Self Reported Health Problems in Bangladesh-Evidence from a Large Scale Survey

1. Self Reported Health Problems in Bangladesh-Evidence from a Large Scale Survey Professor M.A. Razzaque Deptt. Of Statistics, Rajshahi University, Bangladesh & Dr. Md. GolamMostofa Deptt. Of Population science & HRD, R.U.

2. Introduction • Health status on the basis of self-reporting become popular and has been recognized in lower income society like Bangladesh. • A considerable number of researches confirm the usefulness of culturally appropriate, easily recorded self-reported health (SRH) assessments as indicators of underlying health status of a survey population (Rahman et al. 1999; Zimmer et al. 2000; Yu et al. 1998).

3. Introduction (Contd.) • Statistical significance of differentials in self- reported health (SRH) measures of Bangladesh Urban Health Survey (BUHS)-2006 have been studied in this piece of work. • The measures included in the survey are: Assessments of activities of daily living (ADL), personal health status, and recent experience of serious illness, recent injuries, adult nutrition status, hypertension, and diabetes. • The last three SRH measures are related with anthropometric assessments and biomarkers.

4. Introduction (Contd.) • The modified and abbreviated ADL scale was used at the data gathering stage of the BUHS-2006, where ADL assessment was undertaken in the context of general population survey covering the age range 10-59. • Generally ADLs are a set of basic everyday activities or tasks that an individual should be able to perform in order to maintain independence in self-care and participate in their routine social, occupational, and family activities.

5. Introduction (Contd.) • The most common ADL measures are based on Katz Activities of Daily Living Scale (e.g. ability to eat, bathe, dress, transfer from seated to a standing position, use of the toilet without assistance). • In the modified and abbreviated scale included four additional ADL items measuring dimensions of functionality capturing “strength and gross mobility” and “range of motion”.

6. Introduction (Contd.) • Urban Health Survey -2006 was the first of this kind of survey in Bangladesh. The survey obtained information through a micro-level interview of communities, households and individuals throughout the city corporations and a sample of district municipalities. • One of the main objectives of the survey was “To identify vulnerable groups and examine their health profile and care seeking behavior”. • In this article we have tried to identify the vulnerable groups and their association with some risk factors. We have also calculated the numerical value of the risk of being vulnerable in relation to some risk factors.

7. Methodology • For testing the significance a particular proportion in a univariate distribution of a categorical variable, we use Z test. • If the population proportion of a particular category is , then the necessary test statistic is Which follows the standard normal distribution, where p is the sample proportion of the given category, n is total observations and q=1-p.

8. Methodology (Contd.) • Equality of proportion tests are performed with two proportions considering the variation in residence, marital status and educational level. • When the sample observations based on which the population proportions are estimated are large, Z- statistic is used to test the equality between the proportions of the categories. The test statistics is defined as which follows the standard normal distribution.

9. Methodology (Contd.) • Here p1 is the estimate of the population proportion of the first category and p2 is the estimate of the population proportion of the second category. • n is the total number of observations in the combined group i.e. n=n1+n2, n1 and n2 are the sample sizes of the two groups. • The combined proportion and q=1 – p.

10. Methodology (Contd.) • Let us abbreviate the group of person having Health related functional difficulties as HRFD and having no health related functional difficulties as Non-HRFD. We have used these abbreviations in tables for computing odds ratios. • Odds Ratios: A condition, physical characteristic, or behavior that increases the probability (Risk) that a currently healthy individual will develop a particular disease is termed as risk factor for that disease.

11. Methodology (Contd.) • In this study we have considered some Environmental and Social risk factors in relation to SRH difficulties. • Since a large scale survey is Cross-sectional in nature (here individuals are concurrently classified as diseased or disease-free and exposed or non-exposed at a single point of time), prevalence rates are compared between those exposed and those not exposed to certain risk factor. • In this type of study outcomes are evaluated in terms of the Odds Ratio (OR) and the chi-square test.

