Basic Activities of Daily Living and Associated Factors among the Elderly in a Tertiary Care Center, South-East Nigeria

Basic Activities of Daily Living and Associated Factors among the Elderly in a Tertiary Care Center, South-East Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Basic Activities of Daily Living and Associated Factors among the Elderly in a Tertiary Care Center, South-East Nigeria Chijioke Stanley Anyigor-Ogah, Agatha Nkechinyere Ekechi, Chukwuemeka Mbam Ovuoba, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8327691/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background In Nigeria, the elderly is neglected and much attention (if any) is not given to them in terms of their overall health and well-being, thus making them vulnerable. The process of aging is affected by variety of factors (including family dynamics). The various changes that occur as a result of these factors increase the vulnerability of individuals to life threatening diseases, dysfunction and possible death. Elderly population is said to be decreasing in Africa compared to more developed nations. This is probably due to the absence of clear policy or functional social security service for the elderly. Objective This study focused on the effect of socio-demographic characteristics and family support on the functional status (toilet use, feeding and transfers) in the elderly. Methods This was a hospital-based cross-sectional analytical study of 160 elderly aged between 65–98 years selected through systematic random sampling. Chi square test, t-test and logistic regression were used for analysis. Results There was 100 percent response rate in this study. The respondents had mean age of 76.31 ± 8.34 years for males and 76.87 ± 7.47 years for females. There was statistically significant association between age, absence of spouse, poor education and functional dependence in all activities of daily living. Age independently predicted dependence in activities of daily living, while marital status predicted dependence in feeding. Conclusion The high level of functional decline recorded in this study explicitly underscore the fact that an improvement in the biopsychosocial, biomedical and economic well-being of the elderly, as well the incorporation of family-centered approach in the elderly care, will ameliorate the functional decline in the activities of daily living. Elderly malnutrition functional status disability INTRODUCTION In recent decades, the rate of disability has declined in older adults in the developed countries. This is not the case in developing countries like Nigeria. The problems of the elderly in Africa are rapidly increasing as the societies are locked-up in diverse conflicts, economic challenges, natural and man-made disasters, diseases and deterioration in family relationships. 1 The society generally has negative affinity towards older people as various programs are being fashioned out for other population groups except the elderly. 1 The Nigerian elderly are disadvantaged in terms of support, yet the growing population of this group makes it imperative to demand for social support since majority of them live in rural areas, hence this study aimed at studying the functionality of the elderly in selected basic activities of daily living (BADLs), with a view to not only ensure proper policy formulation in providing them with essential healthcare, but also to develop appropriate support and nursing services aimed at obtaining relevant patient-centered information with respect to their individual peculiarities. The elderly in Nigeria who are mainly agricultural workers and subsistence farmers do not benefit from government grant and the retirees are hardly paid their pensions and gratuities. 2 Rural-urban migration of the young people in search of better economic realities has left so many of the elderly unattended to, even those who would have provided the traditional support have been limited by high mortality rates arising from this migration. 1 In a study done in Ondo State Nigeria, majority of the aged males reported participating in sanitization and vigilante activities to make livings while many of their female counterparts participate in market trading and fetching of sacred water to bath for longevity. Only minority of the aged reported patronizing the hospital when sick but many others make use of local herbs. 1 In the same study, few subjects reported lack of accommodation while economic hardship was more prevalent among the uneducated. It has been reported that no social security or policy system has ever been put in place to carter for people at their old age in Nigeria. Even the primary health care system has no special provision for enhancing the healthcare of the elderly. 3 Due to poverty and poor infrastructural developments, the elderly in Nigeria face lower life expectancies and live the greater part of their lives in poor health. 3 This poor health condition is usually aggravated by old age, being separated after marriage, visits by only male children and not receiving financial support among others. The stance of the government towards the overall health of the elderly is poor while the family structure which provided support for them in the past is almost collapsed. 4 Studies have shown that about 54% of French citizens older than 65 years reported having at least one disability while about one-third of the elderly in Califonia had at least one severe disability. 5 , 6 In Taiwan, over 4.4 million elders reported that their disability limits their ADLs and 6.5 million reported difficulties in attending to instrumental ADLs while about 75% of those 85 years or older need assistance with ADLs. 7 With the aging population, there is an increased need for support services to augment the support from the family. 