Anthropometric characteristics, functional capacity and health related quality of life of older people in Blantyre, Malawi: a cross-sectional study

¹School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi, ²Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom, ³Department of Basic Sciences , Malawi Adventist University, Malamulo, Thyolo, Malawi

^&Corresponding author
Charles Nyasa, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi

Introduction    

The population of older people in Malawi is rising, as is the case across Africa. Currently, about 1.2 million people in Malawi are aged 60 years and above, representing 5.3% of the total population and projected to rise to 9% by 2050 [1-3]. In Malawi, 90% of older people reside in rural communities and rely on agriculture, small-scale trading and family ties for livelihood [1-3]. Over the past decade, the country has experienced recurrent climatic crises that have affected farming and disrupted livelihoods. Meanwhile, Malawian communities continue to face heightened levels of urban migration among younger people, which perceptibly accelerates the breakdown of traditional family structures that once protected older people [1,2]. This makes the elderly a particularly vulnerable demographic in the country. In recent years, various efforts have been directed to the elderly sector through policy instruments (such as the National Policy for Older Persons 2016 and the Older Persons Act 2024), cash transfer programmes and disaster management initiatives [4,5]. However, evidence indicates that the majority of older Malawians still live in poor conditions and face care deficits at the family and community level, with 59.7% in multidimensional poverty [2,3,6]. Considering the known realities of old age, these inequalities not only limit older people’s participation in community activities but also hinder the Nation from fully realizing the positive social and economic effects of population ageing. The plight of older people in Malawi is multi-faceted. Apart from declines in physiological reserves, which often characterise older age, older people are prone to degenerative conditions which further challenge their functional capacity and adversely affect participation and overall quality of life. According to sources, over 50% of older Malawians have low mental health and physical health scores [7], 41% have fall problems [8], and musculoskeletal conditions are a common complaint among those seeking outpatient medical services [2]. These challenges collectively limit older people’s mobility and functioning, hindering them from fully participating in community activities, agricultural work, or gainful employment [2,7,8]. This exacerbates poverty, food insecurity, and dependency, which in turn perpetuates discrimination and abuse. Thus, functional capacity influences overall quality of life, and its decline in older age is often considered inevitable. However, the compression of morbidity model provides a framework through which functional capacity can be maintained in older age, leading to increased participation and improved welfare for a longer period.

Proposed by Fries and colleagues [9-11], the compression of morbidity model proposes increasing the period of active life by postponing the onset of health decline and significant disability (compressing morbidity into a shorter period towards the end of life) in a person’s life. It is believed that this leads to improved quality of life for a longer period, reduces health costs, increases opportunities for positive social effects, and is possible through investment in consistent long-term healthcare interventions [10]. For instance, by providing age-appropriate health education, promoting healthy lifestyles, enabling a culture of exercise, and improving access to healthcare, older people can maintain functional independence and take more control of their welfare, leading to numerous social and economic benefits. Therefore, the model offers a suitable framework for the design of national elderly support programmes and aligns with the World Health Organisation’s agendas on ageing (active ageing and healthy ageing), which encourage maintenance of functional ability to enable older people to contribute to society longer and healthily [9,12], making functional capacity a key outcome measure in older age. There is a need to improve quality of life for older people in Malawi and cultivate their contributions to social and economic development. This requires consistent long-term investment in their health to promote wellness, independence, and participation. However, while the health burden on the elderly in Malawi is known [2,7,8], its impacts on participation, quality of life, and the economy are less studied. This scarcity of data on baseline population-health characteristics and economically weighted indices of health status hinders proper design, adaptation, and evaluation of elderly support initiatives in Malawi [2,7,8]. This study aimed to understand anthropometric characteristics, functional capacity, and health-related quality of life (HQoL) of older Malawians who are ageing in place, and contributes to a growing conversation on care needs, experiences, and contributions of older people in Africa.

