval following the intervention, about a quarter of the elderly persons reported that they did not follow the instructions that were provided. The analyses show that the non-compliant participants mostly comprised of relatively old, women and illiterate. Other research also reports that non-compliance with exercise programs is common among older age groups [40]. Hence, it is important to do follow-ups in order to keep this group involved. Although this study provides a profile of the non-compliant group, further research is required to understand the reasons of non-compliance.
Some methodological aspects of the study should be noted. For instance, the severity of illness, frequency of visits to the health care providers and what was practiced as self-care were not considered during data collection. All of these could be useful indicators to examine effects of intervention. Since the prevalence of arthritis-related illness was considered based on self-reports and no objective assessment was done, there is also a possibility of misreporting. However, to minimize misreporting of illnesses, the recall period was limited to 1 month and a commonly known local word was used to make it possible to identify these illnesses. Previous research suggests that using local language and limiting recall period to a short period minimizes misreporting of self-reported illnesses [41]. The strengths of the study are the high response rate of the study participants and that a short interval was allowed after the intervention before conducting the post-intervention survey.
Our research as well as others demonstrates that health education is an essential component for any individual regardless of age [42]. Distribution of knowledge regarding management and prevention of illness among individuals in the community reduces the burden on formal health systems and can potentially improve quality of life. Finally, the aim of the Bone and Joint Decade is to empower patients and the community to take a more protective role in preventing and improving self-managing skills of bone and joint diseases. Hence, community-based initiatives that contribute to the improvement of knowledge regarding management and prevention of joint diseases may be expanded in order to reduce the burden of such illness as well as to achieve the aims of the Decade.
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Conflict of interest statement |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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This study was done under the auspices of PHILL funded by the European Commission (ICA4-CT-2002-10035). We would like to thank the field investigators for collecting the data and the elderly persons of the study villages for their cooperation at various stages of the study. Finally, we are also grateful to the Swedish Institute for providing financial support to A.K.M.M.Rana.
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Received on April 10, 2006; accepted on December 20, 2006
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