Bassem R. Saab
MD, Associate Professor
Faculty of Family Medicine, American University of Beirut
P/O.Box 11-0236. Riad El Solh, Beirut 1107 2020 Lebanon
E-mail: brsaab@aub.edu.lb, Tel no: +961 3 771889, Fax no: + 961 1 744464 (Corresponding Author)
Zana El-Roueiheb
MPH, Research Assistant
Department of Epidemiology and Population Health. Faculty of Health Sciences, American University of Beirut
P.O.Box 11-0236. Riad El Solh, Beirut 1107 2020 Lebanon
E-mail: ze02@aub.edu.lb, Tel no: + 961 3 592108, Fax no: + 961 1 744470
Monique Chaaya
Dr. PH, Associate Professor
Department of Epidemiology and Population Health. Faculty of Health Sciences, American University of Beirut. P.O.Box 11-0236. Riad El Solh, Beirut 1107 2020 Lebanon
E-mail: mchaaya@aub.edu.lb, Tel no: + 961 3 458143, Fax no: + 961 1 744470
Abla Mehio Sibai
PhD, Associate Professor
Department of Epidemiology and Population Health. Faculty of Health Sciences, American University of Beirut. P.O.Box 11-0236. Riad El Solh, Beirut 1107 2020 Lebanon
E-mail: ansibai@aub.edu.lb, Tel no: + 961 3 646688, Fax no: + 961 1 744464
Abstract
Background. Depression among elderly females is an important public health concern. The present study aims at examining factors associated with female elderly depression in three underprivileged communities in Lebanon, one of which is almost solely inhabited by Palestinian refugees.
Methods. Four hundred and twenty-two women age 60-93 years were interviewed. Depression was assessed using the Geriatric Depression Scale (GDS).
Results. Probable and definite depression was diagnosed in 74.5% and 29.6% of the women respectively. Following multivariate analysis, factors significantly associated with definite depression were Palestinian nationality, dissatisfaction with household income, lack of physical activity, and disability.
Conclusion. Findings highlight the need for greater efforts to provide a suitable environment for exercise for elderly. Policy makers need to improve the living conditions of the underprivileged communities in Lebanon, particularly Palestinian refugees.
Keywords: Elderly women; depression determinants; underprivileged communities; Lebanon.
Introduction
Depression is a mental disorder characterized by a cluster of symptoms including prevailing sad mood, fatigue, and anhedonia (reduced interest in and pleasure from normal activities). In the year 1990, depression ranked fourth among the ten leading causes of the total worldwide disease burden, measured in disability adjusted life years (Lopez & Murray, 1998a). Depression is projected to rank second by the year 2020, accounting for 5.7% of the total disability-adjusted life years, compared to 2.6% for HIV (Lopez & Murray, 1998b). Furthermore, depression is expected to become the number one cause of disease burden among females in developing countries (Lopez & Murray, 1998c). In addition to being a major factor in disability, depression increases the risk of suicide and mortality (Neugebauer, 1999). It is estimated that 60% of all suicides are attributable to depression and the much less prevalent diagnosis of schizophrenia (WHO fact sheets, 2004a).
Females constitute a group that is particularly vulnerable to depression as reflected by the difference in female and male prevalence rates (Beekman et al., 2001), (Federal Interagency Forum on Aging-Related Statitics, 2004). Approximately 9.5% of women experience depression within a given year, compared to 5.8% of men; this gender differential is continued across the lifespan (WHO fact sheets, 2004b). Older age is established as a major predictor for depression with 45.2% of women and 26.9% of men afflicted by age 70 (Gottfries CG & Karlsson I, 2004).
While several studies have documented the prevalence of elderly depression and its determinants, few have been conducted in the Middle-East region, and to our knowledge none have focused on depression among poor community-dwelling elderly women. Furthermore, this study is the first of its kind in Lebanon to shed light on the problem of depression among underprivileged elderly women. The main objectives of the study are (a) to determine the prevalence of depression among elderly females residing in underprivileged communities in Lebanon, and (b) to examine the determinants of depression in such a setting.
