Transcript of Professor M.A. Razzaque Deptt. Of Statistics, Rajshahi University, Bangladesh & Dr. Md. Golam...
- Slide 1
- Professor M.A. Razzaque Deptt. Of Statistics, Rajshahi
University, Bangladesh & Dr. Md. Golam Mostofa Deptt. Of
Population science & HRD, R.U.
- Slide 2
- Introduction Health status on the basis of self-reporting
become popular and has been recognized in lower income society like
Bangladesh. A considerable number of researches confirm the
usefulness of culturally appropriate, easily recorded self-
reported health (SRH) assessments as indicators of underlying
health status of a survey population (Rahman et al. 1999; Zimmer et
al. 2000; Yu et al. 1998).
- Slide 3
- Introduction (Contd.) Statistical significance of differentials
in self- reported health (SRH) measures of Bangladesh Urban Health
Survey (BUHS)-2006 have been studied in this piece of work. The
measures included in the survey are: Assessments of activities of
daily living (ADL), personal health status, and recent experience
of serious illness, recent injuries, adult nutrition status,
hypertension, and diabetes. The last three SRH measures are related
with anthropometric assessments and biomarkers.
- Slide 4
- Introduction (Contd.) The modified and abbreviated ADL scale
was used at the data gathering stage of the BUHS-2006, where ADL
assessment was undertaken in the context of general population
survey covering the age range 10- 59. Generally ADLs are a set of
basic everyday activities or tasks that an individual should be
able to perform in order to maintain independence in self-care and
participate in their routine social, occupational, and family
activities.
- Slide 5
- Introduction (Contd.) The most common ADL measures are based on
Katz Activities of Daily Living Scale (e.g. ability to eat, bathe,
dress, transfer from seated to a standing position, use of the
toilet without assistance). In the modified and abbreviated scale
included four additional ADL items measuring dimensions of
functionality capturing strength and gross mobility and range of
motion.
- Slide 6
- Introduction (Contd.) Urban Health Survey -2006 was the first
of this kind of survey in Bangladesh. The survey obtained
information through a micro-level interview of communities,
households and individuals throughout the city corporations and a
sample of district municipalities. One of the main objectives of
the survey was To identify vulnerable groups and examine their
health profile and care seeking behavior. In this article we have
tried to identify the vulnerable groups and their association with
some risk factors. We have also calculated the numerical value of
the risk of being vulnerable in relation to some risk factors.
- Slide 7
- Methodology For testing the significance a particular
proportion in a univariate distribution of a categorical variable,
we use Z test. If the population proportion of a particular
category is, then the necessary test statistic is Which follows the
standard normal distribution, where p is the sample proportion of
the given category, n is total observations and q=1-p.
- Slide 8
- Methodology (Contd.) Equality of proportion tests are performed
with two proportions considering the variation in residence,
marital status and educational level. When the sample observations
based on which the population proportions are estimated are large,
Z- statistic is used to test the equality between the proportions
of the categories. The test statistics is defined as which follows
the standard normal distribution.
- Slide 9
- Methodology (Contd.) Here p 1 is the estimate of the population
proportion of the first category and p 2 is the estimate of the
population proportion of the second category. n is the total number
of observations in the combined group i.e. n=n 1 +n 2, n 1 and n 2
are the sample sizes of the two groups. The combined proportion and
q=1 p.
- Slide 10
- Methodology (Contd.) Let us abbreviate the group of person
having Health related functional difficulties as HRFD and having no
health related functional difficulties as Non-HRFD. We have used
these abbreviations in tables for computing odds ratios. Odds
Ratios: A condition, physical characteristic, or behavior that
increases the probability (Risk) that a currently healthy
individual will develop a particular disease is termed as risk
factor for that disease.
- Slide 11
- Methodology (Contd.) In this study we have considered some
Environmental and Social risk factors in relation to SRH
difficulties. Since a large scale survey is Cross-sectional in
nature (here individuals are concurrently classified as diseased or
disease-free and exposed or non-exposed at a single point of time),
prevalence rates are compared between those exposed and those not
exposed to certain risk factor. In this type of study outcomes are
evaluated in terms of the Odds Ratio (OR) and the chi-square
test.
- Slide 12
- Methodology (Contd.) The odds ratio provides a measure of the
strength of the association between the dichotomous exposure and
the outcome variables. This ratio compares the odds that exposed
and non-exposed individuals will have the disease. The odds ratio
is calculated by the formula given below: Where,
- Slide 13
- Methodology (Contd.) The larger the value of OR, the stronger
the association between the disease in question and exposure to
risk factor. The value of OR close to 1 indicates that the disease
and exposure to the risk factor are unrelated. Values of OR less
than 1 indicate a negative association i.e. there is a protective
effect between the risk factor and the disease.
