Study design and setting
A community based cross sectional study was conducted from April to June 2022. The study was conducted in Gondar town, Amhara regional state, Northwest Ethiopia. The city is located in central Gondar zone, Amhara regional state, 748 kilometers Northwest of Addis Ababa, Ethiopia capital, and about 180 kilometers from Bahir Dar, Amhara regional state's capital. Gondar is one of the ancient and largely populated cities in the country. It has an altitude of 12˚360N 37˚280E and a longitude of 12.60˚N 37.467˚E with an elevation of 2133 meters above sea level. Gondar town has 25 kebeles (the smallest administrative units in Ethiopia).According to the Gondar statistics agency's 2021/22 projection from 2007 population census data, the total population of Gondar town was estimated at 390,000 more than half of the population were women and 9870 were older adults (27).The town has one comprehensive specialized hospital and eight health centers they providing health services to the population.
Population and sample size
The source population was all population of community dwelling older adults aged 60 years and above living in Gondar town. Older adults aged 60 years and above in selected kebeles (which is the smallest administrative unit in Ethiopia) during the study period were the study population. Older adults aged 60 years and above who were permanent residents (≥6 month) in the selected kebeles were included.Those whowere critically ill or mentally unstable to respond and those who did not give informed written consent were excluded.
Sample size determination
The sample size was determined using a single population proportions formula assuming, 50% anticipated prevalence of frailty, since there was no study conducted before in Ethiopia, a 95% confidence interval, and a 5% margin of error.
n= sample size, Zα/2 (1.96) = critical value at 95% confidence interval, p = expected estimates of prevalence value of frailty (50%), d = Margin of sampling error (5%).
n = Z (α/2)2p (1-p)
d2
n= (1.96)20.50.5/ (0.05)2 =3.84160.25/0.0025
n= 384.37385
By considering a design effect of 1.5 and 10% non-response rate multiplier, the minimum adequate final sample size was 636. But because of the effect of cluster sampling, a total of 670 older adults were interviewed from a total of 645 household.
Sampling technique and procedure
Gondar town has 25 kebeles. Eight kebeles were selected by lottery method. A single stage cluster sampling technique was used to select study participants. All eligible older adults in the selected cluster were interviewed in their household (figure 1).
Methods of data collection and tools
After obtained permission from ethical review committee from university of Gondar collage of medicine and health science house to house visit was done. Face-to-face interview was taken from study participants using a predesigned pretested structured schedule with the following domains.
- Socio-demographic characteristics;
- Clinical related factors;
- Tilburg frailty indicator part;
- Katz index of independency;
- Geriatric Depression Scale short form (GDS);
- Life style related factors
The other detailed contents of the questionnaire were developed from previous literature, and the questionnaire was modified based on all the variables that directly meet the objective of the study. It was prepared in an English version and translated to the Amharic language back to English to ensure consistency by language experts. The questionnaire had six parts. The first part of the questionnaire was focus on social-demographic factors, the second part on health-related factors, the third part on ADL dependency, the fourth part on depression, the fifth part on behavioral factors and six part measurement of frailty. Data collection was done by four trained health extension workers and two physiotherapist supervisors, and the data was collected by interviewing the participants using a structured questionnaire.
Tilburg frailty indicator part .It is a self‑reported schedule for assessment of frailty through its three important components, such as physical, psychological, and social. Eight questions regarding physical component, four questions on psychological component, and three questions on social component was asked. Respondents were required to answer ‘yes’ or ‘no’ and the total attainable score is ranged from 0 to 15.An individual with a score of ≥5 considered to be frail (64).
Katz index of independency: is used to assess the functional status of older adults. The index ranks adequacy of performance in the six functions of (bathing, dressing, toileting, transferring, continence, and feeding).It’s interpretation of scored is given yes= 1/no=0 for independence in each of the six functions of items, and a score of 6/6 indicates full function, a score of 4/6 indicates moderate impairment and if it’s score of 2/6 or less indicates severe functional impairment and the attainable score will be 0 to 6.An individual with score of ≤5 was taken as ADL dependence (58).
The Geriatric Depression Scale short form (GDS): Was used to screen for depressive symptoms in this study. The 15 items in the GDS-SF were extracted from the original 30-item GDS. Respondents were required to answer ‘yes’ or ‘no’ to the 15 statements that describe either a positive or a negative emotion/condition. Attainable score ranges from 0 to 15 and an individual with a score of ≥5 considered to be depressed (59).
Operational definition
Frailty: In this study an older adult is considered as frail if the score of Tilburg frailty indicator is ≥5 (28).
ADL dependency: Measured by Katz index of Independence in activities of daily Living an individual with score of ≤5 will be taken as ADL dependence (29).
Depression: Measured by geriatric depression scale, short form (GDS), an individual with a score of ≥5 considered to be depressed (30).
Older adults: The age at which a person becomes 60 years and above refers to the older adults (21, 22, 31, 32).
Physical exercise: Is any kind of regular moderate/vigorous intensity exercise (such as walking, cycling, and sports) done at least 150 minutes per week (33).
Smoker: A smoker is a person who smokes cigarettes daily whatever the number of cigarettes (34).
Alcoholics: Alcoholic is a person who drinks beer, local beer or areke, tella, or tej every day or every other day (34).
Morbidity: is defined as having any type of illness or perceived health problem and/or informed by a physician ahead of data collection period (35).
Statistical analyses
The collected data was entered into Epidata and exported, coded and analysis was done using Statistical Package for the Social Sciences (SPSS) Version 26. First binary logistic regression was undertaken at p-value of 0.25 to identify potential candidates significantly associated with the outcome variable. Then variables were put together into multivariable logistic regression analyzes to identify the independent associated factors of Frailty. Variables with a p value of < 0.05 at 95% confidence interval (CI) and their odds ratio (OR) were used to interpret the findings of the final model.