Methods
The data used in this paper is part of a large study that was conducted by the Center for Research and Population Health (CRPH) of the American University of Beirut. The study was cross-sectional in design and consisted of a survey of 3,300 households from three poor communities in metropolitan Beirut, namely, Hey EL Sellom, Burj El Barajneh, and Nabaa. Hey El Sellom is located in Southeast Beirut, and is mainly inhabited by a majority of Muslims who migrated to the city from South Lebanon and Bekaa for better employment opportunities. Burj El Barajneh is a Palestinian refugee camp located in the vicinity of Hey El Sellom. Nabaa is a poor, densely populated eastern suburb of Beirut that has grown as a result of Christian displacement from Mount Lebanon during the Lebanese wars (1975-1990). For the purpose of data collection, each community was divided into blocks. Sampling was conducted through a stratified two-stage design, where a size-proportional sample of blocks was chosen, followed by selection of a final sample of households from each block. During the first stage (May – July 2002), data were collected from the selected 3,300 households by means of a “household questionnaire” that provided information about control variables including demographics, socio-economics, general health, and insurance coverage. In the second phase (December 2002 – March 2003), data were collected from 3 separate age groups: Adolescents, women, and elderly. The data for the present study was derived from the elderly survey. From the 3,300 households selected for the study, 969 individuals were age 60 years or older. Of these elderly individuals, 740 (76.3%) successfully completed face-to-face interviews conducted by nine trained interviewers. Reasons for non-response included: Refusal (4.1%), and unavailability (19.6%) due to death, or change of domicile. Out of the 740 interviewed, 422 (57%) were females and were considered for the present study. The interviewed women had an age range of 60 to 95 years; 202 women came from Nabaa, 164 from Burj El Barajneh, and 57 from Hey El Sellom.
The questionnaire used during the interviewing measured demographic, socioeconomic, and health variables. Demographic variables included in this study were gender, marital status, nationality, religion, number of children, and age. Socioeconomic factors included: (i) education measured as literate vs. illiterate, because the majority did not continue beyond primary school; (ii) working status measured as ever worked vs. never worked; (iii) marital status represented as currently married vs. currently not married, and (iv) social support. The latter was computed from four items; each respondent was asked whether there is anyone that she can rely on if she needed (i) non-financial support, (ii) financial support, (iii) emotional support, and (iv) company in case she wanted to go somewhere. Respondents who gave less then 3 affirmative answers were classified as having poor social support, and those who gave 3 or more affirmative answers were classified as having strong social support. Socioeconomic variables also included questions about the subjects’ satisfaction with household income, and whether the respondents had progeny who lived with them at home. Health variables examined, related to current practice of any physical activities, and presence of disability. A respondent was considered to be disabled if she was unable to perform one of the Activities of Daily Living (KATZ, FORD, MOSKOWITZ, JACKSON, & JAFFE, 1963) or the Instrumental Activities of Daily Living (Lawton & Brody, 1969). The dependent variable, definite depression, was computed from the short version of the Geriatric Depression Scale (GDS) that was developed in 1986 by Sheikh and Yesavage (Fountoulakis et al., 1999a). The GDS questionnaire has been tested in multiple settings and countries where it yielded a sensitivity of 70.6 % to 92.2% and a specificity of 70.1% to 95.2% (Fountoulakis et al., 1999b), (Fernandez-San Martin et al., 2002), (Chan, 1996). Furthermore, the GDS is the most popular depression scale used in elderly. A score of less than five positive responses indicates the absence of depression, a score of 5 to 10 indicates probable depression, and a score of more than 10 indicates definite depression (Allen et al., 1994).
Data was analyzed using SPSS 10.0 for Windows. Bivariate data analysis was performed and the chi square test was used to test for the association between the presence of depression on one hand, and selected demographic, socio-economic, and health factors on the other hand. The second step of analysis consisted of a logistic regression, where significant variables from the bivariate analysis, and other important covariates (age and education) were included in the model as independent variables and where the dependant variable was presence vs. absence of definite depression.
Results
The mean age of our sample was 68.3 years, with a standard deviation of 6.3 years. The majority 267 (63.2%) was Lebanese, 152 (36.0%) were Palestinian, and only 3 (0.8%) subjects did not report their nationality.
Table 1: Baseline demographic characteristics of the study participants across the three communities
a - Not all numbers (n) add up to 57, 164, and 202 respectively due to missing observations.
The geographical separation of the three communities was paralleled by substantial differences in baseline characteristics of the sample (table 1). For example, while Burj El Barajneh was mainly inhabited by Palestinians (90.9%), Hey El Sellom and Nabaa were almost exclusively Lebanese (100.0% and 98.5%, respectively). While Hey El Sellom and Burj El Barajneh were entirely Muslim communities, 85.1% of the respondents in Nabaa were Christians. Families in the Muslim communities had significantly more children; 87.0% and 83.8% of the women interviewed in Hey EL Sellom and Burj El Barajneh respectively had 4 children or more, compared to 69.5% of the women living in Nabaa.
Probable depression was diagnosed in 315 (74.5%) of the women while definite depression was diagnosed in 123 (29.6%) women.
