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Upadhye, M; Mabey, D (2005) Chronic Fatigue in Developing Coun- Tries: Population Based Survey of Women in India

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Upadhye, M; Mabey, D (2005) Chronic Fatigue in Developing Coun- Tries: Population Based Survey of Women in India View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by LSHTM Research Online Patel, V; Kirkwood, BR; Weiss, H; Pednekar, S; Fernandes, J; Pereira, B; Upadhye, M; Mabey, D (2005) Chronic fatigue in developing coun- tries: population based survey of women in India. BMJ (Clinical re- search ed), 330 (7501). p. 1190. ISSN 0959-8138 Downloaded from: http://researchonline.lshtm.ac.uk/13709/ Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: Creative Commons Attribution Non-commercial No Derivatives http://creativecommons.org/licenses/by-nc-nd/2.5/ 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 Abstract symptom presumptively. Such preparations account for the larg- est category of drugs dispensed in South Asia.3 Objectives To describe the prevalence of and risk factors for Little research has been done on the associations of fatigue chronic fatigue in a developing country; in particular, to with psychological factors in developing countries, particularly determine the association of anaemia, mental health, and in the context of the high prevalence of anaemia and poor nutri- gender disadvantage factors with chronic fatigue. tion. We hypothesised that the principal association of fatigue Design Community survey. was with psychosocial risk factors, similar to patterns seen in Setting Primary health centre catchment area in Goa, India. 4 Participants 3000 randomly sampled women aged 18 to 50 developed countries, and with factors reflecting gender years. disadvantage that are important determinants of women’s 56 Main outcome measures Data on the primary outcome health. (reporting of fatigue for at least six months) and psychosocial exposures elicited by structured interview; presence of anaemia determined from a blood sample. Methods Results 2494 (83%) women consented to participate; 12.1% (95% confidence interval 10.8 to 13.4%) complained of chronic Participants fatigue. In multivariate analyses, older women (P = 0.03) and We recruited participants from the Aldona Primary Health Cen- those experiencing socioeconomic deprivation—less education tre catchment area, north Goa, India. The sampling frame (P < 0.001), families in debt (P = 0.09), or hunger in the past consisted of 8595 women aged 18-45 years listed in the family three months (P = 0.03)—were more likely to report chronic health registers; we randomly selected 3000 women. As the fam- fatigue. After adjustment for these factors, factors indicating ily registers varied in date, we expected that some women listed gender disadvantage (notably sexual violence by the husband; as aged 45 were likely to be older at the time of the study. Inclu- P < 0.001) and poor mental health (P < 0.001) were strongly sion criteria for the study were age between 18 and 50 years, associated with chronic fatigue. Although women with a high being resident in the area for the next 12 months, speaking one body mass index had a reduced risk, suggesting an influence of of the study languages, not having cognitive impairment, and not poor nutrition, no association was found between chronic being pregnant. If a selected woman did not meet these criteria fatigue and haemoglobin concentrations. or was no longer living in the area, the researcher replaced her Conclusions Chronic fatigue was commonly reported by by using a priori steps to identify another eligible woman. women in this community study from India. The strongest Recruitment took place from November 2001 to May 2003. associations with chronic fatigue were for psychosocial factors We gave written information on the project to each selected indicative of poor mental health and gender disadvantage. woman. We scheduled a visit to her home soon after this, at which time consent was obtained. All participants were offered free care by the study gynaecologists and mental health Introduction professionals if needed. The epidemiology of chronic fatigue has mainly been described 1 Data collection in developed countries. In these settings, a significant proportion of people with chronic fatigue do not have a demon- We used a semistructured interview to elicit data on personal strable physical disorder and are often found to have other history and health history. Items were derived from existing somatoform disorders (disorders characterised by medically interviews used in other studies of reproductive and mental 7–9 unexplained physical symptoms) or common mental disorders health in Goa. We estimated haemoglobin concentration from such as depression and anxiety. Fatigue is a common symptom a finger prick sample of blood, by using the Hemocue system. among women in developing countries. In a survey in India, This system has been used in field surveys for estimating haemo- nearly a quarter of women complained of feeling