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Population Based Survey of Women in India Chronic Fatigue In Downloaded from bmj.com on 4 June 2005 Chronic fatigue in developing countries: population based survey of women in India Vikram Patel, Betty R Kirkwood, Helen Weiss, Sulochana Pednekar, Janice Fernandes, Bernadette Pereira, Medha Upadhye and David Mabey BMJ 2005;330;1190-; originally published online 3 May 2005; doi:10.1136/bmj.38442.636181.E0 Updated information and services can be found at: http://bmj.com/cgi/content/full/330/7501/1190 These include: References This article cites 19 articles, 5 of which can be accessed free at: http://bmj.com/cgi/content/full/330/7501/1190#BIBL Rapid responses 7 rapid responses have been posted to this article, which you can access for free at: http://bmj.com/cgi/content/full/330/7501/1190#responses You can respond to this article at: http://bmj.com/cgi/eletter-submit/330/7501/1190 Email alerting Receive free email alerts when new articles cite this article - sign up in the service box at the top right corner of the article Topic collections Articles on similar topics can be found in the following collections • Medicine in Developing Countries (883 articles) • Somatoform disorders (32 articles) Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to BMJ go to: http://bmj.bmjjournals.com/subscriptions/subscribe.shtml Downloaded from bmj.com on 4 June 2005 Primary care Chronic fatigue in developing countries: population based survey of women in India Vikram Patel, Betty Kirkwood, Helen Weiss, Sulochana Pednekar, Janice Fernandes, Bernadette Pereira, Medha Upadhye, David Mabey London School of Abstract and nutritional supplements to treat the symptom pre- Hygiene and Tropical Medicine, sumptively. Such preparations account for the largest Objectives To describe the prevalence of and risk 2 London category of drugs dispensed in South Asia. WC1E 7HT factors for chronic fatigue in a developing country; in Little research has been done on the associations of Vikram Patel particular, to determine the association of anaemia, fatigue with psychological factors in developing coun- reader in mental health, and gender disadvantage factors with international mental tries, particularly in the context of the high prevalence health chronic fatigue. of anaemia and poor nutrition. We hypothesised that Betty R Kirkwood Design Community survey. the principal association of fatigue was with psycho- professor of Setting Primary health centre catchment area in Goa, epidemiology and social risk factors, similar to patterns seen in developed India. 3 international health countries, and with factors reflecting gender disadvan- Helen Weiss Participants 3000 randomly sampled women aged 18 tage that are important determinants of women’s senior lecturer in to 50 years. health.45 epidemiology and Main outcome measures Data on the primary statistics David Mabey outcome (reporting of fatigue for at least six months) professor of and psychosocial exposures elicited by structured Methods communicable interview; presence of anaemia determined from a diseases Participants blood sample. The sampling frame consisted of 8595 women aged Sangath, 831/1 Results 2494 (83%) women consented to participate; Porvorim, Goa, 18-45 years listed in the family health registers in an India 12.1% (95% confidence interval 10.8 to 13.4%) area of north Goa; we randomly selected 3000 women. Sulochana complained of chronic fatigue. In multivariate Inclusion criteria for the study were age between 18 Pednekar analyses, older women (P = 0.03) and those research coordinator and 50 years, being resident in the area for the next 12 experiencing socioeconomic deprivation—less Janice Fernandes months, speaking one of the study languages, not researcher education (P < 0.001), families in debt (P = 0.09), having cognitive impairment, and not being pregnant. Bernadette Pereira hunger in the past three months (P = 0.03)—were If a selected woman did not meet these criteria or was researcher more likely to report chronic fatigue. After adjustment no longer living in the area, the researcher replaced Medha Upadhye for these factors, factors indicating gender researcher her by using a priori steps to identify another eligible disadvantage (notably sexual violence by the husband; Correspondence to: woman. Recruitment took place from November 2001 VPatel P < 0.001) and poor mental health (P < 0.001) were to May 2003. Vikram.patel@ strongly associated with chronic fatigue. Although lshtm.ac.uk women with a high body mass index had a reduced Data collection risk, suggesting an influence of poor nutrition, no We used a semistructured interview to elicit data on BMJ 2005;330:1190–3 association was found between chronic fatigue and personal history and health history. Items were derived haemoglobin concentrations. from existing interviews used in other studies.6–8 We Conclusions Chronic fatigue was commonly reported estimated haemoglobin concentration from a finger by women in this community study from India. The prick sample of blood. A gynaecologist did a general strongest associations