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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 370-373

Socio-cultural tailoring of the comprehensive geriatric assessment tool for low- and middle-income countries: The need of the hour

1 Department of Health Research, India Cancer Research Consortium (ICMR-DHR), Ministry of Health and Family Welfare; Adjunct Professor of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
2 Project ECHO (Extension for Community Healthcare Outcomes), New Delhi, India
3 Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India

Date of Submission27-Mar-2021
Date of Decision31-Mar-2021
Date of Acceptance31-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Ravi Mehrotra
Department of Health Research, India Cancer Research Consortium (ICMR-DHR), Ministry of Health and Family Welfare, 1st Floor, Indian Red Cross Society Building 1, Red Cross Road, New Delhi - 110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_64_21

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How to cite this article:
Mehrotra R, Nethan ST, Yadav K. Socio-cultural tailoring of the comprehensive geriatric assessment tool for low- and middle-income countries: The need of the hour. Cancer Res Stat Treat 2021;4:370-3

How to cite this URL:
Mehrotra R, Nethan ST, Yadav K. Socio-cultural tailoring of the comprehensive geriatric assessment tool for low- and middle-income countries: The need of the hour. Cancer Res Stat Treat [serial online] 2021 [cited 2022 May 27];4:370-3. Available from: https://www.crstonline.com/text.asp?2021/4/2/370/320191

(In response to: Noronha V, Ramaswamy A, Banavali S, Gattani S, Prabhash K. Ethnocultural inequity in the geriatric assessment. Cancer Res Stat Treat. 2020 Oct 1;3 (4):808)

The comprehensive geriatric assessment (CGA) tool is a multidimensional diagnostic questionnaire designed for older persons, to enable appropriate treatment and follow-up planning.[1] Noronha et al., in their article, have described the various aspects of the CGA which are inappropriate for Indian patients with cancer owing to the sociocultural differences between the Indian and Western populations.They have further highlighted the differences in the age cutoff for the elderly; their functional, cognitive, nutritional, comorbidity, mental health, and mobility assessment; and also in the life expectancy between the Indian and Western populations.[2],[3]

India has been referred to as “an aging nation” due to a sharp rise in the proportion of the older population over the years, which can mainly be attributed to the availability of improved health-care services and the resultant reduced mortality rates.[4] The overall life expectancy at birth has also risen from 54 years in 1981 to 67 years in 2011.[5] However, there are currently no scales to assess this. In January 1999, individuals aged 60 years and above were categorized as senior citizens under the “National Policy on Older Persons” in India,[6] as opposed to individuals aged 65 years and above in high-income countries.[7] Furthermore, the retirement age for government employees in India is 60 years.[8]

Stigma contributes to the huge burden of mental morbidity and is a roadblock to seeking treatment among individuals, including older patients with cancer. The National Mental Health Survey of India, 2015–16,[9] reported that the lifetime prevalence of mental morbidity was 15.11% after the age of 60 years, with depression, dementia, and delirium being most common in this age group. Despite this, nearly 80% of the individuals in this age group had not received any treatment for more than 12 months.[9] The Mental Healthcare Act of 2017, implemented to ensure accessibility and availability of mental health services and to protect the rights of the affected individuals, does not have specific provisions for older individuals, which requires adequate consideration.[10]

The following section elaborates additional ideas with appropriate recommendations:

  Changing Trends in India Top

With changing times and an increase in the number of dual-career couples[11] and single men living alone away from their homes by virtue of their employment, more men have started engaging in domestic chores such as cooking, laundry, and housekeeping. A significant rise in this trend was noted, especially during the lockdown imposed during the coronavirus disease (COVID-19) pandemic and lockdown, which lasted for more than 100 days in India.[12] Hence, in the future, it would be appropriate for the instrumental activities of daily living (IADL) scale to have a common scoring system for both the older men and women to assess their levels of functionality.

In addition, over the past few years in India, there has been a rise in the number of nuclear families (couples with unmarried children) owing to rapid urbanization.[13] As per the Demographic and Health Surveys in India, the proportion of such families has markedly risen from 36.5% in 1992 to 41.5% in 2015, thus making nuclear families, the most common household type in India.[14] The proportion of subnuclear families (single-parent households) has also risen from 4.6% in 1992 to 6.3% in 2015.[14] Contrarily, a continuous decline has been noted in the proportion of joint/extended families (various compositions, including parents with married children) from 49.7% in 1992 to 37.1% in 2015.[14] This change is not limited to the urban areas but has also been noted in rural India. For instance, a rise in the proportion of nuclear families from 50.7% in 2001 to 52.1% in 2011 and a sharper decline in the proportion of joint families from 20.1% in 2001 to 16.8% in 2011 have been reported in the rural areas of the country. Similarly, in urban India, the proportion of joint families fell from 16.5% in 2001 to 14.6% in 2011.[13] Hence, the “saas-bahu” (mother-in-law & daughter-in-law) scenario may not be as widely prevalent in the country anymore, leading to an appropriate scoring of the functionality of the older women on the IADL scale, contrary to the authors' belief.

