Bangalore, karnataka proforma for registration of subject for dissertation

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1.Name of the candidate and address

Dr.RockBrittoD. Post Graduate Student Department of Community Health St. John’s Medical College Sarjapur Road Bangalore-560034

2. Name of the Institution

St. John’s Medical College, Bangalore

3. Course of study and subject

MD-Community Medicine

4. Date of Admission to the course

16th April, 2012

5. Title of the topic

Prevalence of chronic disease and health seeking behaviour among elderly persons in an urban underprivileged area, Bangalore city

6. Brief Resume of the Intended Work

6.1—Introduction and need for the study:

The proportion of elderly persons in the Indian population is high, and rising. The population living in urban areas is rising, as also the proportion of population in urban underprivileged areas. Elderly persons living in urban underprivileged areas represent a vulnerable group.

The burden of chronic disease in India is high, with high rates of morbidity and mortality, especially in the elderly, since the prevalence of chronic disease rises with age. It is known that chronic disease is preventable, with 80% of premature heart disease, stroke and diabetes being amenable to prevention (1).With early detection, treatment and support, the burden of chronic disease can be reduced(2).

The health seeking behaviour of the elderly is a determinant of their access to health care(3).Good heath seeking behaviour provides an opportunity for addressing the health problems of elderly persons.

The World Health Day theme for the year 2012 is "Good health adds life to years" (4).In keeping with the theme, this study aims to estimate the prevalence of chronic disease and assess health seeking behaviour among elderly residents of an urban underprivileged area. This is a step towards developing strategies aimed at improving their health status and quality of life

6.2 – Objectives

1. To estimate the prevalence of selected chronic diseases among elderly persons residing in an urban underprivileged area in Bangalore city.

2. To assess the health seeking behaviour of elderly persons residing in the study area.

6.3 – Review of Literature

Literature has been reviewed under the following heads;

a. Elderly population in India

b. Urbanisation, Urban Underprivileged population

c. Chronic disease, globally and in India

d. Chronic disease among elderly in India.

e. Health seeking behaviour among elderly in India.

a. Elderly population in India

The major determinants of population ageing are declines in fertility, mortality and increase in life expectancy (5).The elderly population in India, defined as those above 60 years of age forms 7.5% of the total population currently(6).It is projected that this will go up to 11.9 %by 2031 and 17.3% by 2051(7).Within the next five years, it is expected that the number of adults aged 65 and over will outnumber children under the age of 5, and by the year 2050, older adults will outnumber children under the age of 14(8).

b. Urbanisation, Urban Underprivileged population:

The proportion of urban population in the world has reached almost 50%, estimated to be 65% or more by 2025(9).In many developing countries, the vast numbers of people leaving rural areas for urban places reside in the unsanitary conditions of shantytowns or squatter settlements on the fringe of large cities, where public health problems are many(10).

About 30% of Indian population reside in urban areas, it was estimated that 34% of urban population were residing in slums in India in 2005(11).According to the Indian Government, the number of people living in the slums of India has doubled in the past two decades. India’s slums population had risen from 27.9 million in 1981 to 61.8 million in 2001(12).

c. Chronic disease - Global

The WHO Global status report on non communicable diseases 2010 (GSR 2010) showed that Non-Communicable Diseases (NCDs) are the biggest cause of death worldwide. More than 36 million people died from NCDs in 2008, mainly cardiovascular diseases (48%),Cancers (21%),Chronic respiratory diseases (12%) and Diabetes (3%)(13).Earlier estimates from the Global Burden of Disease Study projected that the number of deaths attributable to chronic diseases would rise from 3·78 million in 1990 (40·4% of all deaths) to 7·63 million in 2020 (66·7% of all deaths) (14).

