Bangladesh is experiencing the third phase in demographic transition that has produced a big number of youthful population and increasing population of older population (Razzaque et al., 2010). At present, the population of Bangladesh is 152518015 million, where percentage of the 60+ elderly populations is more than 6.7 (BBS, 2010). The median age is 23.3. The life expectancy at birth is 70 years for the total population (Index Mundi, 2012).
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Epidemiologic transition generally refers to the shift from acute, infectious and deficiency diseases to chronic, non-communicable diseases (NCDs). This is usually reflected in the mortality and morbidity pattern. A study done at Matlab, a rural area of Bangladesh by Karar et al. (2006) found that in 20 years (1986-2006), there has been a massive alteration in mortality profile from acute infectious and parasitic diseases to NCDs, degenerative and chronic diseases. During this period there was great reduction in mortality due to diarrhea and dysentery and respiratory infections (except tuberculosis) and increase in mortality due to NCDs such as cardiovascular and cerebrovascular diseases and malignant neoplasms. It has been predicted further that the mortality due to NCDs will increase greatly in the next two decades whereas number of deaths due to communicable diseases will decrease. The reduction in the child and infant mortality was explained by improvement in maternal education, primary health care services, water and sanitation practice, use of oral rehydration solution and high immunization coverage. The rise in mortality due to NCDs was explained by possible change in diet and lifestyle (Karar et al., 2006)
Due to demographic and epidemiologic transitions, elderly population has rapidly increased and so has their morbidity (Biswas et al.,2006). As Bangladesh is going through both epidemiologic and demographic transitions, there are being reductions in fertility and mortality rates that have resulted in increased life expectancy among the population. This means there are increase in older people in the population and increase in prominence of chronic conditions among these elderly. Chronic diseases usually accumulate with ageing and are presented as multiple morbidities. Multimorbidity in the same person refers to co-occuring of various harmful medical conditions. Khanam et al( 2011) found higher prevalence of multimorbidity among elderly (>60years old) in a rural place in Bangladesh called Matlab. It was around 53.8% among the study population. Arthritis and hypertension occurred the most commonly. Multi-morbidity was higher in women than men and in non-poorest (Not poorest. Socio-economic status was divided into two parts: poorest and non-poorest). The same study found that multimorbdity can also be affected by living and working environment, lifestyle pattern, socio-economic status, behavioral risk factors and gender. From the prevalence rate, one can estimate the real burden in the general rural population. It shows every elderly in the population is suffering from at least one chronic condition.
This means the health sector of Bangladesh should be prepared to deal with the increasing NCD cases. Through improved diagnostic facilities and better referral system, NCD patients can be helped. Health policy should be updated accordingly to allocate bigger budget to facilitate health services for the elderly (Karar et al, 2009).
Formal and informal care
Study by Biswas et al. (2006) focused on strategies elderly people use to cope in case of illnesses. As perception of ill health and severity of illness varied from one elderly to another, this study revealed that elderly people avoided visiting a qualified doctor until severity of illness deteriorated because of the associated cost. Even in situations when these qualified doctors are consulted, there are rare follow up visits, again due to the financial barrier. Therefore, elderly people often prefer going to traditional healers (eg. Kobiraj). Huge trust is placed on this type of healers’ treatments. Often when these treatments bear no result, trust is not lost and the lack of result is often attributed to “ill fate” (Biswas et al., 2006).
On the other hand, if the disease is assumed to be of low severity, self-care is practiced, that is home remedies are undertaken and drugs are bought over the counter at the drugstore by a family member. However decision making process comes into play if severity of the disease increases and is influenced by various factors such as decision about where to take the patient, who to go with the patient and how to manage money. Out of all these factors, the financial issue grabs the bigger priority. Usually a service provider that can ensure flexibility in the treatment cost and payment options is picked. Payment is done with the help of savings, loan from adult children, friends or relatives or sometimes NGO and selling of livestock and poultry (Biswas et al,2006)..