Methods     

Study design and setting: this was a cross-sectional study of a convenient sample of eighty-five male and female older Malawians (aged 60 years and above) residing in a catchment area of Kalibu Elderly Clinic, a free-access elderly care establishment situated in the rural outskirts of Blantyre, a commercial district in Malawi. This setting was chosen because it well represented the country’s general population dynamics as majority of older Malawians reside in rural communities [1,2].

Study population: participants were recruited on various occasions as they presented at a set-up community health post or in their homes, following consent after information about the study was read to them. Malawians aged 60 years or older who were on the facility’s outreach programme and were able to walk independently were included in the study. Candidates presenting with uncontrolled diabetes or hypertension, obvious mental health conditions affecting their ability to understand and follow verbal instructions, or acute respiratory disease were excluded from the study. The Cochran’s formula was used to calculate the study’s sample size (a minimum of 84 participants) with adjustment for a finite population of 107 people who were on the facility’s outreach programme in the locality at a 95% confidence level, 0.05 margin of error, and 0.5 maximum population variability. A method detailed by Bartlett et al. was used for the adjustment [13].

Data collection: upon recruitment, all participants had their demographic information, medical history, and baseline anthropometric data recorded before proceeding to HQoL evaluation using the descriptive system of the EQ-5D-3L health state assessment questionnaire. After that, participants were asked to report to the elderly facility on the next day for functional capacity testing. Functional capacity was evaluated using the Six Minute Walk Test (6MWT) based on American Thoracic Society (ATS) guidelines [14]. Data were collected over a cumulative period of nine months. All anthropometric measurements were taken three times, and an average was recorded. Additionally, the 6MWT was administered in a controlled environment to maximise safety, and testing was carried out by a single experienced physiotherapist (CN).

Definition of variables: for this study, baseline anthropometric and physiologic measures included height, weight, heart rate, body composition (BMI) and blood pressure scores were collected using standard clinical assessment. For quality-of-life evaluation, the paper questionnaire of the EQ-5D-3L tool was administered, asking participants to indicate their own health status on five dimensions of wellness, namely mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. Lastly, the 6MWT was administered by requiring participants to walk as fast as they could for six minutes along a 30-metre-long walkway, with appropriate verbal cueing. Resting heart rate (RHR), Six minute walk distance (6MWD) and Post-exercise heart rate (PEHR) were recorded 5 minutes before, during and immediately after the test, respectively.

Statistical analysis: data were entered in Microsoft Excel before importing into STATA® data analysis software (Stata Corp., TX) version 14. All p-values presented are 2-sided, and a 0.05 significance level was chosen for all hypothesis tests. In this study, anthropometric and physiologic data were analysed through descriptive statistics (mean ± standard deviation for continuous variables, and percentages and range for categorical variables). To allow for broad application of study results, health states were summarized as health profiles as well as frequency plots. Health profiles were converted to utility index values (valuation) by applying the Time-Trade-Off (TTO) method using the Zimbabwe value set as a valuation tariff that closely approximates the current study’s population since Malawi does not have its own [15]. Lastly, 6MWD was expressed as Mean ± SD, and inter-group differences were tested by way of t-tests and ANOVA. Multiple linear regression analysis was performed to explore factors associated with high HQoL among older Malawians.

Ethical considerations: this study was approved by the College of Medicine Research and Ethics Committee (COMREC), clearance number P.03/20/2983. Written informed consent was obtained in the presence of a guardian before all assessments. Permission to use the EQ-5D tool was granted by the EuroQoL Group, Registration ID: 37244.