d. Chronic disease - India

India is experiencing a rapid health transition, with large and rising burdens of chronic diseases, which accounted for 53% of all deaths and 44% of disability-adjusted life-years (DALYs) lost in 2005(14). In 2010, 53% of deaths were due to NCD’s, of which Cardio Vascular Diseases(CVDs) accounted for 24%, Respiratory diseases 11%, Cancers 6%, Diabetes2% and Other NCDs 10% (13).Studies show that chronic disease is a problem in urban and urban underprivileged areas. A Faridabad study had reported 15.8% prevalence of hypertension among women in slums(15).A Surat slum based study showed that the prevalence of hypertension among the elderly was found to be 73.3%(16).A Nagpur slum based study showed that the total prevalence of Diabetes among the elderly was found to be 17.5% (17).

e. Chronic disease among the elderly in India

A study in 13 urban slums of Bangalore city showed that 82.9% of the elderly persons reported suffering from at least one illness. The most important conditions found wereCataract 72.9%,Anaemia12.6%,Osteoarthritis 6.2%, chronic bronchitis 6.1% and Hypertension5.1% (18).A study among the elderly in a rural area of Tamil Nadu identified common existing medical problems such as like anaemia, arthritis, cataract, hypertension, and diabetes mellitus. It was found that 72.4% of the study population was suffering from at least one illness(19).A rural based Andhra Pradesh verbal autopsy study showed that among elderly the mortality pattern is as follows: CVDs– 39%, External causes like accidents– 8%, Infectious diseases– 9%, Cancer–7% and Respiratory diseases–6%(20).

f. Health seeking behaviour among elderly in India:

Health seeking behaviour is defined as any activity undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy(21).

A rural based study among the elderly in Karnataka by Shailendra Kumar B. Hegde showed 91.7% sought health care for their chronic illness and 85.65% sought health for their acute illness(22).A Tamil Nadu based Study showed that 79% of the aged persons sought care for their ailments. Analysis showed that aged people in the urban region sought health care marginally less than those in the rural region (OR:0.94, p<0.05)(23).

A Study by S.Vijayakumar in rural India showed that about 30% of the elderly suffering from illnesses seek treatment and over 55% don’t receive even minimum care and personal help(24).However, in Kerala, 90% of the elderly, irrespective of sex, consult (90% allopathic, and 10% ayurvedic/homeopathic) doctors. Recognition of disease by elderly, his/her response to it, reaching a provider, or changing the provider depends on several factors such as age, literacy, poverty, social activity, and status of health, marriage, and socio-economic status(25, 26).

7--Materials and Methods

7.1 Study design- Cross Sectional study.

7.2 Study area - LaxmanRao Nagar slum in Bangalore cityconsisting of total population of about 8000 in 36streets .

7.3 Sampling unit – An elderly person equal to or above 60 years who is a resident of the LR Nagar area for more than one year.

7.4 Sample size– 253 elderly persons in the age group of equal to or above 60 years, assuming prevalence of chronic disease (from a similar study) is 72.4%, with a precision of 5.8% (8% of 72.4%) and 95% confidence. Sample size was calculated using the formula n = Z2pq/d2 where,

z = relative deviate (1.96 at 95% confidence),

p = prevalence (72.4%),

q = (100 – p),

d = precision (5.8%).

Using the formula, n = 228.

After calculating 10% non response rate, sample size for study = 253
7.5 Sampling method –Systematic Random Sampling, with sampling interval (SI) of 2.5 (640/253).The first subject will be selected randomly, subsequent subjects will be identified by serially adding SI and rounding off to the nearest whole number.

7.6 Study period – January 2013 to December 2013

7.7 Inclusion criteria – elderly person who is residing in the study area continuously for more than one year

Exclusion criteria –An elderly person who is seriously ill, orunable to give information.
7.8 Operational definition of certain terms used in the study:

a. Elderly person :- a person who has completed 60 years. Government of India adopted ‘National Policy on Older Persons’ in January, 1999 defines ‘senior citizen’ or ‘elderly’ as a person who is of age 60 years or above (27).

b. Chronic diseases:- Includes Hypertension, Coronaryartery disease, Stroke, Bronchial asthma, COPD, Cancer, Diabetes, Cataract, Deafness, Musculoskeletal Disorders, Mental illness, Anemia, Urinary problems (28).

