The AHSETS study: This study was carried out as part of a comprehensive effort to assess the health status of the elderly under the AHSETS study.(17)(8) The findings of the AHSETS study aim to inform policy interventions for the National Program of Healthcare of the Elderly (NPHE) in India such as routine screening practices for identifying, managing and preventing health and social disorders in rural communities. (18)
Study design, setting and population: We undertook a cross-sectional study, carried out in the rural block of Tigiria in Cuttack district, Odisha, India, between June 2019 and February 2020. Tigiria is an administrative block of Odisha, India, consisting of 52 revenue villages with a total population of 74639.(19) The study participants were residents of Tigiria block, aged over 60 years who were conversant, comprehensible and provided their written informed consent to participate. We excluded seriously ill, bedridden patients as well as those with severe cognitive impairment. The details of the AHSETS study methodology is discussed elsewhere and we describe it briefly below. (17)(8)
Sample size and sampling: The minimum sample size was calculated to be 725.(20)(17) We used a cluster sampling technique to select 30 clusters (revenue villages) based on a Probability Proportional to Size (PPS), each cluster with a size of 25 sampling units. Systematic random sampling method was used in each of the clusters for identification of study participants.
Data Collection: Data were collected by interviews conducted by trained field investigators using a pre-tested tool and recorded on an Open Data Kit (ODK) form installed on android tablets. Multimorbidity was assessed using the MAQ tool developed and validated by Pati et. al.(21). Elder abuse status was assessed using the pre-validated Hwalek-Sengstock Elder Abuse Screening Test tool. This included a series of questions to assess direct abuse, vulnerability and abusive situation administered in local language to the elderly and out of total score of 15, a score of more than equal to 3 was taken as the risk of being abused, neglected, or exploited. We further categorized the risk of abuse as No risk of abuse (<2 score), Low risk of abuse (3-5 score) and high risk of abuse (>6 score).(22) Dependence for the activities was assessed using the validated Lawton IADL scale with a score range from 0 to 8. This tool categorizes elderly based on functional dependency as dependent (score <2), partially dependent (score 3-6), and independent (score >7) for women while, a score of > 5 is taken as independent for men to reduce gender bias.(23) Socio-demographic data were collected following standard census of India operational definitions. Socio-economic status (SES) was assessed using the per capita household income method outlined in the updated BG Prasad tool.(24) Economic Dependency was assessed as minimum monthly income as per central government of India’s cut-offs from any source, including pension along with decision-making capacity to use this amount.(25)
Quality control: Data collection was commenced after a comprehensive training of the study staff using a standardized manual of operating procedures (MOP) for the study and existing validated tools for the Indian population were used after their translation (and back translation) into the regional language, Odia, to ensure generalizability.
Statistical Analysis: Following data preparation and descriptive analysis, bi-variate analysis was done using Chi-square test and Kendall-Tau ranked correlation. The assumption of proportional odds was tested using the Brant's test and subsequently, the following ordinal logistic regression model was built to adjust for multiple factors:
Logit (PRisk of abuse (0-2)) = β0 + β1 (Age groups) + β2 (Gender) + β3 (Literacy) + β4 (Dependence) + β5 (Multimorbidity) +β6(Socio-economic status) +β7(Marital Status) +β8(Type of Family)
Where, PRisk of Abuse = Probability of Elder Abuse (No risk, Low risk and High risk) & β0- β5=Regression Coefficients.
All analyses were performed using R statistical software packages (build ver. 4.0.3).
Ethical considerations: Ethical approval was obtained from the institutional human ethics committee of ICMR-RMRC Bhubaneswar (Approval No- ICMR-RMRCB/IHEC-2019/022). Written informed consent was obtained from all participants and the national ethical guidelines for biomedical research were followed.(26)