Results     

General characteristics of the study population: a total of eighty-five older males (twenty-seven) and females (fifty-eight) aged sixty to ninety years participated in this study (Table 1). Seven were exempted from functional capacity assessment due to frailty and acute exacerbation of pain but were fit to participate in the rest of the assessments. In terms of physical profile, males (1.6±0.1 metres) were significantly taller than females (1.5±0.1 metres, p < .001) and registered significantly lower BMI scores (p = .003), with no major differences in age (males: 73.0±7.3, female: 71.7±5.8 years, p = .403) and weight (males: 51.8±8.1, females: 52.0±10.6 kg, p = .936) between the sexes (Table 1). Majority of participants presented with musculoskeletal (43.5%) and cardiovascular (17.7%) related complaints. 5.5% of the participants had obesity, and over 68.8% had elevated blood pressure (Table 1).

Health state and HQoL among older Malawians: health state responses using the EQ-5D-3L tool showed that pain was the most prevalent (86.3%) health problem among participants, followed by mobility issues (68.8%) and activity (usual activities) restriction (68.8%). Despite this, over half of the participants had no problems performing self-care activities, and none reported extreme problems in the mobility dimension. Two-thirds of the respondents had some form of anxiety or depression (Figure 1), and only two had no problems across all dimensions of health as assessed by the tool (Table 2). Translation of participants’ EQ-5D-3L data to EuroQoL health states revealed thirty-two unique health profiles (combinational summaries of reported status on each dimension) out of the tool’s possible 243. These states were then converted to utility values (Table 2), using the Zimbabwe value set which was developed via the TTO method. Based on this value set, participants who reported a health profile indicative of full health (i.e. Profile 11111- meaning no problems across all dimensions, only two participants in this study) were assigned the highest utility index value of 0.90 (Table 2). Five most prevalent health profiles in this study were 22222 (health state characterised by moderate problems in all EQ-5D-3L dimensions); 11121 (moderate pain and no issues in the rest of the dimensions); 21222 (no problems with self-care activities but moderate problems in all the other dimensions); 22233 (moderate problems in mobility, self-care and usual activities coupled with severe pain and depression); and 11112 (moderate anxiety or depression with no issues in the rest of the dimensions) (Table 2). Overall, the mean health utility score, representing overall HQoL for this population, was 0.6 ± 0.2, which translates to the fact that, assuming 10 years of life left, participants would trade four years of their life for six years of full health rather than continue living in their current state for the whole ten years. In this study, there were no profiles that suggested that any of the participants considered themselves to be in a state worse than dead (i.e. heath state profile having a negative index value).

Six-minute walk distance and factors associated with high HQoL: in this study, the mean 6MWD among the participants was 304.3 ±112.4 metres with a range between 78 and 564 metres. Older males (330.2 ± 135.6 metres) walked longer distances than females (291.2 ± 97.4 metres), although this difference was not statistically significant (p = .1497). There were also no significant differences in walked distance with respect to medical complaint (p = .103). Multiple linear regression analysis found that longer walk distance on the 6MWT was significantly associated with higher HQoL scores (β: 0.09, 95% CI: 0.03 - 0.15; p = .007), which means that for every 100-metre increase in walked distance on 6MWT, HQoL increases by 0.09 units in EuroQoL utility values, holding all other variables constant (Table 3). There were no significant relationships between HQoL and the rest of the variables in this study (Table 3).

Discussion     

This study aimed to understand anthropometric characteristics, functional capacity, and HQoL among community-dwelling older people in Blantyre, Malawi. Out of eighty-five participants recruited in the study, we found that males were taller and had lower BMI scores than females. We further found that the majority presented with musculoskeletal and cardiovascular problems and over two-thirds had elevated blood pressure. On the EQ-5D-3L assessment, pain was the most reported dimension, along with mobility issues and activity restriction. Overall, the mean HQoL score for older Malawians in this study was 0.6 ± 0.2, and longer walk distance on the 6MWT was significantly associated with higher HQoL. Scores on anthropometric characteristics observed in the current study are consistent with reports from diverse African societies. For instance, average BMI lower than 25kg/m² were reported among older people in Ghana (19.4kg/m²), Tanzania (18.2kg/m²), Ethiopia (20.1kg/m²) and Kenya (21.1kg/m²) [16]. However, consistent with earlier studies in Malawi [17,18], there was a significant difference in BMI with respect to sex in the present study, where males scored lower than females. As BMI is a correlational measure of nutritional status, this likely reflects a continually widening gap in body composition, diet, and physical activity demands between older men and women in Malawi. Musculoskeletal (MSI) and cardiovascular (CVI) impairments topped the list of participants’ complaints in this study (Table 1), highlighting a significant burden among older Malawians. This is consistent with global patterns. Evidence indicates that musculoskeletal disorders such as arthritis, fractures, and myofascial pain account for over half of chronic pain cases among older adults globally and are a leading cause of immobility, falls, and early retirement among older people [19,20].