In Bangladesh, elderly people depend largely on care provided by the family members. It’s a common practice for family members to look after elderly persons. Sometimes even when there’s a will, family members cannot take proper care of the elders due to financial constraints. Furthermore, adult children of that family often migrate somewhere else to find work, leaving the elderly behind. In urban areas, this scenario is worse. Along with the men of the family working, there’s women’s participation in labor force due to which the elderly are also neglected. (Jesmin & Ingman, 2011). There is stigmatization of Older women who visit male doctors (who aren’t direct family members) due to which women stay back home even when they are ill and suffer even more.
From the government’s side there is meager amount of Old Age allowance and pension for the elderly. This amount hardly covers up treatment costs. There are institutional cares provided by the NGOs in different parts of Bangladesh. But this are being unable to meet the increasing demands of increasing number of the aged people (Hossain et al, 2006). We can see that modernization and urbanization results in migration of young adults and inclusion of women labour force. Elderly people are neglected. There is poor health care service for them. Financially they become weak. They begin to lose their functional ability with age and become dependent on others. But ageing is a natural process for which they are not responsible. Therefore it’s our duty to provide them with utmost care, respect and security.
Ageing population and functional ability:
When we talk about functional ability of elderly population, we mean if the elderly person is functionally able to perform daily tasks. We draw conclusions based on physical and cognitive incompetence. But we often neglect the context to which the person belongs. It’s environmental and socio-cultural factors. Urban and rural areas vary highly in terms of these factors. There are also gender differences as to certain tasks performed by men and women are bound by social norms and generally don’t overlap. Domestic work typically belongs to women’s domain and public chores belong to men (Kabir et al., 2001). If we picture a rural context, we can understand how environment plays a role as a barrier to functional ability. Toilets are usually placed outside the home, at a distance and water source is far from toilet. An elderly person has to go a nearby pond or have someone carry the water to them (Ferdous et al., 2009b). Older women who visit male doctors (who aren’t direct family members) are stigmatized (Biswas et al.,2006). Therefore there’s a tendency of women staying home and not seeking help. As a result, with time, they become more ill and functionally disable to perform daily activities. Studies have shown elderly women to have higher prevalence of illness then elderly men (Kalam et al., 2006). Studies done on nutritional status of elderly people have found nutrition to play a vital role in performing daily activities. Elders with poor nutritional status have more limitations in their physical function than elders who are well nourished. Good nutritional status has been associated with better cognitive function as well. (Ferdous et al., 2009a). As the elderly population is increasing in number, it’s our responsibility to see how they can achieve healthy ageing. There can be many suggestions like having high nutritious diet, improved infrastructure like building ramps in hospitals, treatment at early stage etc but whether these can or will be implemented is highly dubious. Bangladesh is poverty stricken country and inspite of National Elderly Policy being present, its goals of protecting elderly are inactive (Unnayan Onneshan, 2011). Poverty is beyond our control but policy is something we can take care of. Policies incorporating elderly issues should be implemented and our approaches towards the ageing population should be in such a way that this population is benefited, secured and meets demand of basic needs.
“The Prevention of Diabetes, Bangladesh” Program from life course perspective
In the developing countries, there is a growing concern and awareness of the increasing incidence of Non Communicable Diseases (NCDs) (Darton-Hill et al., 2004). More than 40% of all people with diabetes in least developed countries live in Bangladesh (Novonordisk, 2012). Type 2 Diabetes Mellitus (T2DM) is highly preventable and its occurrence can be delayed. The main focus of prevention of this disease is mostly on modification of lifestyle patterns of adults. Behavior such as unhealthy diets and lack of physical activity particularly receives high attention. But there is huge evidence now that supports the fact that a lot of the risks associated to T2DM arise during fetal stages of life. At this stage, these factors are characterized by maternal’s nutritional status, presence or absence of diabetes and fetal and post-natal environment. This indicates that disease process advances throughout life course. There are also evidences showing that these risks begin during fetal stage and progresses till old age (Darton-Hill et al., 2004). A study on genetic changes has revealed high chances of diabetes being activated in the womb. As environmental, genetic and biological factors can be passed from generation to generation, a life course approach is therefore critical to lessen this intergenerational transmission of diabetes. (IDF, 2011a).