12. Methodology (Contd.) The odds ratio provides a measure of the strength of the association between the dichotomous exposure and the outcome variables. This ratio compares the odds that exposed and non-exposed individuals will have the disease. The odds ratio is calculated by the formula given below: Where,

13. Methodology (Contd.) • The larger the value of OR, the stronger the association between the disease in question and exposure to risk factor. • The value of OR close to 1 indicates that the disease and exposure to the risk factor are unrelated. • Values of OR less than 1 indicate a negative association i.e. there is a protective effect between the risk factor and the disease.

14. Methodology (Contd.) • Attributable Risk (AR) defines the excess risk of disease that can be ascribed to exposure to the risk factor, over and above that experienced by people who are not exposed. • It thus provides an estimate of the number of cases of the disease that might be prevented if exposure to risk factor were eliminated and is useful for determining the magnitude of the public health problem posed by such exposure. • Attributable risk can be calculated by the formula:

15. Methodology (Contd.) Population attributable risk (PAR) is a measure of excess risk of disease in a population that can be solely attributed to the risk factor. PAR= AR*P(exposure).

16. Results The description of the hypotheses that we tested and the conclusions drawn from the test results are presented below: • The first hypothesis we tested is regarding health related functional difficulties among currently married females living in urban slums and non-slums.

17. Results (Contd.) • Let π1 be the proportion of currently married females living in slums and having health related functional difficulties, and • π2 be the proportion of currently married females living in non-slums and having health related functional difficulties. The computed value of the Test statistic

18. Results (Contd.) • The null hypothesis is rejected. • So we can infer that there is significant difference in the health related problems among the proportion of currently married females living in slums and non-slums. • Thus it is revealed that same types of health facilities are not available in slum and non-slum areas of Bangladesh. • We can also say that dissemination of health knowledge and facilities throughout the country are not just. As in the case of economy there are lots of disparities among the slum and non-slum population.

19. Results (Contd.) • It is to be noted that health sector is one of the areas where Bangladesh is ahead of its neighboring Asian countries. The government of Bangladesh also were praised and prized by the United Nations in this regard, still there are disparities in health facilities of the slums and non-slums of the urban areas. • Finally we can infer that public health facilities are not evenly distributed in Bangladesh. Further to find the contribution of this risk factor (residence type) we conducted the following risk analysis.

20. Results (Contd.)

21. Results (Contd.) • From the above risk analysis we can comment that association exists between health related functional difficulties and type of residence. People living in the slums are 1.31 times more vulnerable to HRFD than those living in the non-slums. • Risk of having HRFD in the slum is increased by approximately 0.032. Assuming that P(HRFD) is 0.25, based on the report of medical literature the PAR=0.008 i.e. the excess risk of HRFD in the slum population is 0.008.

22. Results (Contd.) • Further Attributable Fraction in Exposed group=AR/P(HRFD|Exposed)=0.032/0.217= 0.15 . So we can say that 15% of the excess HRFD that occurred among those exposed were attributable to the risk of being the residents of slums. • Having the above findings we are interested to know whether currently married women are more vulnerable to health related problems than other categories of women. • In this case we have compared the group with the divorcees, because aged and divorces in our country are currently enjoying a few economic safety net programmers.

23. Results (Contd.) • For this we have developed the hypothesis regarding functional difficulties of currently married women and divorcees living in the same type of residential area. • Let π1 be the proportion of currently married females living in slums and having health related functional difficulties, and • π2 be the proportion of divorcee females living in slums and having health related functional difficulties.

24. Results (Contd.) The computed value of the Test statistic

25. Results (Contd.) • The null hypothesis is rejected. So we can infer that there is significant difference in the health related problems among the proportion of currently married females living in slums and the proportion of divorcees in slums. • We can say that in slums the proportion of currently married females having health related functional difficulties is significantly higher than that of divorcees in the slums. • Huge burden of the family on the currently married females of the slums may have contributed for this significant difference. We must note that these categories of females are to take care of their children in addition to their household works.

