Introduction:
In 2005, older people were 8% of the population in the developing countries, and the proportion is expected to increase to 20% by 2050.1 Active ageing remains at the core of old age care programmes, where it is defined as “the process of optimizing opportunities for health, participation and security in older to enhance quality of life as people age".2 The word ‘active’ refer to continuous participation in social, economic, cultural, and spiritual activities. Incident of fall leading to subsequent interference with physical mobility is one of the common barriers in active ageing among older people. According to International Classification for Diseases (version 10), the term ‘fall’ is defined as, “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects".3
In India, 28–35% falls occur among older people over 65 years of age in each year.3 A survey done in Southern part of India have reported inadequate lighting, uneven and slippery floor of the house, inadequate handholds, use of Indian toilet, loose carpets on the floor as environmental risks for fall.4 Majority of falls were found to occur inside the house and the surrounding environment,5 and most of these environmental risk factors are preventable. There is limited information available on the magnitude of these environmental risk factors for fall among older people in our context. Such information can be useful in developing engineering measures at household level. Hence, the present study was undertaken to assess the potential environmental risk factors for fall in and around the rural households.
Material and Methods:
Study setting: The present study was undertaken in 14 villages of Primary Health Care Centre (PHC), Thirubhuvanai, Pondicherry, having 36,509 as the total population. The study site is located at the border of Pondicherry and Villupuram District of Tamil Nadu. Nearly 50% of the population is involved in the traditional agricultural work. Half of the people live in pucca houses where roof, wall and floor are made of permanent materials.
Study design and duration: It was a Community-based, descriptive cross-sectional study. The study sample consisted of houses of older people aged 65 years and above. The data was collected during the months of September 2017 – December 2017.
Sample size and sampling: Considering, one of the risk factors (absence of western toilet) for fall in rural housing as reported in a previously reported regional study to be 62%6 and assuming the design effect of 1.5, precision of 7.5% and α error 5%, a sample size of 543 was calculated. Assuming 5% non response rate, it was further inflated to 570 (calculated by Epi_Info version 7.2.1.0). A list of 14 villages in the study area and their population was obtained from the Medical Officer in-charge of Primary Health Center, Thirubhuvanai. Two-stage cluster sampling was adapted to select the representative sample of 570 houses. At first stage, 30 clusters were selected by Population Proportional to Size (PPS) method from the list of 14 villages. To begin with, cluster interval (1216) was calculated by dividing the total number of population (36,509) and the number of clusters (30). Later, a random number (617), which fell between 1 and cluster interval was generated by using the random number generator in Epi_Info (version 7.2.1.0) software. At the second stage, 19 houses were at least having one older people (≥ 65years) was selected from each selected cluster by the ‘random walk’ method. The random walk method was done in two steps - first step is to identify the centre of the village and then randomly select a direction for selection of houses. A pen was rotated at the village centre to get the direction for the selection of the houses in the given lane. To being with the second step, the first house in a randomly selected lane was chosen by selecting the last number of a randomly picked up currency note and then subsequent houses was selected till the desired sample of 19 houses in each cluster was achieved.7
Data collection (tools): The data was collected by a team comprising of trained postgraduates in Community Medicine as field investigators and medical interns as an assistant in data collection process. The investigators used an “observer as participant” method, where the observer is not the member of the community and participants are aware of the observations being done.8 This stance of observation was suitable, feasible and ethically appropriate for the purpose of present research. After obtaining the informed consent, the interviewer observed the household using the pre-designed and pre-tested check list. If required, the respondents were asked for clarifications. We didn’t find rural housing standard checklists available for Indian context for assessing the household environmental risk factors for fall in older people. Based on the review of literature, and interview with a physiotherapist who had experience dealing cases with fall among older people, we developed the checklist for the rural housing settings in our context. It was pre-tested to check the validity of the check list. It included the following items: type of house, presence of stairs without support on both sides, unstable furniture (broken furniture, three legged stool, and plastic cup boards), adequate lighting arrangement (presence of natural or artificial lighting sufficient to read without eye strain),9 presence/use of latrine, supports in toilet and bathroom (Hand rails, grab bars) were observed. Written informed consent was obtained from the participants.
Statistical analysis: The data was entered using Epi_Info (version 7.2.1.0) software package and analyzed using SPSS (Version 24.0). Descriptive statistics, which included frequency, mean and percentages were used to describe the data.
Ethical Consideration: Clearance from the Research Committee and Institutional Ethics Committee of Sri Manakula Vinayagar Medical College and Hospital, Pondicherry was obtained before the conduct of the study.