with chronic fatigue were for medical examination for participants who consented. psychosocial factors indicative of poor mental health We organised the data as follows. and gender disadvantage. Socioeconomic risk factors—We collected information on age, education, religion, and marital status from all Introduction participants, including those who refused to partici- pate. We measured economic status through type of Fatigue is a common symptom among women in housing, access to water and a toilet, household developing countries. In a survey in India, nearly a composition and income, employment status, quarter of women complained of feeling weak or tired; more than half of them had had these problems for more than six months.1 Fatigue in women has often This is the abridged version of an article that was posted on been attributed to nutritional deficiencies and anae- bmj.com on 3 May 2005: http://bmj.com/cgi/doi/10.1136/ mia. Physicians are likely to prescribe iron, vitamins, bmj.38442.636181.E0 1190 BMJ VOLUME 330 21 MAY 2005 bmj.com Downloaded from bmj.com on 4 June 2005 Primary care indebtedness, and experience of hunger in the Results previous three months. Psychological factors—We used two measures of psy- Of the 3000 randomly selected women, 2494 (83.1%) chological factors. The scale for somatic symptoms consented to participate in the study. The most measures somatic symptoms that are features of common reasons for refusal were that the woman did somatoform disorders and has been used previously in not have time to participate (265, 52.4%) or that a India.9 The scale elicits experience of four categories of family member had not given permission (95, 18.8%). somatic symptoms in the previous two weeks. We Compared with participants, women who refused were summed the scores on the pain related symptoms and less likely to be ethnic non-Goans, more likely to be sensory symptom scales to generate a somatoform dis- Christian, more likely to be unmarried, younger, and order symptom score. The second measure was the more educated. Of those who participated, 957 (38.4%) revised clinical interview schedule, a structured replaced a randomly selected woman; the most interview for the measurement of common mental dis- common reasons for replacement were that the orders in community settings. A version of the selected woman was no longer resident (400, 41.8%) or schedule used in the study had been previously used in was unlikely to be resident for the duration of the study Goa.10 The sum of the section scores, excluding the (45, 4.7%) and errors in the records of the family health fatigue item scores, generated a total score which we register (381, 39.8%). used as a measure of non-psychotic psychiatric Fatigue was reported by 423 (17.0%) participants, morbidity. of whom 301 (12.1%, 95% confidence interval 10.8% to Gender disadvantage and social support—Questions 13.4%) had experienced it for at least six months. Par- on gender disadvantage and social support covered ticipants who were experiencing chronic fatigue had four domains. The first domain was the lifetime experi- significantly poorer WHO disability assessment sched- ence of verbal, physical, and sexual violence by the ule scores (mean score 14.1 (SD 2.5) v 12.4 (1.3); − spouse and concerns about the spouse’s extramarital t = 19.03, P < 0.0001); they reported having to cut relationships and substance use habits. Questions in back on their daily activities on an average of 3.0 (2.2 to the second domain were summed to generate an 3.9) days in the previous month compared with an autonomy score. Questions in the third domain were average of 0.5 (0.3 to 0.6) days for participants who had summed to generate a social integration score. Finally not experienced chronic fatigue (P < 0.001). we summed the questions in the last domain to gener- Associations with socioeconomic risk factors ate a family support score (see bmj.com). Older participants, participants living in households Physical health and anaemia—We asked all partici- with more than three children under the age of 18, and pants about any pregnancies and asked participants those facing socioeconomic difficulties were signifi- who were sexually active in the past year about any dif- cantly more likely to be experiencing chronic fatigue ficulty in conception and their use of contraceptives. (see bmj.com). However, we found no association with We evaluated anaemia as a categorical variable. We household income. Compared with married partici- measured weight, height, and blood pressure. We pants, single participants had a lower risk, whereas measured disability by using the World Health Organi- divorced or widowed participants had a higher risk. In zation 12 item disability assessment schedule. This multivariate analyses, the following factors were signifi- generates a total score and a measure of the number of cantly associated with chronic fatigue: lower education days in the previous 30 days that the participant had to (school completers v no education; odds ratio = 0.57, cut back her usual activities.
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