In Malawi, Ngoie and colleagues reported a census-based, population-level MSI prevalence of 9.5% as of 2021 [21]. However, although specific data on older Malawians are scarce, the prevalence of MSI in this demographic is expected to be higher. It is known that as people age, progressive losses in skeletal muscle mass (sarcopenia) occur and are accompanied by a decrease in strength, flexibility, and reflexes [20]. As this happens, muscle fibres are replaced by connective and adipose tissue, posing adverse effects on motor control and functional performance. Similarly, joints suffer decline in synovial fluid production coupled with thinning of articular cartilage and shortening of ligaments. This exposes joints to considerable wear and tear such that by age 80 most people develop some form of arthrosis [22], further exacerbating pain, functional limitation and fall risk. Over two-thirds of older people in the current study reported most problems in pain, mobility, and activity dimensions of the EQ-5D-3L tool (Figure 1). Allain et al. Reported a 41% incidence of falls among community-dwelling older Malawians in 2014 [8]. Through EQ-5D valuation, the present study found that HQoL for older Malawians who are ageing in place is 0.60 ± 0.20. Compared with other diverse populations, this score is reflective of poorer health states, so much so than age-matched populations in Indonesia (0.89) and the United Kingdom (0.73) [23,24], adults living with breast cancer in Ethiopia (0.8 ± 0.25) [25], and rural miners in Zimbabwe (0.9 ± 0.1) [26]. This may be due to differences in disease risks, health-seeking behaviours and access to healthcare. Indeed, compared with other societies, older Malawians face a huge burden of undernutrition, musculoskeletal disorders and discrimination affecting both physical and mental health [2,8]. Moreover, the shortage of healthcare facilities in rural areas, under-inclusiveness of existing primary health care (PHC) models, and the structural inaccessibility of free healthcare likely push the elderly towards informal health remedies. A lucid detail of strategies for enhancing PHC access for older people in Malawi was outlined by Kwaitana et al. [27].

To our knowledge, this is the first time that health status for older Malawians is expressed in economically weighted utility scores. Therefore, the study sets a foundation for future cross-population comparison. While it is possible that Malawians value health differently than Zimbabweans (as population differences have been observed in the literature [15,23]), our use of the Zimbabwe tariff as a value set close to Malawi was informed by standard practice [28]. The Zimbabwe tariff was developed through a standardized valuation exercise using the TTO technique in a representative sample of the Zimbabwe population [15,29]. In practice, TTO involves asking participants how many years of life they would be willing to trade to avoid a hypothetical impaired health state. (i.e., giving up some years of life in exchange for momentary full health) [24,30]. The mean index value obtained from the valuation exercise represents the population’s overall HQoL. Usually, such exercises are followed by statistical modelling to generate figures which, in combination with other parameters (such as survival estimates and intervention costs), allow calculation of quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER) for new interventions, aiding decisions in population health planning [31-33]. To date, EQ-5D value sets for Malawi are not available, although studies on psycho- and clinimetric performance of locally adapted versions have reported satisfactory results [34-36], paving the way for population-wide application. In this study, mean 6MWD was positively associated with HQoL, where HQoL increased by 0.09 units (in EuroQoL utility values) for every 100-metre increase in 6MWD. This reflects nearly 0.1 QALYs gained for every year an older person lives in the improved state. To put it in perspective, this is equivalent to ~1 QALY gained for every 10 years of life (QALY = time in years x utility value) and highlights the impact of improved functional tolerance on quality of life.