Results:
Out of 570 houses, majority 285 (50%) were pucca houses and most [340 (59.6%)] of the houses were cemented, followed by tile flooring in 153 (26.9%) of the houses. A total of 537 (94.2%) and 449 (78.8%) houses had adequate lighting in living room and in kitchen respectively. Stairs were present in 252 (44.2%) of houses, in that handrails were not seen in 12 (4.7%) houses. (Table 1)
| Table 1: Potential risk factors for fall in living area, kitchen and upstairs (N=570) |
Type of house |
n (%) |
Pucca |
285 (50) |
Semi-pucca |
194 (34) |
Kutcha |
91 (16) |
Flooring of house |
Cement |
340 (59.6) |
Tiles, Granite, marbles |
153(26.9) |
Mud |
77 (13.5) |
Lighting in the living area and Unstable furniture |
Presence of adequate lighting in living room |
537 (94.2) |
Presence of adequate lighting in kitchen |
449 (78.8) |
Presence of unstable furniture |
341 (59.8) |
Stairs without support |
12 (4.8) |
Among 570 houses, only 333 (58.4%) houses had a latrine and among those houses, 284 (85.2%) were reported to use the latrine. Most [211 (63.4%)] of the latrines were observed to be located outside the main house building. Majority [285 (85.5%)] of the houses had Indian type followed by western type latrines. In most [248 (74.8%)] of the houses, cement flooring was seen. The presence of adequate lighting was seen in 292 (87.7%) latrines. Notably, majority of the houses [315 (94.3%)] didn’t have any type of support in their latrine. (Table 2)
| Table 2: Potential Risk factors for fall in latrine (N=333) |
Latrine |
n (%) |
Location of latrine |
Outside the house |
211 (63.4) |
Inside the house |
122 (36.6) |
Type of latrine |
Indian type |
287 (86.2) |
Western type |
35 (10.5) |
Both Indian type and western type |
11 (3.3) |
Flooring of latrine |
Cement |
248 (74.8) |
Tiles |
81 (24.3) |
Mud |
4 (0.9) |
Lighting and support in latrine |
Absence of support in latrine |
315 (94.3) |
Absence of adequate lighting in latrine |
41 (12.3) |
Out of 570 houses, 338 (59.3%) houses had a bathroom and among those houses, 284 (85.2%) houses were reported to use the bathroom. In most of the houses [248 (73.4%)], bathroom flooring was of cement flooring, followed by tiles [86 (25.4%)]. Notably, the presence of adequate lighting was seen in 279 (82.5%) bathrooms which were observed in the evening and night hours for the working conditions of bulbs in the bathroom. Majority [327 (96.8%)] of the houses didn’t have any kind of support in their bathroom. (Table 3)
| Table 3: Potential Risk factors for fall in bathroom (N=338) |
Bathroom |
n (%) |
Flooring of bathroom |
Cement |
248 (73.4) |
Tiles |
86 (25.4) |
Mud |
4 (1.2) |
Lighting and support in bathroom |
Absence of support in bathroom |
327 (96.8) |
Absence of adequate lighting in bathroom |
59 (17.5) |
Discussion:
Out of 570 houses, 50% were pucca and most of the houses had cement flooring and tiles. Unstable furniture was present in one third of the houses. The latrines were present in nearly half of the houses, whereas majority (63.4%) of the latrines were located outside the house premises. Notably, majority (85.2%) of the latrines were in use and only 5.7% latrines had support. Two third of the houses had bathroom facility and among them only 3.2% bathrooms had support. Most of the houses had adequate lighting in living room, bathroom and toilets; however, it was relatively poor in the kitchen. One third of the houses had stairs, and 5% of them had no support.
As found in the present study, hand rails in toilets and bathrooms were almost absent in the surveyed houses. In rural Coimbatore, Chacko et al found that only 1.8% houses had support in the toilets, which was similar to our study finding.6 There was inadequate lighting in the bathroom (17.5%) and toilets (12.3%) in our study. A community based study from Bangalore has reported that nearly 30.1% fall occurred in bathroom4 and another study has reported that 75% of the falls occurred in bathroom and toilet.10 Most of these falls tend to occur due to accidental slip and hence having a support might prevent such type of falls in toilets and bathrooms.
