Effectiveness of the psychoeducation module for screened positive cases of depression among elderly females in rural South India, a Quasi experimental study


 Background:
 
With the increasing population of geriatric women in India, it has become more necessary to identify morbidities in this population as well as potential interventions to treat them. In this study, we estimate the prevalence of depression in geriatric women living in a district in rural South India, and evaluate the effectiveness of a psycho education on improving knowledge and awareness on depression.
 
Methods:
This cross sectional study was performed among 218 females above the age of 60 years in rural areas who were interviewed using Beck’s Depression Inventory and evaluated for depression. A questionnaire was then administered to assess knowledge and attitudes regarding depression once prior to and once after the psychoeducation module was presented to assess the effectiveness of the module. Multivariate analysis was performed to identify key variables that predisposed participants for depression as well as those variables that affected the effectiveness of the psychoeducation module.
 
Results: The study showed 31.7% of the participants to have depression using Beck’s Depression Inventory. Low education status [ AOR: 5.95(1.04-34.10), p = 0.04], decreased social interactions [AOR: 10.97 (1.43-84.13), p = .02.], daily concerns regarding health [AO: R5.09 (1.031-25.10), p = 0.05), loans to settle [AOR: 18.55(2.65-129.64), p = 0.003] and poor sleep quality [AOR:94.82 (13.97-643.72, p < .001] were positively correlated with the presence of depression. Of those participants diagnosed with depression, the psychoeducation module was less effective in those who engaged in hobbies/social activities, had good relationships with family and had concerns about their health.
 
Conclusion:
Of those interviewed, one-third were estimated to have depression. Administration of a psycho-education was seen to reduce stigma and improve health-seeking behavior. As this stigma is particularly pervasive in geriatric women in rural south India, population specific interventions need to be identified in order to improve knowledge and health seeking behavior.
Keywords: Depression, Elderly, Rural India, Women, Geriatric, Psychoeducation, Intervention


Introduction
As the elderly population of India is progressively increasing, interest in morbidity trends in this community is also growing. It is well known that as this population is more predisposed to morbidities, and is also more susceptible to depression.(1) (2) (3) Since there are a larger number of comorbidities present in this population, depression, a condition already difficult to recognize, is prone to be overlooked. (4) Depressive symptoms in the geriatric population is often attributed to the ageing process and medical care is deemed unnecessary. Amongst the elderly, those residing in rural India are more susceptible to living with undiagnosed depression than their urban counterpart because of both, their lack of education and awareness on the issue, as well as the difficulties they face in receiving adequate health care.
(2)(6) Therefore, though the prevalence of depression is high, the diagnosis and treatment of the condition in this population remains inadequate. As elderly people with depression have poorer outcomes with other comorbid conditions such as hypertension, and diabetes, it becomes even more important to address this deficit in health care.(5)(7) Geriatric females, especially those in rural India are an especially vulnerable group as studies have shown them to have a higher prevalence of depression as compared to their male counterpart. (8) (9) This issue is exceptionally important in India, because of the stigma associated with having depression and the idea that depression is not a medical illness but only a result of lacking mental strength and integrity an can be overcome by perseverance rather than medical care. Studies done in other parts of the world have shown factors such as lower levels of education, income, occupation, and quality of sleep to all have significant associations with depression in the elderly. (10) (11) (7) This study aims to screen the specific population of rural geriatric women for depression and to identify important socioeconomic associations, specific to the demographic of rural south India, which could potentially result in preventative care strategies.
Additionally, we aim to provide health education to all individuals/families of the selected population in an attempt to overcome the stigma associated with the issue as well improving the support the patient receives from their individual families. We will be assessing the effectiveness of psycho-education as a strategy to improve the knowledge, attitude and practices of our study population in regards to depression and depressive symptoms.

Study population
This study was carried out in two phases: The first phase was a cross sectional study, carried out in the Udupi district of Karnataka, India from February, 2016 to August, 2017. 218 females above the age of 60 years in rural areas served by the Department of Community Medicine, KMC Manipal were assessed. Anticipating 31% of geriatric women to have depression with a relative precision of 20% at 95% confidence level, 218 geriatric women were assessed. In the second phase, a psychoeducation module was administered to approximately 68 screened positive cases of depression. Geriatric females who were unable to comprehend or provide answers to the questions were excluded from the study.