- Slide 14
- Methodology (Contd.) Attributable Risk (AR) defines the excess
risk of disease that can be ascribed to exposure to the risk
factor, over and above that experienced by people who are not
exposed. It thus provides an estimate of the number of cases of the
disease that might be prevented if exposure to risk factor were
eliminated and is useful for determining the magnitude of the
public health problem posed by such exposure. Attributable risk can
be calculated by the formula:
- Slide 15
- Methodology (Contd.) Population attributable risk (PAR) is a
measure of excess risk of disease in a population that can be
solely attributed to the risk factor. PAR= AR*P(exposure).
- Slide 16
- Results The description of the hypotheses that we tested and
the conclusions drawn from the test results are presented below:
The first hypothesis we tested is regarding health related
functional difficulties among currently married females living in
urban slums and non-slums.
- Slide 17
- Results (Contd.) Let 1 be the proportion of currently married
females living in slums and having health related functional
difficulties, and 2 be the proportion of currently married females
living in non-slums and having health related functional
difficulties. The computed value of the Test statistic
- Slide 18
- Results (Contd.) The null hypothesis is rejected. So we can
infer that there is significant difference in the health related
problems among the proportion of currently married females living
in slums and non-slums. Thus it is revealed that same types of
health facilities are not available in slum and non-slum areas of
Bangladesh. We can also say that dissemination of health knowledge
and facilities throughout the country are not just. As in the case
of economy there are lots of disparities among the slum and
non-slum population.
- Slide 19
- Results (Contd.) It is to be noted that health sector is one of
the areas where Bangladesh is ahead of its neighboring Asian
countries. The government of Bangladesh also were praised and
prized by the United Nations in this regard, still there are
disparities in health facilities of the slums and non-slums of the
urban areas. Finally we can infer that public health facilities are
not evenly distributed in Bangladesh. Further to find the
contribution of this risk factor (residence type) we conducted the
following risk analysis.
- Slide 20
- Results (Contd.) Health status Risk factors Slum Non- slum
ARPAROR HRFD14779710.0320.0081.31 Non- HRFD 53284576
- Slide 21
- Results (Contd.) From the above risk analysis we can comment
that association exists between health related functional
difficulties and type of residence. People living in the slums are
1.31 times more vulnerable to HRFD than those living in the
non-slums. Risk of having HRFD in the slum is increased by
approximately 0.032. Assuming that P(HRFD) is 0.25, based on the
report of medical literature the PAR=0.008 i.e. the excess risk of
HRFD in the slum population is 0.008.
- Slide 22
- Results (Contd.) Further Attributable Fraction in Exposed
group=AR/P(HRFD|Exposed)=0.032/0.217= 0.15. So we can say that 15%
of the excess HRFD that occurred among those exposed were
attributable to the risk of being the residents of slums. Having
the above findings we are interested to know whether currently
married women are more vulnerable to health related problems than
other categories of women. In this case we have compared the group
with the divorcees, because aged and divorces in our country are
currently enjoying a few economic safety net programmers.
- Slide 23
- Results (Contd.) For this we have developed the hypothesis
regarding functional difficulties of currently married women and
divorcees living in the same type of residential area. Let 1 be the
proportion of currently married females living in slums and having
health related functional difficulties, and 2 be the proportion of
divorcee females living in slums and having health related
functional difficulties.
- Slide 24
- Results (Contd.) The computed value of the Test statistic
- Slide 25
- Results (Contd.) The null hypothesis is rejected. So we can
infer that there is significant difference in the health related
problems among the proportion of currently married females living
in slums and the proportion of divorcees in slums. We can say that
in slums the proportion of currently married females having health
related functional difficulties is significantly higher than that
of divorcees in the slums. Huge burden of the family on the
currently married females of the slums may have contributed for
this significant difference. We must note that these categories of
females are to take care of their children in addition to their
household works.
- Slide 26
- Results (Contd.) Also these women sometimes are to work in
garments or as maid. So it is clear that the nature of the life
style of the currently married females in slums may have
contributed for having more health related problems. Further the
extent of help given by the husbands of the currently married
females of slums may be not up to the expectation. From these
findings we can infer that currently married women in slums need
special public health programs. To verify this finding we conducted
the similar test of significance for the same categories of
respondents living in non-slums and having health related
problems.