This makes 6MWD an outcome measure directly correlated with economically weighted indices of quality of life and relevant in the evaluation of interventions targeting functional capacity and wellness in older age. Originally developed in 1982 as a measure of endurance and exercise capacity for individuals with cardiopulmonary pathology based on McGavin’s 12-minute field performance test [37], the 6MWT offers a reliable and widely accepted method for assessing functioning and exercise tolerance among older individuals [38]. This is mainly because of the test’s versatility, allowing assessment of multiple body systems in a single session. For instance, by requiring participants to walk a set distance at moderate-to-high but self-regulated levels of exertion (intensity), the test offers a quick, affordable, and well-tolerated way for examining the integrity of the musculoskeletal system (muscles, joints and bones), temporo-spatial parameters of gait (e.g. Step width, cadence or foot progression angle), and walking independence (motor control, balance and flexibility) in older age. Additionally, the test’s demand for repetitive activity (walking) within controlled time limits provides a physiologically plausible method for measuring cardiorespiratory endurance, making it a suitable outcome measure for both institutionalized and community-dwelling older adults. In two separate studies, peak oxygen uptake (VO2) on 6MWT corresponded with 80% of VO2max and 79% of maximal heart rate (HR max) as obtained on ramp protocol (maximal) cardiopulmonary test (CPET) on treadmill [39,40]. Thus, results of a 6MWT represent multiple physiological measures that collectively reflect the biological state of capacity and ability in older age. Several strategies were employed to standardise assessments used in this study; however, some limitations were encountered. During assessment of height, although participants were encouraged to stand erect, measurements may have been confounded by varying degrees of kyphosis and slouching, which are common in older age. For this reason, height was measured three times and averages were recorded. Furthermore, walking speed on the 6MWT was regulated within limits of safety to prevent falls and may have differed from the maximum achievable by each participant. However, based on ATS guidelines, there is no indication to aim for maximal levels of exertion, as clients are advised to slow down, stop, or rest as needed during the test. Lastly, there was unequal sex distribution in the current study. As such, observed sex differences should be interpreted with caution.

Conclusion     

Anthropometric and physiological characteristics of older Malawians reported in this study are consistent with data from diverse African populations. Similarly, musculoskeletal and cardiovascular diseases are a shared global concern. Health-related quality of life for older Malawians who are ageing in place is 0.6±0.2 and is lower than age-matched populations in other countries. Lastly, walk distance on 6MWT is a relevant outcome measure positively associated with economically-weighted indices of HQoL and should be integrated in interventions targeting functional capacity and wellness among older Malawians

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Charles Nyasa, Anthony Mwakikunga, and Enock Chisati: conceptualised the study, collected data and took part in analysis. Yamikani Nangwale: analysed and interpreted the data. Anthony Mwakikunga and Enock Chisati: jointly monitored data quality. Charles Nyasa and Yamikani Nangwale drafted the manuscript. All the authors have read and agreed to the final manuscript.

Acknowledgments     

The authors thank the nurses and physiotherapists of Kalibu Elderly Clinic for assistance with records and guidance on participants’ safety.

Tables and figures     

Table 1: anthropometric and physiologic characteristics of community dwelling older people in rural Blantyre, Malawi

Table 2: valuation table for self-reported health states showing older Malawians’ health profiles and corresponding health utility values

Table 3: results of multiple linear regression analysis to explore factors associated with high health-related quality of life among older people in Malawi

Figure 1: summary of responses on five dimensions of health status among community dwelling older people in rural Blantyre, Malawi. Note that majority of participants indicated problems in the pain dimension at the time of interviews

References