Discussion
Summary of the study findings
In Bangladesh, nearly two-fifths of the elderly population does not meet the WHO PA recommendations. The overall prevalence of IPA among women and men was similar. Besides, the prevalence of IPA was higher among the higher age groups, residents of non-slum urban areas, educated men, people with self-reported NCDs (hypertension, diabetes, heart diseases and asthma) and those with higher waist circumferences. The study also revealed several socio-demographic, behavioural, clinical and anthropometric factors associated with IPA. Among these factors, higher age, residence in non-slum urban areas, being unemployed or homemaker, not being currently married, sedentary behaviour, and self-reported hypertension were associated with IPA in both sexes. Besides, higher education, inadequate fruits and vegetable consumption, self-reported asthma and higher waist circumference among men and higher household income and self-reported diabetes among women were associated with IPA.
Prevalence of IPA in the elderly population
In our study, the overall weighted prevalence of IPA among elderly people was 38.4%. However, the prevalence of IPA observed in our study was higher than the prevalence of IPA (23.1%) among those aged 55–69 years, reported by the Bangladesh NCD risk factors survey 2018.6 In the NCD risk factors surveys using the WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) method, participants are usually between 18–69 years of age. Accordingly, data are relatively unavailable for elderly people aged 70 years and above. Only 1 out of 30 studies included in a recently published systematic review had data on the PA of the elderly population.33 However, we could not compare our findings with the findings of that study as the researchers did not follow any specific method to measure IPA. In Bangladesh, life expectancy at birth has increased from 66 years in 2001 to 72.6 years in 2019.34 As elderly population is more vulnerable to NCDs and IPA is one of the key risk factors of NCDs, periodic data collection of PA among elderly people is crucial.
Though there is limited evidence of IPA among the elderly population in Bangladesh, we could compare our findings with the prevalence of IPA among the elderly population of similar age groups in the recent WHO STEPS survey conducted in South Asian countries. The prevalence of IPA in our study was found higher than that in Afghanistan (34.9%; 45–69 years), Nepal (11.6%; 55–69 years), Bhutan (6.4%; 40–69 years), Sri Lanka (36.0%; 60–69 years) and lower than the prevalence of IPA among elderly people in Kerala, India (61.4%; 56–65 years), Tamil Nadu, India (53.5%; 60–64 years), Pakistan (52.9%; 60–69 years) and Maldives (45.3% in men and 47.5% in women; 55–64 years).35–42 However, our reported prevalence is still lower than the prevalence of IPA among elderly people in some western countries, such as in the USA (64,2%; 65+ years)43 and Australia (69% in men and 75% in women; 65+ years).44 In the UK, 40% of the people aged 55–74 years and 62% of those aged 75+ years were physically inactive.45 A cross-sectional analysis of the Wave-4 data of the Survey of Health, Ageing, and Retirement in Europe database of the people aged 55+ years from 19 countries of Europe and Israel reported the prevalence of IPA from 4.9% (Sweden) to 29% (Portugal).46 Globally, 17% to 97.6% of the elderly people do not meet the recommended PA requirement, according to a systematic review conducted by Sun et al10 The prevalence of IPA among the countries might vary due to the differences in study settings, age groups, study timeline, socio-demographic and other factors.
Factors associated with IPA among elderly people
The findings of our study revealed an association between age and IPA, and the prevalence of IPA was higher among the higher age groups in both sexes. This finding corroborates with several other studies conducted in Bangladesh and elsewhere.6 8 A systematic review of PA among elderly people also found a similar relationship between age and physical inactivity.10 Elderly people in higher age groups often suffer from different NCDs resulting in limited mobility and less participation in PA.47
In our study, elderly people living in urban areas were less physically active than their rural counterparts. Several studies included in a systematic review corroborated these findings.33 In Bangladesh, urban people are confined indoors due to a lack of outdoor recreational space and security.33 As Bangladesh is experiencing rapid urbanisation, and one in every three people live in an urban area,48 special consideration should be given to the urban people while designing public health programmes aimed to improve PA.