Each of the diseases listed above will be identified as follows:

c. Hypertension:-Sphygmomanometric examination, with a resting systolic blood pressure (SBP) of 140 mmHg or greater and/or diastolic blood pressure (DBP) of 90 mmHg or greater in adults and/or who are taking antihypertensive medication (29).

d. Diabetes Mellitus – Glucometric examination, random plasma glucose value >= 200 mg /dl and/or the person is on oral anti-diabetic drug or Insulin(30).

e. The following conditions will be identifiedbased on self report/ clinical examination

Coronary artery disease, Stroke, Bronchial asthma, COPD, Cancer, Musculoskeletal problems including osteoarthritis, Mental illness, Anemia, Urinary problems

Cataract – clinical examination using a torchlight

Hearing impairment – clinical examination by whisper test
f. Health seeking behaviour:Respondents will be asked about any illness (communicable or non-communicable) in the 3 months prior to interview. Information on types of healthcare sought, reasons for seeking care by the subject will be obtained. Reason for not seeking treatment will be documented
7.9 Method of Collection of Data

a. Local leaders will be seen and community consent will be requested.

b. An Interviewer-administered questionnaire will be developed to collect information on demographics, chronic disease and health seeking behaviour among the elderly. After validation, pre testing will be done in a non study area and necessary modifications will be made.

c. A map of the study area will be obtained.

d. Starting from the first house, the first elderly person will be selected randomly by currency method.

e. After establishing a rapport with the family, an informed written consent will be obtained from each individual prior to interview.Following this, the subjects identified will be administered the questionnaire, and will be subjected to clinical examination including sphygmomanometry and glucometry

f. Subsequently 253 elderly individuals will be included in the study by the systematic random sampling method
7.10 Analysis

The data collected will be entered in Microsoft Excel and analysed using SPSS version 16 and Epi info version 7 software. The demographic data will be initially analyzed using frequencies, means, median and standard deviations. Analysis will also be performed at univariate and multivariate levels, studying individual variables or groups of variables. For this, tests of significance such as Chi square test, ANOVA or logistic regression will be used as appropriate.

7.11 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

Glucometry needs a finger prick and a drop of blood. No other investigations.

7.12 Has ethical clearance been obtained from your institution?

8.0 List of References

1. Chronic disease facts – WHO.(Online), (Dated 13 Aug 2012), Available from

2. Chronic disease and health promotion.(Online), (Dated 13 Aug 2012), Available from

3.World health day theme 2012..(Online), (Dated 14 Aug 2012), Available from

4. Babar TS and Juanita H, Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. Journal of Public Health; 27(1): 49–54

5.Roger Detels, James McEwen, Robert Beaglehole and Heizo Tanaka, Oxford text book of Public Health: The Practice of Public Health. Fourth Edition.Volume 3.Oxford University Press; 2002.Page 1714.

6.Park K, Park’s Text Book of Social and Preventive Medicine,21st edition. India: M/s BanarsidasBhanot Publishers 2011 Page 446.

7. Population ageing and health in India – prediction based on Census 2001.(Online), (Dated 14 Aug 2012) Available from

8.Aging facts – WHO. (Online), (Dated 13 Aug 2012), Available from

9.Un World Population and Urbanization trends, (Online), (Dated 8 Aug 2012), Available from http.//

10.Wallace/ Maxcy – Rosenau – Last, Public health & Preventive Medicine. 15th Edition. USA. The McGraw-Hill Companies; 2008.Page 46.