26. Results (Contd.) • Also these women sometimes are to work in garments or as maid. So it is clear that the nature of the life style of the currently married females in slums may have contributed for having more health related problems. • Further the extent of help given by the husbands of the currently married females of slums may be not up to the expectation. • From these findings we can infer that currently married women in slums need special public health programs. • To verify this finding we conducted the similar test of significance for the same categories of respondents living in non-slums and having health related problems.

27. Results (Contd.) • Let π1 be the proportion of currently married females living in non-slums and having health related functional difficulties, and • π2 be the proportion of divorcee females living in non-slums and having health related functional difficulties. The computed value of the Test statistic

28. Results (Contd.) • We are at the same conclusion that currently married women of non-slums are more vulnerable to health related problems than the divorcees of the non-slums. • Since we have concluded that public health facilities are not evenly distributed in slums and non-slums in Bangladesh, so special public health programs for currently married women are to be launched to keep this sect of population physically fit as far as possible. • Because this is the age group of childbearing and child caring. The health of our future children heavily depends on this group. The government should also think about the safety net programs for this vulnerable group.

29. Results (Contd.)

30. Results (Contd.) • There is protective effect of marital status i.e. currently married women are 0.75 times less vulnerable to HRFD than Divorcees, Separated and Widows. • It is to be noted that many divorcees are under the safety net programs of the government. May be these have contributed to have less functional difficulties among the divorcees. • To test this hypothesis we have taken the proportions of divorcees with health related functional difficulties from slums and non-slums and proceeded with the following test of significance.

31. Results (Contd.) • Let π1 be the proportion of divorcee females living in slums and having health related functional difficulties, and • π2 be the proportion of divorcee females living in non-slums and having health related functional difficulties. The computed value of the Test statistic

32. Results (Contd.) • The test of significance clearly indicates that there is no significant difference in proportions between the divorcees of slums and non-slums having health related functional difficulties. So the safety net programs for the divorcees and their less-burden may have positive impact on the general health of the divorcees in the society. • Thus we can again say special public health programs are needed for the currently married women in Bangladesh. These public health programs should also include the family planning issues, otherwise the country will be further burdened by its population growth. Public health education programs should also be continued to impart knowledge to reduce health related problems.

33. Results (Contd.) • To see the impact of the public health education we studied the impact of education on the health related problems of females in slums having education “Secondary incomplete” and “Secondary or higher” levels. We proceed with the following test of significance. • Let π1 be the proportion of females having health related functional difficulties with incomplete secondary level of education and living in slums, and • π2 be the proportion of females having health related functional difficulties with secondary and higher education and living in slums.

34. Results (Contd.) The computed value of the Test statistic • We noticed from the test of significance that education has impact on the health related functional difficulties in women. • So we can say spread and upliftment of education in general and transmission of health education through public health programs for females will contribute a lot in reducing health related functional difficulties.

35. Results (Contd.)

36. Results (Contd.) • Association exists between health related functional difficulties and level of education. • People who have not completed secondary education are 1.34 times more vulnerable to HRFD than those with secondary and higher education. • For people who have not completed secondary education, her risk of having HRFD is increased by approximately 0.05. • Assuming that P(HRFD) is 0.25, based on the report of medical literature the PAR= 0.01 i.e. the excess risk of HRFD in the population who have not completed secondary education is 0.01.

37. Results (Contd.) • Further Attributable Fraction in Exposed group =AR/P(HRFD/Exposed)=.047/0.221= 0.21 . So we can say that 21 % of the excess HRFD that occurred among those exposed were attributable to the risk factor “Incomplete Secondary level education” • We have also studied the impact of economic status on the health related functional difficulties. The results are presented below.