Table 2: Distribution of study sample by presence of definite depression, and demographic, socio-economic and health factors.a - P value computed based on Chi square test
Table 2 shows the association of definite depression among the women with demographic, socio-economic and health factors. Nationality of the participants was significantly related to definite depression, where 41.6 % of the Palestinians had definite depression compared to 23.3 % of the Lebanese (P < 0.001). Elderly women’s perception of satisfaction with household income was also significantly associated with depression where 39.2% of those who stated that their household income was insufficient were depressed, compared to only 21.8 % of those who thought that their income was sufficient (P < 0.001). Definite depression was significantly associated with decreased physical activity where 37.0% of sedentary women and only 20.2% of women who engaged in regular bodily exercise were depressed (P < 0.001). Disability was also significantly related to definite depression with 40.7% of the disabled women suffering from depression compared to only 16.9% of non-disabled women (P < 0.001).
Table 3: Risk factors of definite depression among elderly women using logistic regressiona - Controlling for age and education
b - Odds Ratio c Confidence interval
Table 3 presents the results of the logistic regression model for definite depression, and the 4 independent variables that were significantly related to it on bivariate analysis, controlling for age and education. The association between definite depression and nationality (OR = 2.1, 95% CI: 1.3-3.4), satisfaction with household income (OR = 2.1, 95% CI: 1.4-3.4), practice of physical exercise (OR = 2.0, 95% CI: 1.2-3.3), and disability (OR = 2.4, 95% CI: 1.4-4.0) all remained significant.
Discussion
Depression among the elderly in general, and elderly women in particular, is an important public health concern because it is a major factor of disability and mortality. The prevalence and consequences of depression may be more profound in third world countries. This study revealed a high prevalence of definite depression among elderly women living in three diverse, underprivileged communities in the suburbs of Beirut, Lebanon.
This study is only one of very few that investigated determinants of depression among elderly women in the Middle East region. The prevalence rate (29.6%) of depression among elderly women from under-privileged communities in Lebanon is similar to findings from other countries in the Eastern Mediterranean region, where depression among elderly females reached 27.7% in Saudi Arabia (Abolfoutouh MA, Daffallah AA, Khan MY, Khattab MS, & Abdulmoneim I, 2001) and 33% in Turkey (Bekaroglu, Uluutku, Tanriover, & Kirpinar, 1991). Like this study, Abolfoutouh employed the GDS scale to assess depression, but classified the elderly as depressed if they scored only 5 points or more, which clearly led to an over estimation of depression. By contrast, depression among elderly women in the present context is much higher than that reported in a general county population study of the United States (4.4%) (Steffens et al., 2000), and that reported among women in a survey of 35 communities that used the GDS scale in Bangkok, Thailand (9.63%) (Thongtang et al., 2002). The higher prevalence of depression among elderly women in the Middle East may be linked to women’s rights and social roles. The United Nations Development Program (UNDP) report on Arab Human Development showed that gender inequality in employment was too high in the Arab world as compared to other Islamic, East Asian, and Sub Saharan African countries (United Nations Development Program (UNDP), 2003). Despite some advances in women’s rights in the Arab countries, women are still expected to perform all domestic chores and to be the main caregivers for the children and the husband. Of course, the stress in the lives of the women in our study is greatly aggravated by their poverty, thus being “the poor of the poor.”
In the present study, one of the important variables that correlated significantly with depression was nationality. Elderly Palestinian women were at higher odds of being depressed than the Lebanese women. This may be attributed to social and political factors. The Lebanese government policy is to prevent the integration of Palestinian refugees in Lebanon. In March 2001, a law was passed that denies Palestinians the right of buying property on Lebanese territory, a right given to other expatriates. Not possessing a house has been linked to increase morbidity (Kind, Dolan, Gudex, & Williams, 1998) and mortality (Breeze, Sloggett, & Fletcher, 1999). Furthermore, Palestinians are denied work in more than 60 occupations that mostly constitute white-collar jobs (Ajial Center for Statistics and Documentation, 2004). Palestinians in Lebanon do not have any retirement benefits, and have minimal access to good quality health care services, schools and universities (U.S Committee for Refugees, 2002). During the last decade there were cuts in the budget of the United Nations Relief and Works Agency (UNRWA) for Palestinian refugees. The fate of the refugees is neither self-determined nor clear. They do not know whether they are going to return to their homeland, remain in Lebanon, or end up in another country. Many elderly Palestinians who escaped during the 1948 war still carry the key to their houses in Palestine with the dream of returning home one day. It has been documented that uncertainty about the future may result in increased psychological distress among women (Ritsner, Ponizovsky, Nechamkin, & Modai, 2001). Historical dispossession, lack of current opportunities, and extremely harsh living conditions are all likely to play major roles in increasing depression among Palestinian refugees in Lebanon. In addition to any depression-specific intervention, the general living conditions and prospects of Palestinian refugees in Lebanon need to be improved in order to prevent and alleviate depression among this sub-population.