11. Percentage of slum population in India- WHO 2005 Report. (Online), (Dated 9 Aug 2012), Available from

12.Living conditions in Indian slums- Population statistics.The Minister for Housing and Urban Poverty Alleviation stated that, (Online), (Dated 8 Aug 2012) Available from

13. WHO – NCD country profiles, 2011. (Online), (Dated 14 Aug 2012), Available from

14. Global Health Statistics. Global Burden of Disease and Injury Series.(Online), (Dated 14 Aug 2012) Available from

15. Anand K, ShahB, Yadav K, Singh R, Mathur P, Paul E, Kapoor SK. Are the urban poor vulnerable to noncommunicable diseases? A survey of risk factors for non-communicable diseases in urban slums of Faridabad, National Medical J of India 2007; 20(3): 115-20.

16. Pawar AB, Bansal RK, Paresh B, Pancha, Shaishav, Patel HB, Padariya PK, Patel GH, Prevalence of hypertension among elderly women in slums of surat city,National Journal of Community Medicine 2010; 1(1): 39-40.

17. Singh JP,Saoji AV,Kasturwar NB, Pitale SP, Deoke AR, Nayse JG, Epidemiological study of diabetes amongst geriatric population in an urban slum, Nagpur. National Journal of Community Medicine July-Sept 2011; 2(2): 204-8

18. NiranjanGV, VasundhraMK, A Study of health status of aged persons in slums of urban field practice area, Bangalore.Indian Journal of Community Medicine Jan-Dec 1996; 21(1-4): 37-40.

19. Purty AJ , Joy B, Malini K,Kavita V, Anita V, Panda P, Morbidity Pattern Among the Elderly Population in the Rural Area of Tamil Nadu, India. Turk J Med Sci 2006; 36(1): 45-50.

20.Joshi R,Cardona M,Iyengar S,Sukumar A, Raju CR,Raju KR et al. Chronic diseases now a leading cause of death in rural India—mortality data from the Andhra Pradesh Rural Health Initiative. International Journal of Epidemiology 2006;35:1522-29.

21. Ward H, MertensTE, Thomas C, Health-seeking Behaviour and the control of sexually transmitted diseases. Health policy and planning,Oxford Journal of medicine 1996; 12: 19-28

22. Hegde SKB - A Study of factors associated with health seeking behaviour of elderly in a rural community. MD Thesis.St John’s Medical College. 2009.

23.Deenadayalan VS- Health Care Seeking Behaviour of Elderly in Tamil Nadu (South India): Implications for Health Policy.Presented at International health economics association 8th World Congress on Health Economics in Toronto, July 2011 Available from

24.Vijaya KS. Growing old in rural India, problems and perspective. Challenges before the elderly: an Indian scenario. New Delhi; MD publication,1995..(Online), (Dated 13 Aug 2012) Available from

25. Indrani G, Purnamita DG, Health seeking behavior in urban Delhi: an exploratory study, Journal of health and population in developing countries 2003; 3(2): 1-20

26. Indira JP. Issues in mental health and psychological well being of older persons. In: Murali Desai and Siva Raju, editors. Gerontological social work in India: some issues and perspectives. Delhi: BR. publishing corporation, 2000. Page185-200

27.National Policy on Older Persons by govt. of India.(Online), (Dated 14 Aug 2012) Available from

28.Chronic disease facts – WHO. (Online), (Dated 13 Aug 2012), Available from

29.The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.(Online),(Dated 21 Aug 2012).Available from

30.Screening for Type 2 Diabetes - Report of a World Health Organization and International Diabetes Federation meeting.(Online), (Dated 10 Aug 2012). Available from



11.1 Guide:


Professor and Head

Department of Community Health

St. John’s Medical College

Bangalore 560034.
11.1.2 Co-Guide:


Assistant Professor

Department of Community Health

St. John’s Medical College

Bangalore 560034
11.2 Head of the Department


Professor and Head

Department of Community Health

St. John’s Medical College

Bangalore 560034.
12.1 Remarks of the Chairman and Principal

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