38. Results (Contd.) We have also studied the impact of economic status on the health related functional difficulties. The results are presented below.

39. Results (Contd.) • High Association exists between health related functional difficulties and economic condition . People who are at the poorest quintile are 1.81 more vulnerable to HRFD than the richest. • Risk of having HRFD of the poorest is increased by approximately 0.08. Assuming that P(HRFD) is 0.25, based on the report of medical literature the PAR= 0,01 i.e. the excess risk of HRFD in the poorest population is 0.02.

40. Results (Contd.) • Further Attributable Fraction in Exposed group =AR/P(HRFD/Exposed)=.081/0.243= 0.33 . So we can say that 33 % of the excess HRFD that occurred among those exposed to risk factor were attributable to the risk of being poor.

41. Discussion and Conclusion • The study reveals that there is significant difference in the health related problems among the proportion of currently married females living in slums and non-slums. • From the risk analysis it is revealed that association exists between health related functional difficulties and type of residence. People living in the slums are 1.34 times more vulnerable to HRFD than those living in the non-slums.

42. Discussion and Conclusion(Contd.) • It is to be noted that health sector is one of the areas where Bangladesh is ahead of its neighboring Asian countries. • The government of Bangladesh also were praised and prized by the United Nations in this regard. • To maintain the achievements public health facilities are to be evenly distributed in Bangladesh.

43. Discussion and Conclusion(Contd.) • We noted that there is significant difference in the health related problems among the proportion of currently married females living in slums and the proportion of divorcees in slums. • We can say that in slums the proportion of currently married females having health related functional difficulties is significantly higher than that of divorcees in the slums. • Huge burden of the family on the currently married females of the slums may have contributed for this significant difference.

44. Discussion and Conclusion(Contd.) • We must note that these categories of females are to take care of their children in addition to their household works. • Also these women sometimes are to work in garments or as maid. • So it is clear that the nature of the life style of the currently married females in slums may have contributed for having more health related problems. • Further the extent of help given by the husbands of the currently married females of slums may be not up to the expectation. • From these findings we can infer that currently married women in slums need special public health programs.

45. Discussion and Conclusion(Contd.) • Since we have concluded that public health facilities are not evenly distributed in slums and non-slums in Bangladesh, so special public health programs for currently married women are to be launched to keep this sect of population physically fit as far as possible. • This the group of childbearing and child caring age. The health of our future children heavily depends on this group. • The government should also think about the safety net programs for this vulnerable group. It is to be noted that many divorcees are under the safety net programs of the government.

46. Discussion and Conclusion(Contd.) • The test of significance clearly indicates that there is no significant difference in proportions between the divorcees of slums and non-slums having health related functional difficulties. • The safety net programs for the divorcees and their less burden may have positive impact on the general health of the divorcees in the society. • Thus we can strongly recommend for special public health programs the currently married women in Bangladesh.

47. Discussion and Conclusion(Contd.) • These public health programs should also include the family planning issues, otherwise the country will be further burdened by its population growth. Public health education programs should also be continued to impart knowledge to reduce health related problems.

48. Discussion and Conclusion(Contd.) • We noticed from the test of significance and risk analysis that education has impact on the health related functional difficulties in women. • So we can recommend for spread and upliftment of education in general and transmission of health education through public health programs for females will contribute a lot in reducing health related functional difficulties.

49. Discussion and Conclusion(Contd.) • Finally there is protective effect of marital status i.e. currently married women are 0.75 times less vulnerable to HRFD than Divorcees, Separated and Widows. • The great advantage of marriage bonding specially in Asian region should be continued and if necessary special packages can be introduced specially for the poor to continue their married life. Because the married life of the poor are sometimes hindered by economic hardship.

50. Discussion and Conclusion(Contd.) • It is to be noted that high association exists between health related functional difficulties and Economic condition. People who are at the poorest quintile are 1.81 more vulnerable to HRFD than the Richest.