- Slide 27
- Results (Contd.) Let 1 be the proportion of currently married
females living in non-slums and having health related functional
difficulties, and 2 be the proportion of divorcee females living in
non-slums and having health related functional difficulties. The
computed value of the Test statistic
- Slide 28
- Results (Contd.) We are at the same conclusion that currently
married women of non-slums are more vulnerable to health related
problems than the divorcees of the non-slums. Since we have
concluded that public health facilities are not evenly distributed
in slums and non-slums in Bangladesh, so special public health
programs for currently married women are to be launched to keep
this sect of population physically fit as far as possible. Because
this is the age group of childbearing and child caring. The health
of our future children heavily depends on this group. The
government should also think about the safety net programs for this
vulnerable group.
- Slide 29
- Results (Contd.) Health status Risk factors Currently married
Divorce, Separate, widowed ARPAROR HRFD11612150.0580.0120.75 Non-
HRFD 4237587
- Slide 30
- Results (Contd.) There is protective effect of marital status
i.e. currently married women are 0.75 times less vulnerable to HRFD
than Divorcees, Separated and Widows. It is to be noted that many
divorcees are under the safety net programs of the government. May
be these have contributed to have less functional difficulties
among the divorcees. To test this hypothesis we have taken the
proportions of divorcees with health related functional
difficulties from slums and non-slums and proceeded with the
following test of significance.
- Slide 31
- Results (Contd.) Let 1 be the proportion of divorcee females
living in slums and having health related functional difficulties,
and 2 be the proportion of divorcee females living in non-slums and
having health related functional difficulties. The computed value
of the Test statistic
- Slide 32
- Results (Contd.) The test of significance clearly indicates
that there is no significant difference in proportions between the
divorcees of slums and non- slums having health related functional
difficulties. So the safety net programs for the divorcees and
their less-burden may have positive impact on the general health of
the divorcees in the society. Thus we can again say special public
health programs are needed for the currently married women in
Bangladesh. These public health programs should also include the
family planning issues, otherwise the country will be further
burdened by its population growth. Public health education programs
should also be continued to impart knowledge to reduce health
related problems.
- Slide 33
- Results (Contd.) To see the impact of the public health
education we studied the impact of education on the health related
problems of females in slums having education Secondary incomplete
and Secondary or higher levels. We proceed with the following test
of significance. Let 1 be the proportion of females having health
related functional difficulties with incomplete secondary level of
education and living in slums, and 2 be the proportion of females
having health related functional difficulties with secondary and
higher education and living in slums.
- Slide 34
- Results (Contd.) The computed value of the Test statistic We
noticed from the test of significance that education has impact on
the health related functional difficulties in women. So we can say
spread and upliftment of education in general and transmission of
health education through public health programs for females will
contribute a lot in reducing health related functional
difficulties.
- Slide 35
- Results (Contd.) Health status Risk factors Secondary
incomplete Secondary or higher ARPARORAFE
HRFD270690.0470.011.340.21 Non- HRFD 951326
- Slide 36
- Results (Contd.) Association exists between health related
functional difficulties and level of education. People who have not
completed secondary education are 1.34 times more vulnerable to
HRFD than those with secondary and higher education. For people who
have not completed secondary education, her risk of having HRFD is
increased by approximately 0.05. Assuming that P(HRFD) is 0.25,
based on the report of medical literature the PAR= 0.01 i.e. the
excess risk of HRFD in the population who have not completed
secondary education is 0.01.
- Slide 37
- Results (Contd.) Further Attributable Fraction in Exposed group
=AR/P(HRFD/Exposed)=.047/0.221= 0.21. So we can say that 21 % of
the excess HRFD that occurred among those exposed were attributable
to the risk factor Incomplete Secondary level education We have
also studied the impact of economic status on the health related
functional difficulties. The results are presented below.
- Slide 38
- Results (Contd.) We have also studied the impact of economic
status on the health related functional difficulties. The results
are presented below. Risk factors Health status
PoorestRichestARPAROR HRFD607400.0810.0091.81 Non- HRFD
1890225
- Slide 39
- Results (Contd.) High Association exists between health related
functional difficulties and economic condition. People who are at
the poorest quintile are 1.81 more vulnerable to HRFD than the
richest. Risk of having HRFD of the poorest is increased by
approximately 0.08. Assuming that P(HRFD) is 0.25, based on the
report of medical literature the PAR= 0,01 i.e. the excess risk of
HRFD in the poorest population is 0.02.
- Slide 40
- Results (Contd.) Further Attributable Fraction in Exposed group
=AR/P(HRFD/Exposed)=.081/0.243= 0.33. So we can say that 33 % of
the excess HRFD that occurred among those exposed to risk factor
were attributable to the risk of being poor.