weak or tired; globin in capillary blood and gives results comparable to more than half of them had had these problems for more than estimates obtained by sophisticated laboratory methods.810 A six months.2 Fatigue in women has often been attributed to gynaecologist did a general medical examination for participants nutritional deficiencies and anaemia. Physicians are likely to pre- who consented. We organised the data collected from these three scribe iron, vitamins, and nutritional supplements to treat the sources as follows. BMJ Online First bmj.com page 1 of 7 Primary care Socioeconomic risk factors World Health Organization 12 item disability assessment sched- We collected information on age, education, religion, and marital ule, the precursor of which (the brief disability questionnaire) has status from all participants sampled, including those who refused been used in Goa.8 The WHO schedule generates a total score to participate. We measured economic status through type of and a measure of the number of days in the previous 30 days that housing, access to water and a toilet, household composition and the participant had to cut back her usual activities. income, employment status, indebtedness, and experience of hunger in the previous three months. Outcome We defined the outcome on the basis of the responses to the Psychological factors fatigue section of the revised clinical interview schedule. This We used two measures of psychological factors. The scale for section has two optional questions on fatigue: (1) Have you somatic symptoms measures somatic symptoms that are features noticed that you’ve been getting tired in the past month? (2) 11 of somatoform disorders and has been used previously in India. During the past month have you felt you’ve been lacking in The scale elicits experience of four categories of somatic energy? Participants who answer positively to either of these are symptoms in the previous two weeks: pain related symptoms asked a series of four questions about the severity of the such as headache and body ache; sensory symptoms such as hot problem: (1) In the past seven days, on how many days have you or cold sensations and tingling; non-specific symptoms such as felt tired or lacking in energy? (2) Have you felt tired or lacking tiredness and weakness; and biological function symptoms such in energy for more than three hours in total, or most of the day, as poor sleep and constipation. Each symptom is rated on a on any day in the past seven days? (3) Have you felt tired or lack- Likert-type scale of 0-2 indicating increasing severity. We ing in energy so that you’ve had to push yourself to get things summed the scores on the pain related symptoms and sensory done during the past seven days? (4) Have you felt tired or lack- symptom scales to generate a somatoform disorder symptom ing in energy when doing things that you enjoy during the past score for each participant (range 0-20). The second measure was seven days? the revised clinical interview schedule, a structured interview for Each question generates a score of 0 or 1 based on the sever- the measurement of common mental disorders in community ity of the problem, so that a participant may obtain a total score 12 settings. The Konkani language version of the schedule used in of 0-4. We defined the outcome of chronic fatigue as a score of at 13 the study had been previously used in Goa. The interview con- least 1 on the fatigue section of the revised clinical interview sists of 14 sections, each covering specific symptoms such as schedule (that is, participants who had experienced fatigue in the anxiety, depression, irritability, fatigue, obsessions, compulsions, past month and had scored at least 1 on the severity questions) and panic. The sum of the section scores, excluding the fatigue and having experienced fatigue for a minimum duration of the item scores, generated a total score (range 0-53), which we used past six months. as a measure of non-psychotic psychiatric morbidity. Analysis Gender disadvantage and social support We used logistic regression for all analyses, with chronic fatigue Questions on gender disadvantage and social support covered coded as a binary outcome (present or absent). Firstly, we four domains. The first domain was the lifetime experience of estimated the association of each socioeconomic factor with the verbal, physical, and sexual violence by the spouse and concerns outcome; all determinants for which the association reached sig- about the spouse’s extramarital relationships and substance use nificance at P ≤ 0.1 were included in a multivariate model. All habits. The second domain inquired about the autonomy the factors that remained significantly associated with the outcome participant had to make decisions about visiting her mother or a in this model were included in subsequent steps. Next, we friend’s home, seeing a doctor, keeping money aside for personal estimated the association of the outcome with factors in the use, and having time to do things for herself.
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