“The primary prevention of diabetes, Bangladesh” is a program by the World Diabetes Foundation, partnering with Diabetes Association of Bangladesh (DAB). The program ran for 4 years 10 months (January 2007-October 2011).The objective of the program was “to define and pilot strategies for lifestyle intervention in the primary prevention of diabetes in Bangladesh and to develop guidelines for a long term National Diabetes Prevention Programme” (http://www.worlddiabetesfoundation.org/composite-1144.htm). The program will be elaborately discussed from a life course perspective in the following sections.
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The main focus of this program was on lifestyle interventions. They produced six leaflets that described steps of prevention of diabetes at different levels of society. The levels targeted were individual, family and friend, social/cast level, health service provider, employer and media. Messages about risk factors of diabetes were recorded and used during training sessions. Folk singers, school teachers and religious leaders were involved in delivering messages. Doctors, community counselors, employees and employers were trained in diabetes awareness and lifestyle interventions. Around 87 students took part in diabetes educator program (where the students got trained on educating others about diabetes and the associated life style interventions). All these activities suggest that the focus has been on adults. Though it has not been mentioned which risk factors this program considered, but hoping they have included the three most common behavioral risk factors such as obesity, lack of physical activities and smoking. Numerous studies have shown these risk factors to be associated with type 2 diabetes.
From Fig. 1 (Annex) it can be seen that in adult life, the risk is the risk that accumulates from fetal life, infancy and childhood, adolescence. This accumulated risk is a cumulative risk, which
means the consequences are even getter and detrimental. The figure also shows that the risk actually begins before conception of the life. Therefore, interventions should be focused on mothers planning to conceive, alongside focusing on every stage of the life of a person from fetal to adult. This program has not focused on pregnant mothers, let alone pre-conception stage.
For preconception phase, the women could be educated that pregnancy can act as a risk factor for the development of diabetes. They could be advocated to take balanced nutrition and refrain from smoking. They could also help their partners to stop smoking. In pregnancy phase, there could be intervention regarding uptake of appropriate nutrition. There could be intervention regarding management of gestational diabetes to lessen the transference of T2DM to the fetus. Mothers with gestational diabetes and the ones with child of low birth weight could also be suggested to have follow-up check-ups (IDF, 2011b)
There were no interventions for infancy and childhood period in this program as well. As part of this program, exclusive breastfeeding could be promoted for the first six months. Mothers could be educated and supported on appropriate nutrition for their infants. For school going children, exercise and healthy eating could be promoted (IDF, 2011b). This program also didn’t incorporate interventions targeting the adolescence. Adolescents are important group of people who practice unhealthy eating, physical inactivity and lead a sedentary life style. Smoking among adolescents is very popular among Bangladesh. They also should have been a target of this prevention program. Studies have shown that the age of onset of diabetes has shifted from working age group to adolescents. Therefore more women that belong to reproductive age group are having diabetes and their pregnancies are being complicated by diabetes (International Diabetes Federation, 2011b). Therefore lifestyle interventions should have been applied to this population. Healthy diets and awareness about smoking could be promoted at schools and through educational programs. Alongside anti-smoking programs, awareness regarding illicit drug use and alcohol could be built up as well. Adolescents could be well informed about the consequences of consuming alcohol. To combat drug use, children and adolescents could be informed about the physical, psychological and social effects of using drugs. Both adolescents and adults could be taught ways to build confidence and self esteem, which can empower them to say “no” to drugs (WHO, 1999).
At every stage of life, there could be strong emphasis on physical activity. Lack of it, along with other factors, can predispose an individual to T2DM. It has also been shown to reduce gestational diabetes (Dornhorst et al., 1998). The program could encourage physical exercise in children by accommodating it in the school curricula and family activities. Also supportive environments could be helped to be built for all ages to engage in physical activity.
Some life course factors such as socio-economic cannot be changed. Behavioral risk factors can be changed. This program should have aimed at all the stages of life course model to be able to cover wider population and reach greater success in preventing diabetes.
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