Self-reported disability in relation to mortality in rural Malawi: a longitudinal study of over 16 000 adults.

Josephine E Prynn,Albert Dube,Oddie Mwiba,Steffen Geis,Hannah Kuper,Olivier Koole,Alison J Price,Joseph Mkandawire,Amelia C Crampin,Moffat Nyirenda,Elenaus Mwaiyeghele,Lackson Kachiwanda

doi:10.1136/bmjopen-2019-034802

Abstract

ObjectivesWe investigated whether self-reported disability was associated with mortality in adults in rural Malawi.SettingKaronga Health and Demographic Surveillance Site (HDSS), Northern Malawi.ParticipantsAll adults aged 18 and over residing in the HDSS were eligible to participate. During annual censuses in 2014 and 2015, participants were asked if they experienced difficulty in any of six functional domains and were classified as having disabilities if they reported ‘a lot of difficulty’ or ‘can’t do at all’ in any domain. Mortality data were collected until 31 December 2017. 16 748 participants (10 153 women and 6595 men) were followed up for a median of 29 months.Primary and secondary outcome measuresWe used Poisson regression to examine the relationship between disability and all-cause mortality adjusting for confounders. We assessed whether this relationship altered in the context of obesity, hypertension, diabetes or HIV. We also evaluated whether mortality from non-communicable diseases (NCD) was higher among people who had reported disability, as determined by verbal autopsy.ResultsAt baseline, 7.6% reported a disability and the overall adult mortality rate was 9.1/1000 person-years. Adults reporting disability had an all-cause mortality rate 2.70 times higher than those without, and mortality rate from NCDs 2.33 times higher than those without.ConclusionsSelf-reported disability predicts mortality at all adult ages in rural Malawi. Interventions to improve access to healthcare and other services are needed.

Highlights

Disability is a complex concept encompassing long-term physical, mental, intellectual or sensory impairments which, in interaction with personal and environmental factors, may limit people’s participation in society on an equal basis with others.[1]
Setting and data collection The Karonga Health and Demographic Surveillance Site (HDSS) in Northern Malawi comprises a population of around 40 000 individuals, which is largely representative of the rural Malawian population in terms of age and sex structure.[11 12]
Verbal autopsy is done after every death using a semistructured interview of a family member using an adaptation of a WHO instrument.[13]

Summary

Introduction

Disability is a complex concept encompassing long-term physical, mental, intellectual or sensory impairments which, in interaction with personal and environmental factors, may limit people’s participation in society on an equal basis with others.[1]. ►► A limitation of the study is that we have considerable missing data in chronic health states (body mass index, hypertension, diabetes, HIV), which limits our understanding of how these are related to disability and mortality, and that verbal autopsies were used to establish cause of death. Disability is expected to be linked to increased mortality through various pathways Both disability and mortality are related to ageing and poverty, and so associations may arise through confounding.[1 2] An underlying disease may cause both disability and mortality, for instance, diabetes can lead to impairments (eg, visual impairment from diabetic retinopathy) and premature death. People with disabilities may find it more difficult to seek healthcare due to a range of barriers,[1] thereby increasing their mortality risk.

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