In contrast to the global findings, our analysis revealed that elderly men with relatively higher education are more likely to be physically inactive.16 17 A study conducted in nine rural sites of five South-East Asian countries, including Bangladesh, reported similar findings where higher-educated people were less likely to be physically active.8 Similarly, a systematic review identified the same pattern in seven South Asian countries, including Bangladesh.9 It may be possible that in Bangladesh and other developing countries, people with higher levels of education are mostly wealthy and do not require work-related PA. Besides, transport and leisure-time PA contribute much less to the overall PA among the Bangladeshi population, especially among the elderly.49 50 Another reason might be that, in Bangladesh, people with higher levels of education mostly live in urban settings. In our study, only 6% of rural and about 24% of non-slum urban participants had ≥10 years of education, and the urban environment is not usually favourable for physical activities due to several reasons, including lack of infrastructure, lack of parks, use of motorised vehicles and dependence on labour-saving devices in household activities.50
Occupation and marital status were also associated with IPA among elderly people. Among both men and women, unemployed people or homemakers were more likely to be physically inactive. In Bangladesh, elderly people are more likely to be unemployed or retired. They are primarily dependent on their families for their livelihood, making them reluctant to perform PA. Therefore, initiatives should be taken to promote PA among elderly people who are unemployed or homemakers. The elderly persons without a spouse were less likely to be physically active, and the association is stronger among women than men. Similar findings were reported from the studies conducted in Malaysia and the USA.16 51 The familial responsibilities that come with marriage might explain why not-currently married people are less physically active.
Among modifiable factors of IPA, sedentary behaviour measured by higher sedentary time was associated with IPA in both sexes. A systematic review conducted by Mansoubi et al reported a similar association where sedentary time and PA.52 This relationship can be explained by the so-called displacement hypothesis—which suggests that sedentary time may displace PA.53 Objective monitoring of sedentary time is necessary to explore this association further. Interventions should be provided to balance sedentary time and PA to receive the full benefit of PA. We also observed that inadequate fruits and vegetable consumption was associated with IPA among elderly men. A study in Malaysia had similar findings where inadequate consumption of fruits and vegetable was significantly associated with a higher prevalence of IPA.16 Physically active people might consume more fruits and vegetable due to a relatively high awareness of NCD risk factors. In this population, a higher waist circumference or central obesity was associated with IPA among elderly men. This finding is supported by several studies in which PA was associated with lower waist circumference.54
In our study, self-reported hypertension in both sexes, self-reported diabetes in women, and self-reported asthma in men were associated with IPA. While the association between PA and NCDs is recognised, physical inactivity among people who already know their NCD status is somewhat related to a lack of knowledge and awareness. Vongpatanasin et al stated that hypertensive people are often reluctant to exercise out of fear of heart attack and stroke.55 Elderly people with diabetes might be afraid of a hypoglycaemic episode during exercise.56 Similarly, people with asthma might also be reluctant to perform PA to avoid exacerbation.57 Proper health education and guidance are necessary to promote PA among people with existing NCDs.
Strengths and limitations
To the best of our knowledge, this is the first study in Bangladesh reporting national and regional estimates of prevalence and associated factors of IPA among elderly people. However, several limitations should be considered while interpreting the findings of the study. First, the measure of PA was subjective (self-reported) rather than objective, where a recall bias can compromise the study findings. Second, a modified version of the GPAQ questionnaire was used instead of the full version. Third, seven rural clusters were dropped due to administrative and financial constraints, which might affect the overall representativeness of the study. Finally, the lack of temporality of the associations between IPA and the factors was another limitation. We suggest further research to objectively measure the PA of elderly people and identify the determinants of IPA by conducting appropriately designed studies.
Policy implication
Our analysis showed that in Bangladesh, a large proportion of the elderly women and men is not performing the recommended level of PA. Besides, the prevalence of IPA is higher among certain classes of elderly people in the country. We observed that IPA is associated with several unmodifiable (age, place of residence, marital status, self-reported hypertension, self-reported diabetes, self-reported asthma) and modifiable factors (sedentary behaviour, inadequate fruits and vegetable consumption, higher waist circumference). The unmodifiable factors can be used to identify people with IPA. The modifiable factors can help us design appropriate interventions. As IPA has many adverse effects on overall health and increases the healthcare burden, the government of Bangladesh should take steps to increase PA in the elderly population. In Bangladesh, only 3% of people participate in recreational PA, suggesting that promoting recreational or leisure-time PA can reduce IPA.49 The lack of recreational PA is a concern for both the physical and mental well-being of the elderly population, and opportunities for elderly population specific recreational PA can be created. The government should establish more infrastructures such as parks, gymnasiums and PA clubs for the senior citizens. National awareness programmes can be taken with the help of religious institutions such as mosques, temples and churches. Besides, a national guideline for PA should be developed considering the cultural and socio-demographic situation of the country. Mass awareness, health education and counselling at the primary healthcare facilities and community level can also be effective.