6 MATERIALS AND METHODS Ethical Considerations and Consent to Participate Approval for this study was sought and obtained from the Research and Ethics Committee of the Federal Teaching Hospital, Abakaliki on 1 ST June, 2018, with reference number FETHA/REC/VOL.2/2018/060. This research work complied with the Helsinki declaration of 1975, as revised in 2013 on human research. All selected participants were informed about the objectives and contributions of the study and written informed consents were obtained before the questionnaires were administered. Participants were informed that they had the right to decline participation in the study. They were also informed that all data obtained from them would be kept confidential. Study Design: This was a cross-sectional analytical study which spanned for duration of three (3) months. : Study Population : The study population comprised the elderly patients aged ≥ 65 years, who presented at the Geriatric Clinic of the hospital within the period of study. Selection Criteria: The selection of the participants was based on some inclusion and exclusion criteria. Included in this study were patients aged 65 years and above, who gave their consent to participate in the study. Excluded from this study were the severely or terminally ill patients because the functional status might be influenced by the illness and not the patients’ characteristics, patients with severe disabling conditions because this might bias the assessment of functions Sample Size Determination: The sample size (N) was determined using the Fisher’s formula thus: 8 N = Z 2 pq/d 2 , where: n is the minimum sample size, Z is the standard normal deviate at 95% confidence level (which is 1.96), P is the prevalence of functional impairment in the elderly from previous study which is 17% 9 , q is regarded as 1-p (proportion of the population that does not have malnutrition, (0.83), d is the degree of precision (level of accuracy desired) and it is usually set at 0.05. From the above figures; sample size, N = 216.82 Since the study population is 606 (not up to 10,000 and above), the sample size was corrected using the formula: N f = n/[1+(n/N)] 10 , where N f is the corrected sample size; n is the population size (606); N is the sample size (216.83). Applying the formula, N f = approximately 160. Hence, the sample size was 160. Sampling Techniques: Participants for this study were selected by systematic random sampling. Since sample size, N f = 160; Average number of elderly, 65 years and above seen at the Geriatric Clinic in three months in the hospital was 606, hence, the population size (n). This gave a sample interval of approximately 4. That is, for every 4 patients, one was selected as soon as they presented at the Geriatric clinic. The number of the first elderly patient included in the sample was randomly chosen by picking one out of 4 elderly patients by balloting among them. However, during the selection, any number that was selected which did not meet the inclusion criteria was dropped and the next number picked. Such a selection did not affect the next random selection. Study Instruments: Data for this research was collected by face-to-face interviewer-administered structured and pre-tested questionnaires. The pre-testing was carried out at the General Outpatient Clinic (GOPC) of a similar health facility with the aim of modifying the questionnaire and making other adjustments were necessary. The questionnaires were prepared in English language but were interpreted in Igbo language for those that could not understand English. To ensure validity, the questionnaires were transcribed from English language to Igbo language by an Igbo language lecturer of the State College of Education. This translation was back-translated to English language by an English language lecturer of the same school and was compared with the previous questionnaire. Both translations made the same sense. The questionnaire was developed using a modified Katz and Lawton’s index. 11 , 12 It consisted of two parts (see the supplementary material). The first part documented the socio-demographic characteristics and social support while the second part of the questionnaire assessed the functional status of the patients (basic and instrumental activities of daily living). Based on self-reporting, an elderly who needed help in one or more items was regarded as functionally dependent. Research assistants were selected and trained. The training included discussions on the objectives of the study, consent form, contents of the questionnaires, data collection techniques and issues of confidentiality of the participants. Participants were made to understand that their participation in the study was not compulsory and that they could decide to opt-out at any point within the study period without any untoward consequences. Data Analysis: All the questionnaires were checked visually, and were exported to the statistical package for the social sciences (IBM SPSS Inc& Chicago, IL,USA) version 20.0 for analysis. Mean and standard deviations were estimated for numerical variables while number and percentages were estimated for categorical variables. Comparison between numerical variables was made using student’s t-test while Chi-square square test was used to compare the categorical variables. Logistic regression analysis was employed in finding the independent association between the variables. The strength of the association between the independent and dependent variables was assessed using odds ratio (OR) at 95% confidence interval. The associations were considered statistically significant at P < 0.05 level. RESULTS This study had a response rate of 100 percent, with a mean age of 76.61 ± 7.87 years (76.31 ± 8.34 for males and 76.87 ± 7.47 for females). Socio-demographic Characteristics of the Respondents Participation was more among those aged above 80 years, farmers, females, the educated, those with spouse and low income. Majority of the participants had no care at