- Slide 41
- Discussion and Conclusion The study reveals that there is
significant difference in the health related problems among the
proportion of currently married females living in slums and non-
slums. From the risk analysis it is revealed that association
exists between health related functional difficulties and type of
residence. People living in the slums are 1.34 times more
vulnerable to HRFD than those living in the non-slums.
- Slide 42
- Discussion and Conclusion(Contd.) It is to be noted that health
sector is one of the areas where Bangladesh is ahead of its
neighboring Asian countries. The government of Bangladesh also were
praised and prized by the United Nations in this regard. To
maintain the achievements public health facilities are to be evenly
distributed in Bangladesh.
- Slide 43
- Discussion and Conclusion(Contd.) We noted that there is
significant difference in the health related problems among the
proportion of currently married females living in slums and the
proportion of divorcees in slums. We can say that in slums the
proportion of currently married females having health related
functional difficulties is significantly higher than that of
divorcees in the slums. Huge burden of the family on the currently
married females of the slums may have contributed for this
significant difference.
- Slide 44
- Discussion and Conclusion(Contd.) We must note that these
categories of females are to take care of their children in
addition to their household works. Also these women sometimes are
to work in garments or as maid. So it is clear that the nature of
the life style of the currently married females in slums may have
contributed for having more health related problems. Further the
extent of help given by the husbands of the currently married
females of slums may be not up to the expectation. From these
findings we can infer that currently married women in slums need
special public health programs.
- Slide 45
- Discussion and Conclusion(Contd.) Since we have concluded that
public health facilities are not evenly distributed in slums and
non-slums in Bangladesh, so special public health programs for
currently married women are to be launched to keep this sect of
population physically fit as far as possible. This the group of
childbearing and child caring age. The health of our future
children heavily depends on this group. The government should also
think about the safety net programs for this vulnerable group. It
is to be noted that many divorcees are under the safety net
programs of the government.
- Slide 46
- Discussion and Conclusion(Contd.) The test of significance
clearly indicates that there is no significant difference in
proportions between the divorcees of slums and non-slums having
health related functional difficulties. The safety net programs for
the divorcees and their less burden may have positive impact on the
general health of the divorcees in the society. Thus we can
strongly recommend for special public health programs the currently
married women in Bangladesh.
- Slide 47
- Discussion and Conclusion(Contd.) These public health programs
should also include the family planning issues, otherwise the
country will be further burdened by its population growth. Public
health education programs should also be continued to impart
knowledge to reduce health related problems.
- Slide 48
- Discussion and Conclusion(Contd.) We noticed from the test of
significance and risk analysis that education has impact on the
health related functional difficulties in women. So we can
recommend for spread and upliftment of education in general and
transmission of health education through public health programs for
females will contribute a lot in reducing health related functional
difficulties.
- Slide 49
- Discussion and Conclusion(Contd.) Finally there is protective
effect of marital status i.e. currently married women are 0.75
times less vulnerable to HRFD than Divorcees, Separated and Widows.
The great advantage of marriage bonding specially in Asian region
should be continued and if necessary special packages can be
introduced specially for the poor to continue their married life.
Because the married life of the poor are sometimes hindered by
economic hardship.
- Slide 50
- Discussion and Conclusion(Contd.) It is to be noted that high
association exists between health related functional difficulties
and Economic condition. People who are at the poorest quintile are
1.81 more vulnerable to HRFD than the Richest.
- Slide 51
- Abstract Urban Health Survey -2006 was the first of this kind
of survey in Bangladesh. The survey obtained information through a
micro- level interview of communities, households and individuals
throughout the city corporations and a sample of district
municipalities. One of the main objectives of the survey was To
identify vulnerable groups and examine their health profile and
care seeking behavior. One of the findings of Bangladesh Urban
Health Survey (BUHS)- 2006 report says Respondents in slums (21 to
26 percent) were more than their non-slum (13 to 19 percent) or
District Municipality (15 to 16 percent) counterparts to report a
health- related functional difficulty in the past months.
- Slide 52
- Abstract (Contd.) Like these there are many descriptions where
the report narrates the findings in terms of percentage of the
events related to health related functional difficulties. But the
statistical significance of the numerical results has not been
tested. This paper evaluates the statistical significance of the
results presented in the BUHS report. Statistical analyses have
been carried out using the test of significance for (i) proportion
(ii) equality of proportions and (iii) finding the Odds ratios of
the exposed group (having self-reported health problems) in
relation to time, education level, residence type, gender and age
of the respondents. Based on these analyses some recommendations
have been made for policy development in public health sector to
reduce SRH problems in Bangladesh.