Data collection and management
The study subjects were identified in the field practice area with the help of an Auxiliary Nurse Midwife who serve as the chief contact between health care providers and the community. The ANM's each work in a rural center that functions for a well demarcated community and each ANM is well versed in the demographics and common morbidities of their respective communities. A pre-designed questionnaire was administered to the subject to record sociodemographic details and morbidities present.
Beck Depression Inventory, a psychometric test to screen for depression, was administered by the investigators to the subject in either English or Kannada, to screen subjects for depression. A score of 17 and above was considered a possible case of depression. The inventory was also used to classify participants into categories of depression. The interpretation of the results was then revealed to the subject and, with their permission, to their family.
Those determined to have borderline, moderate or severe depression were administered an intervention and a questionnaire before and after the questionnaire to assess their awareness on depression. The questionnaire had 8 questions with yes/no answers and each participant was awarded one point for every answer deemed most appropriate with a maximum score of 8. Following this, the investigators administered an appropriate and predefined intervention in the form of psychoeducation to the subject and family, if present. The content of the intervention administered included:

1.
What is depression? The same predesigned questionnaire was re-administered to the subject, once immediately after the psychoeducation to assess the effectiveness of the psychoeducation given.

Statistical analysis
All data was entered and analyzed using the Statistical Package for Social Services (SPSS) version 15. The outcome of depressed vs not depressed was measured dichotomously with depressed including borderline, moderate and severe depression. Descriptive analysis was performed on the data and significant associations between socio-demographic details and the outcome variables (using Chi-square or Fisher's Exact) was done. A univariate analysis was first performed and a multivariate binary logistic regression model was then made using those variables with a p-value <0.2 in the univariate analysis to further identify independent variables affecting the participant's likelihood of being depressed. In addition to the statistically significant variables, an extra variable "preference of staying at home alone or in the company of others" was added to the binary logistic regression model due to its theoretical relevance. The addition of this variable improved the Hosmer Lemeshow goodness of fit from c 2 (8) = 2.12, p = .98 to c 2 (8) = 1.73, p = .99 All of the statistical analysis was done using a p-value of <0.5 as being statistically significant and with a confidence interval of 95%.

Ethical Considerations
The study protocol was approved by the Institutional Ethics Committee of the Kasturba Hospital and Kasturba Medical College, Manipal Academy of Higher Education and was conducted according to its guidelines. All study participants were informed of the voluntary nature of the study and gave a written informed consent.

Results
The study included a total of 218 female participants with a mean age of 70.11+ sleeping 49 (71%) as well as they could before, most had no problems with weight loss 61 (88.4%), decision-making 53 (76.8%) or a belief that they look more unattractive than they used to 53 (76.8%).

B. Associations between socio-demographic characteristics and depression
Cross tabulation was performed to check for any associations between socio- whether they got a good night's sleep on most days, whether they had a good relationship with their family, whether they had any concerns about loans that they needed to settle as well as concerns about their health, whether they preferred staying alone or in the company of others, and their educational status.

B.1 Education on depression
The bivariate analysis showed that those participants with no formal education or only a primary school level of education were more likely to be depressed than those who had educational qualifications of secondary school or higher with an AOR of 5.95(1.04-34.10) and was a significant association c 2 (1) = 4.01, p = .04.

B.2 Social interactions on depression
Participants who preferred staying at home alone were more likely to be depressed than those who preferred to be in the company of others with an AOR= 10.97 (1.43-84.13) and a statistically significant association c 2 (1) = 5.31, p = .02. Participants who felt that they did not have a good relationship with their families had a higher likelihood of being depressed than those who did, with an AOR of .05 (.03-.76) and a statistically significant association c 2 (1) = 4.67, p = .03.

B.3 Physical health and daily worries on depression
Presence of a comorbid condition did not seem to have a significant association with depression. Those with daily concerns regarding their health had a higher chance of being depressed with an AOR=5.09 (1.031-25.10) and was statistically significant with c 2 (1) = 3.99, p = .05), as well as those participants who had concerns regarding loans to settle who also had a higher chance of being depressed with an AOR of 18.55(2.65-129.64) and was also significant at c 2 (1) =8.66, p = .003.

B.4 Sleep quality on depression
Participants who complained of not getting a good night's sleep had a higher chance of being depressed with an AOR=94.82 (13.97-643.72) and was statistically significant at c 2 (1) =8.66, p < .001.