their disposal or any source of social support. Only 62.5% of those who received care, had family members as source of care. Sources of social support differed among those who had them. Out of the number that had social support, only 21.2% received support from family members, and only 3% received it always. Transportation service was available to only 10% of respondents most of the time. See Table 1 . Association between Socio-demographic Characteristics and Functional Status Socio-demographic Characteristics and Toilet Use Statistically significant association existed between dependence in toilet use and age ( p = 0.000 ), female gender ( p = 0.045 ), absence of spouse ( p = 0.000 ), higher education ( p = 0.000 ), low income level ( p = 0.000 ) and religion ( p = 0.047 ). The greater the distance to source of food supply, the more the functional dependence and vice versa ( p = 0.045 ). See Table 2 Logistic Regression on the Association between Socio-demography and Toilet Use The probability of being functionally dependent in toilet use was 28 times higher in the respondents above the age of 75 years when compared to those aged 65–75 years (OR = 28.090; 95%CI = 3.235–243.940). See Table 3 . Socio-demographic Characteristics and Functional Support (Feeding). There was statistically significant association between functional dependence in feeding and age above 75 years ( p = 0.000 ), absence of spouse ( p = 0.000 ), low level of education ( p = 0.000 ), low income level ( p = 0.001 ). See Table 4 Socio-demographic Characteristics and Functional Status (Transfers) Functional dependence in transfers was significantly associated with increasing age ( p = 0.000 ), absence of spouse ( p = 0.000 ), low level of education ( p = 0.000 ), low income level ( p = 0.000 ), and being a Christian ( p = 0.005 ). See Table 5 . Logistic Regression on the Association between Socio-demographic Characteristics and Functional Status (Feeding/Transfers) Only age group ( p = 0.000 ) and marital status ( p = 0.003 ) had statistically significant independent association with functional support in feeding when confounders were eliminated. Also, age ( p = 0.000 ) had statistically significant independent association with functional support in the elderly on elimination of confounders. See Table 6 . DISCUSSION As shown in (Table 1 ), the overall response rate of 100% was recorded, with more female participants and those above 80 years. The greater participation among the respondents above 80 years in this study might have resulted from frequent hospital visits resulting from the geriatric giants as well as undifferentiated complaints from metabolic or biochemical imbalance which are common in this age group. Conversely, a comparative cross-sectional descriptive study in South-west Nigeria had most participation among those aged 58–68 years. 13 The finding of more female respondents in this study is similar to another cross-sectional study in South-west Nigeria which demonstrated more female participation. 14 Similarly, in surveys on health-seeking behaviour of older people in Nigeria and Australia, women above 65 years consulted doctors more than their male counterparts. 15 , 16 Our study finding could be attributed to greater co-morbidities in females resulting from menopausal changes which frequently make them seek care more than their male counterparts. It has been shown that while disability in men is related to cardiovascular diseases (CVDs), it is related to osteoporosis and other problems associated with menopause in women. 17 Also, our study participants were mostly married, farmers, educated, low income earners and Christians. The participants had farming as the predominant occupation, had greater chances of being married, considering their ages and were mostly retirees, hence the high proportion of them receiving one form of formal education or the other. The number of low income earners as recorded could be as a result of poor policy implementation on pension among the retirees on one hand and poor socioeconomic status of others, notwithstanding the lower likelihood of having health insurance when compared with other groups. These findings in this study are similar to another cross-sectional study by Afolabi and colleagues in South-west Nigeria which showed majority of respondents to be married, farmers and low income. 13 It is also in line with other studies on health-seeking behavior among the elderly, which demonstrated more participation among the married, farmers, low income earners and the educated. 18 , 19 The findings from this study is expected considering that in developing countries such as Nigeria, lifestyle choices including nutrition, healthcare utilization and to a larger extent, the level of disability among the elderly depend on the financial capability of these individuals. 13 Level of Support Received by the Respondents There were variations in the source of care at the disposal of respondents (Table 1 ). The greater proportion of those who had no care at their disposal could be due to elderly neglect at all levels of care and portrayed that family care was the major source of elderly care in this locality. This was not unexpected considering the fact that culturally, in this part of the Continent, elderly welfare and care aimed at ensuring stable psychosocial health status are the primary roles of immediate family members. Animasahun and Chapman demonstrated that the psychosocial health status of the elderly in Nigeria are affected by changes in family dynamics, increased demand for healthcare, rising economic stress and decreased functional independence. 20 Family members were said to be providing up to 90% of home care for the elderly in Nigeria and this is attributed to lack of institutionalized centers or private home care as practiced in some developed nations. 