In the present study, unstable furniture and stairs without handrails were present in 59.8% and 4.8% houses respectively. Chacko et al found in their survey that 5.5% stairs didn’t have handrails.6 A study in Chandigarh reported 36% falsl as occurring on the stairs and 35% falls from furniture.10 Poorly designed or maintained stairs without handrails and inappropriate furniture had been reported as risks for falls.11 The locally suitable and cost-effective engineering interventions to reduce the unstable features of the furniture, and putting hand rails in toilet and bathrooms would be an appropriate interventions to minimize the risk for falls. In rural India, Centre of Science for Villages (CSV) in Wardha has made an effort to develop the cost-effective housing for rural poor.12 Currently we do not have guidelines and regulations for housing constructions to ensure safety for old people. However, in the United Kingdom, the housing standards insist that the wall areas should have grab rails to assist frail residents in bathrooms and toilets.13 American Elder Care Research Organization provides funding for home modifications, which include bathroom modifications (grab bars and rails in bathrooms and hallways), lighting modification within the home and around the home and for wheel chair ramps.14 The National Program for Health Care of Elderly (NPHCE) in India envisages the need to identify specific programmes targeted at improving geriatric health and has committed funding for the programmme.15 Since falls are an emerging significant problem with increasing older population, there is a need for elder friendly policies and regulations concentrating on engineering measures for fall prevention at the houses in India.
To the best of our knowledge, this was the first community-based study in our setting. The findings of the present study are based on direct observation by using the pre-designed and pre-tested checklist. However, it was a small scale descriptive cross sectional study. In conclusion, we found that majority of the houses of older people had risk factors for fall. The results of this study indicate the need for environmental inspection and hazard reduction measures in their houses. We need housing standards to be defined and implemented for rural people which must fulfill the requirements of elder friendly houses in the community.
References:
- Dsouza SA, Rajashekar B, Dsouza HS, Kumar KB. Falls in Indian older adults: A barrier to active ageing. Asian Journal of Gerontology and Geriatrics 2014; 9(1): 33-40.
- Active ageing: A Policy framework [Online]. April 2002 [Cited on 12 Jan 2018]; Available from URL: https://extranet.who.int/agefriendlyworld/wp-content/uploads/2014/06/WHO-Active-Ageing-Framework.pdf.
- Yoshida S. A Global Report on Falls Prevention – Epidemiology of fall [Online]. February 2016 [Cited on 10 Dec 2018]; Available from URL: http://www.who.int/ageing/projects/1.Epidemiology%20of%20falls%20in%20older%20age.pdf.
- Patil SS, Suryanarayana SP, Rajaram D, Murthy NS. Circumstances and Consequences of Falls in Community – Living elderly in North Bangalore Karnataka. Journal of Krishna Institute of Medical Sciences University 2015; 4(4): 27 – 35.
- World Health Organization. WHO Global Report on Falls Prevention in Older Age [Online]. March 2007 [Cited on 10 Jan 2018]; Available from: URL: http://www.who.int/ageing/publications/Falls_prevention7March.pdf.
- Chacko TV, Thangaraj P, Muhammad GM. How Fall-Safe is the Housing for the Elderly in Rural Areas?: A Cross Sectional Study using Fall Prevention Screening Checklist. Journal of the Indian Academy of Geriatrics 2017; 13: 124-130.
- Chromy JR. Probability Proportional to Size (PPS) sampling. SAGE Research Methods [Online]. 2008 [cited on 20 Feb 2018]; Available from: URL: https://srmo.sagepub.com/view/encyclopedia-of-survey-researchmethods/n405.xml.
- Gold, R. L. (1958). Roles in sociological field observations. Oxford University press 1958; 36(3): 217-223.
- Park K. Park’s Text Book of Preventive and Social Medicine. 24th ed. Jabalpur: Bhanot publishers; 2017. 766-767.
- Tripathy NK, Jagnoor J, Patro BK, Dhillon MS. Epidemiology of falls among older adults: A cross sectional study from Chandigarh. India. Int.J.Care Injured 2015; 46: 1801-1805.
- Dionyssiotis Y. Analyzing the problem of falls among older people. Int J Gen Med 2012; 5: 805-813.
- Centre of Science for Villages [Online]. 2015 [Cited on 15 Feb 2018]; Available from URL: http://www.csvtech.in/housing.html.
- Older people’s housing design guidance – Royal borough of Kensington and Chelsea [Online]. 2015 [Cited on 12 Feb 2018]. Available from URL: https://www.rbkc.gov.uk/sites/default/files/atoms/files/Older%20People%27s%20Housing%20Design%20Guidance%20%28low%20res%29.pdf
- Paying for senior care – How to make and pay for home modifications to enable aging in place [Online]. 2017 [Cited on 20 Jan 2018]; Available from URL: https://www.payingforseniorcare.com/home-modifications/how-to-pay-for-home-mods.html
- Government of India. Operational Guidelines on National Programme for Health Care of the Elderly [Online]. 2011 [Cited on 15 Feb 2018]; Available from URL: https://mohfw.gov.in/sites/default/files/8324324521Operational_Guidelines_NPHCE_final.pdf.
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