Depression has always been linked to poverty (Yen & Kaplan, 1999); our findings are not different in this respect. The significant association between depression and satisfaction with household income strongly suggests that financial difficulties are affecting the participants’ mental health. This is more true in Lebanon, a country with an unsteady economy where 28% of families live below the poverty line (Saab, Damluji, Lakkis N, & Usta J, 2003), and where the government does not provide all the elderly with sufficient pension plans (Sibai, Sen, Baydoun, & Saxena, 2004). The majority of the elderly therefore depend either on their own savings or on their progeny to make ends meet.
As shown in other studies (Strawbridge, Deleger, Roberts, & Kaplan, 2002b), the elderly women who declared practicing some kind of physical activities were less likely to be depressed. Of the 3 factors that proved to have a significant association with depression, physical activity is the one that can be most easily addressed as a focus for intervention. Introducing exercise programs may be a useful intervention to reduce depression. Policy makers should work on providing accessible and affordable exercise programs for the elderly. In view of the limited financial resources, one suggestion is to utilize the school premises within each community off the school hours as a place where the elderly can get together and participate in age-appropriate physical exercise programs 4 to 5 times a week. In addition to exercise, this gives the elderly the chance to socialize and meet new people. One can also employ women from the community to prepare and serve a hot meal to the elderly after their exercise session. This may help in reducing the financial hardships faced by these marginalized females in the communities studied. Serving a meal, besides its nutritional value, may encourage some elderly to attend the exercise sessions.
A significant relationship was found between depression and disability. This finding underlines the serious nature of elderly depression where it can lead to incapacity of performing the simple activities of daily living. Although this causality cannot be established by the present cross-sectional study, other longitudinal studies have recognized it (Beekman, Deeg, Braam, Smit, & Van Tilburg, 1997). Such an alarming association calls for increased efforts to detect and treat depression among the elderly.
Another problem arises when it comes to detection of depression, and that is stigmatization. Due to stigmatization, depressed elderly tend to conceal their condition and when they seek professional help, they are more likely to present with somatic symptoms. This usually leads to improper diagnosis by the primary care physician, (Kessler, Lloyd, Lewis, & Gray, 1999). Stigma has been strongly associated with mental health problems (Sadavoy, Meier, & Ong, 2004) (Ertugrul & Ulug, 2004). Furthermore, the World Health Organization classified stigma as a major difficulty related to managing mental health in the Arab countries and called for the need of stigma reduction campaigns (The Regional Comittee for the Eastern Mediterranean, 2004).
Neither age nor marital status were significantly linked to definite depression in the present study. This is interesting because the literature reports that geriatric depression increases in the older age groups (Mueller et al., 2004), and in elderly with no spouse (Lai, 2004). This difference may be due to the role that the extended family plays in oriental cultures in general and Lebanon in particular. Unlike Western countries where elderly of older age groups tend to live in nursing homes, it is almost a disgrace for a Lebanese family to place an elderly in a nursing home. In Lebanon, the nuclear and/or extended family has the duty of taking care of their elderly. The strength of these family bonds might prevent the older, and the unmarried Lebanese elderly from being more depressed.
The principal limitation of the present study resides in its design. Being cross-sectional, one cannot infer causal relationships. For example, there is considerable evidence in the literature indicating that a sedentary life style increases the risk of depression (Strawbridge, Deleger, Roberts, & Kaplan, 2002a). Nonetheless, lack of physical activity can be a product of depression, rather than a contributing factor. Another limitation is that only a small portion of the study sample (13.5%) came from Hey El Sellom. This is because the elderly in this area, who are originally from South Lebanon and Bekaa, move back to their original hometowns once they can no more work.
This study, along with other similar ones, will serve as a basis for some action; indeed, research activities are underway to develop appropriate interventions targeted at improving the life quality of these poor community-dwelling elderly. In the light of the discussed findings, efforts to improve the living conditions of these poor populations, especially of Palestinians, are needed. Involving the elderly in age-appropriate physical exercises may be a good intervention measure. General practitioners should be well trained to “think depression” in order not to miss the diagnosis, which would lead to a poorer prognosis and higher morbidity.
Acknowledgments
This work was carried out with the aid of a grant from the Wellcome Trust, which is an independent research-funding charity that aims to improve human and animal health.
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