  The Maid Culture Top

The maid culture in India refers to outsourcing household work to another male/female member hired temporarily.[15],[16] This could have an impact on the overall scoring on the IADL scale, not only for the women but also for the working men living alone in cities. Initially, this culture was prevalent only in the metropolitan cities, but now, even the smaller cities have caught up.[17],[18]

  Technological Proficiency of the Older Individuals Top

The latest village-level data from the Rural Development Ministry of the Government of India, as a part of Mission Antyodaya, 2018, has shown that mobile phone services are available in more than 72% of the Indian villages.[19] Such a rapid surge in the use of mobile phones in the villages has also rendered the landlines near-redundant.[20] In a survey conducted in 12 villages in Bihar, multiple uses of mobile phones were reported by the villagers which included gathering information for agricultural and non-agricultural (employment, education, health, business, and banking) purposes, in addition to, communicating with family and friends.[21] It should be noted that the technological proficiency/mobile phone usage has less to do with the level of education but more with the willingness of the older individuals to learn new things.[22] A recent multi-country survey reported a wide usage of at least a basic mobile phone (52%) among adults aged 50 years and above (which includes the geriatric age group) in India (urban and rural) in 2018.[23]

With cheaper internet plans[24] and mobile phones, owing to fierce competition in the telecommunications industry,[25] the access to and usage of mobile phones with internet services have increased not only among youngsters but also among older individuals.[26],[27] Newer social media campaigns emerging in support of mental health issues[28] might motivate older individuals to share their difficulties and seek appropriate care.[29] This could also provide insights into their mental healthcare-seeking behavior and the barriers to the same. Hence, in addition, a question regarding the usage of social media may be included in the CGA. A question regarding the social life and day-to-day interaction may also be included in the CGA to make it more comprehensive.

  Questionnaires Based on Residence Type and in Different Indian Languages Top

The majority of the Indian population lives in the rural areas. However, there has been rapid urbanization in the past decade. As per the last census held in 2011, the rural population comprised 68.8% of the total population of the country.[30] Hence, questions pertinent to both the rural and urban sections are mandated in the CGA.

According to the census of 2011, more than 19,500 languages or dialects are spoken in India.[30] Of these, 121 languages are considered as mother tongues, and 22 languages that account for the mother tongues of 96.72% of the Indians are included in the Eighth Schedule of the Indian Constitution.[30] At present, 43.63% of Indians speak Hindi. Between 2001 and 2011, the proportion of Hindi-speaking individuals increased by 25%, with 43.63% of the population being reported to be conversant with Hindi in 2011.[30] Hence, the self-administered questionnaires must preferably be available in Hindi and the other common regional languages, given the diversity in our country.

Due to rapid and unplanned urbanization, a new area entity has come into being, namely the urban villages. This entity remains isolated and alienated and is exploited by property dealers, political power brokers, and speculators.[31] These may also be accounted for in the questionnaire.

  Seasonal Variations in India Top

The climate of India may be broadly described as the tropical monsoon type. The Indian Meteorological Department designates four official seasons, namely winter (December to early April); summer/pre-monsoon (April to July in north-western India); monsoon (June-September); and post-monsoon (October-December).[32] The climatic conditions vary across the country depending on various factors such as the location and latitudinal extent, distance from the sea, northern mountain ranges, upper air circulation, and western disturbances and tropical cyclones.[33] The city of Mumbai experiences year-long weather variations, with harsh conditions during certain months. The temperature exceeds 30°C (86°F) during the day even in the month of January but drops at night to less than 20°C (68°F). From November to May, there are scarce rains and frequent sunshine. Between March and May, the temperature increases, with the minimum at night reaching up to 24/26°C (75/79°F) and the maximum reaching up to 33°C (91°F) (at times up to 40°C/104°F). Intense monsoon with frequent showers lasts from June to early October with an average rainfall of 800 mm (31.5 inches). In July and August, the sky is mostly cloudy and the humidity is high.[34] Older individuals are more susceptible to weather changes and experience difficulties. Hence, the question regarding mobility in bad weather is appropriate in this context.

  Conclusion Top

To enable performing the CGA of older patients with cancer, the existing tools must be tailored as per the prevalent sociocultural needs of the older population, especially in developing countries. Further initiatives may also be undertaken toward developing such country-specific geriatric assessment tools.

  References Top

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Noronha V, Ramaswamy A, Banavali S, Gattani S, Prabhash K. Ethnocultural inequity in the geriatric assessment. Cancer Res Stat Treat 2020;3:808.  Back to cited text no. 2
  [Full text]  
Noronha V, Ramaswamy A, Dhekle R, Talreja V, Gota V, Gawit K, et al. Initial experience of a geriatric oncology clinic in a tertiary cancer center in India. Cancer Res Stat Treat 2020;3:208.  Back to cited text no. 3
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