C. Pre and Post intervention
Of the 218 participants in this study, 69 were considered to have borderline, moderate or severe depression and were administered a psycho-education. A questionnaire with 8 questions (each worth 1 point) regarding knowledge and attitudes towards depression was also administered before and after the psychoeducation. The median score before administration of the psycho education was 4 while the median score after administration of the psychoeducation was 8. It was seen that 50 of the 69 participants (73.53%) showed improvement in the score after the psycho-education. Of the 19 participants that showed no improvement, the median score in the pre-psychoeducation questionnaire was 8 ( When the one-tailed Wilcoxon signed ranks test was performed, it showed that participants had a tendency to have higher test scores after the administration of the questionnaire rather than before. (p=<0.001).

Education on Depression
It was observed in the present study that those participants with no formal education or only a primary school level of education had 5.95 times the odds of being depressed as compared to those having attended secondary school or higher.

4.1a Knowledge and Awareness regarding Depression
When assessing the knowledge and awareness of the study participants regarding depression it was noted that half 36 (52.2%) of the participants with some level of depression did not believe that mental illness needs to be taken seriously od that it requires medical attention. In addition, more than half of the participants to whom the questionnaire was administered believed that depression can be overcome with only will power and perseverance and that suicidal threats by a patient need not be taken seriously. Absence of a perceived need for healthcare has been shown to be a contributing factor in reduced health seeking behavior. (17) In addition, the median score on the pre psycho-education questionnaire was 4. These findings highlight a lack awareness regarding the disease. V Lopez et al reported that people who are well educated regarding depression and its symptoms are less likely to experience stigma for seeking treatment and also that those who do not experience this stigma respond better to the treatment regimens. (14)

Social Interactions
Those participants who prefer staying at home alone as compared to in the company of others had a 10.97 times higher chance of being depressed than those who (22) In addition to social interactions, familial relationships were seen to have a statistically significant association with depression. Participants who did not feel that they had a good relationship with their families had a higher odds of being depressed as compared to those that did. This was also reported in a study by H.
Dessoki et al., who noted a higher prevalence of depression among those living in geriatric homes (87.9%) as compared to those living with their families (56.7%). (23) Studies have shown that the prevalence of depression in elderly individuals living with their families was significantly lower than those who were not, indicating possible associations between family care and depression. (24) The lack of this support could burden them with monetary concerns such as loans to settle. Our study showed that participants with these concerns were 18.55 times more likely to have depressive disorder. These concerns, coupled with the inability to receive emotional reassurance from family members could have a significant impact on the development of depression in the elderly.

Comorbidities and sleep
It was interesting to note that having comorbidities was not seen to be significantly

Post-interventional improvement
In our study most of the participants who showed no improvement had perfect to near perfect scores on the questionnaire even prior to administration of the

Improving health-seeking behavior: What can be done?
As was seen in this study, participants who are well informed regarding depression have superior health seeking behavior due to the direct and indirect effect on relieving the stigma associated with depression. It has been found that patients believe that doctors do not have enough time to listen to the patient's personal problems and take less interest in the problems of the elderly and this can often be a barrier to health seeking behavior. (25) As general practitioners have the most frequent contact with this demographic of elderly women in rural India, improved patient communication and routine screening for depression in elderly women could unearth many undetected cases of depression. Additionally, this study found significant associations between an increase in social participation and decreasing rates of depression. Encouraging social participation in elderly women via social groups with more regular meet ups, entertaining activities and prearranged transportation would not only help in preventing depression but also make those who are already depressed more responsive to psychotherapy. Finally, regularly educating elderly women on the symptomatology of depression could empower them to notice the beginnings of the illness both in themselves as well as others within their community.

Limitations of the study
The limitations of our study included the non-response by a few geriatric woman in the community due to the stigma associated with depression. Additionally, ensuring privacy while conducting the interviews was difficult as family members were often present throughout the interview and could have limited the openness with which the participant's answered the questions. Our post intervention improvement was also administered immediately after the intervention instead of after a gap of a couple days which could have resulted in our questionnaires evaluating immediate recall rather than an actual improvement in the knowledge of and attitudes towards the illness.

Conclusion
This study showed that 31.7% of the study participants (69/218) were categorized as borderline, moderate or severe depression using Beck's Depression Inventory.
Low education status, decreased social interactions, daily concerns regarding health and loans to settle and poor sleep quality were all found to have significantly positive correlations with depression. As this stigma is particularly pervasive in geriatric women in rural south India, population specific interventions need to be identified in order to improve knowledge and health seeking behavior.
Administration of a psycho-education was seen to improve both knowledge and health seeking behavior. Therefore, routine screening for depression and psychoeducation by physicians to all elderly women in rural India could aid in identifying and treating many cases of depression that would otherwise go unnoticed.    Probable target correlates to improve health seeking behavior