20 Similar to our study, another study in Nigeria by Mudiare reported significant proportion of elderly neglect in all aspect of care as result of decline in family and societal values. 21 The total absence of care as recorded in significant number of respondents in this study agreed with a similar study in North-central Nigeria which demonstrated high proportion of low care (well-being) among the elderly with age, marital status, financial support and children living with the elderly as predictors of poor well-being. 3 Furthermore, the absence of social support among the greater proportion of the respondents might be due to the abysmal level of investment in elderly social benefit programs by the government at all levels, probably in the belief that children would always take care of their aged parents. Inadequate healthcare programs such as the establishment of elderly care centers and social security system which would have ensured holistic and continuum of care among this group of citizens might be another explanation. The obvious lack of social support as recorded in this study agreed with a cross-sectional study by Mayston and colleagues among dependent older people which showed that the government was largely not involved in care and support of this population, leaving family members to negotiate the welfare of the older people with a marked stretch on family finances. 22 Majority of the participants could access their food supply with difficulty, which could have been due to poor road network, distant market sources, low income or frailty. An ethnographic-based study in Western Spain demonstrated major difficulties among the elderly in accessing their food supply, attributed to barriers in distance, physical limitations of the elderly, limitations of rural public transport and the remoteness of their living areas as were observed in our study. 23 Socio-demographic Characteristics and Toilet Use Respondents above 75 years, females gender, absence of spouse, low income and higher education level and far distance to source of food supply were statistically and significantly more functionally dependent in the use of toilet (Table 2 ). However, only age group had statistically significant independent association with functional status (in toilet use) when confounders were eliminated with the probability of being functionally dependent in toilet use about 28 times higher in the respondents above the age of 75 years when compared to those aged 65–75 years (Table 3 ). This finding could have resulted from poor grip strength due to sarcopenia and frailty associated with aging, instability and menopausal-related changes in bone minerals which affects bone and muscle strength in females, lack of companion and social support in those without spouse, increased co-morbid conditions such as CV-related diseases among those with higher education who might have better employment with sedentary lifestyle as well as poor socio-economic conditions usually associated with low income level which imparts on nutrition and overall healthcare. It has been shown that poor health condition is usually aggravated by old age, being separated after marriage and not receiving financial support among others while the family structure which provided support for them in the past is almost collapsed. 4 Our finding is in keeping with a cross-sectional study by Lestari and colleagues in six middle income countries which demonstrated that at age 80 years and above, being a female and low income were statistically and significantly associated with functional decline in toilet use. This is not different from a study done by Ahmed and colleagues which revealed statistical significant association between increasing age, female gender, low income, not being married and dependence in toilet use and attributed their findings to sedentary lifestyle among the respondents. 9 Socio-demographic Characteristics and Functional Support (Feeding). There was statistical significant association between functional status in feeding and age, marital status, educational status and income level, with functional dependence in feeding having statistically significant association with age above 75 years, being without a spouse, poor education and low income level (Table 4 ). However, only age group and marital status had statistically significant independent association with functional support in feeding when confounders were eliminated with the probability of being functionally dependent in feeding about 8 times higher in respondents above the age of 75 years when compared to those aged 65–75 and the probability of being functionally dependent in feeding about 4 times higher in respondents without spouse when compared to those with spouse (Table 6 ). The findings here could be due to increased incidence of Parkinsonism in the elderly with poor handgrip strength, possibly aggravated by lack of partner support and poor socio-economic well-being which imparts on the overall health status of the elderly such as cerebrovascular accident (CVA) and osteoarthritis. Low handgrip strength has been shown to be associated with multiple morbidity, cognitive impairment and disability. 24 The finding in this study is in line with a study in South-South Nigeria by Morgan and colleagues. 25 This did not differ from the work of Kagawa and colleagues in Brazil. 26 On the contrary, a study by Ajayi and colleagues in South-west Nigeria showed no statistical significant association between age, gender, income level and ADL in feeding and attributed this to the fact that independence in feeding is usually the last set of activities to be lost. 27 Our findings also slightly varied from other studies which also showed no statistical significant difference between age, gender and functional dependence in feeding. 27 , 28 Socio-demographic Characteristics and Functional Status (Transfers) The association between socio-demographic characteristics and functional status in transfers revealed statistically significant association between ADL (in transfer) and age, marital status, educational level, level of income and religion with respondents above 75 years, absence of spouse, low level of education, low income and non-Christians being functionally dependent in transfers. Moreover, there was no statistical significant association between functional dependence in transfers and gender, employment status, availability of care, social support and distance to source of food supply (Table 5 ). The significant findings in this study could be explained on the basis of reduced grip strength and arthritis associated with aging, lack of partner-motivated physical exercise, inadequate knowledge of self-care and poor nutritional status from inadequate income which affects the overall psychosocial and cognitive function in the elderly. It has been shown that reduced grip strength, socioeconomic, psychosocial and cognitive impairment affect quality of life in the elderly. 29 However, the probability of being functionally dependent in transfers was about 12 times higher in respondents above 75 years when compared with those aged 65–75 years (Table 6 ). The findings in our study is similar to a study in South-west Nigeria by Ajayi and colleagues who deposited that overall functional disability in transfers among the elderly was statistically and significantly associated with age above 80 years, poor education and low income level and attributed this to poverty, malnutrition and poor health services in this age group. 27 This is also in keeping with some findings in studies done in Brazil and India. 26 , 28 Limitations of the Study: This is a hospital-based cross-sectional study, hence its findings may not particularly portray adequate representation of the elderly in the study area. A population-based study of a larger sample of the elderly will show more generalizability. Furthermore, the presence of co-morbidities was not assessed, hence their impact on the overall functional status were not ascertained. Data collection on the nutritional and functional status was done in retrospect with the possibility of a recall bias. However, the available options made in the questionnaire were constructed to aid recall. Conclusion The functional status of the elderly in the various ADL was affected by various socio-demographic factors. Functional dependence in toilet use and transfers had age as the only independent risk factor, with age and marital status as the independent risk factors for functional dependence in feeding. These findings portray the wide gap in disability management in the elderly between developed and developing countries, and explicitly underscore the fact that an improvement in the biopsychosocial, biomedical and economic well-being of the elderly will ameliorate the impact of decline in functional status in the ADL. Declarations Acknowledgement: We sincerely, thank the management of Alex Ekwueme Federal University Teaching Hospital for their support. We also appreciate the staff of Geriatric Clinic, in the Department of Family Medicine for their support. Special appreciation goes to our tutors and supervisors, for their kind support and continued advice throughout the duration of this research. The cooperation and willingness of the participants all through the study is appreciated. Ethical approval : Approval for this study was obtained from the Research and Ethics Committee of the study institution on 1 st June, 2018 with approval number: FETHA/REC/VOL.2/2018/060. This study complied with the Helsinki declaration 2013 on human research. Consent to participate : Written informed consents were obtained from all respondents before the questionnaires were administered. Participants were informed that they had the right to decline participation in the study, and that all data obtained from them would be kept confidential. Consent to publish : Not applicable Criteria for Authorship : The authors contributed equally in the design, data acquisition/analysis/interpretation, article drafting and revision and gave approval for the final version to be published. Authors’ Contributions : CS Anyigor-Ogah, AN Ekechi, DU Aghor (conceptualization, methodology, data analysis, writing initial draft and revision, reading and approving final version); CM Ovuoba, CN Idakari, IH Amazue (methodology, data collection, supervision, reading and approving final version); AC Anyigor-Ogah, IM Idika, IA Ogah, ME Chukwuonyeye (validation, data curation, supervision, reading and approving final version); BI Umezurike, NO Okezie, IN Umezurike (data analysis, data curation, revisions, project leadership) Authorship Statement : We affirm that this manuscript has been read and approved by all the authors, requirement for authorship has been met and each author believes that the manuscript represents honest work. Availability of Data and Material : The sets of data generated and analyzed in this study are available from the corresponding author on reasonable request through the e-mail address of [email protected] Competing Interest : The authors declare that there is no financial or non-financial competing interest in this research Funding : There was no source of external funding to this research References Adeleke JO. Living with modernity: Challenges of aging in a traditional Nigerian society. Nig J Appl Behav Sci. 2014;2014:245–54. Abdulkadir RL, Abdullah NAH, Wong W. Dividend payment behaviour and its determinants: The Nigerian evidence. Afr Dev Rev. 2016;28(1):53–63. Adebowale SA, Atte O, Ayeni O. Elderly well-being in a rural community in North-Central Nigeria, sub-Saharan Africa. Public Health Res. 2012;2(4):92–101. Kaneda T, Lee MA, Pollard K. 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Anyigor-Ogah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYHACNjDJx8B84MAHBoYEIrUkgEi2xIczSNTCY2zMQ4wWfv7Fzx7+/GGXxyaRYyZt22aXx8/ewPjhYw5uLZIznpkb8yQkF7NJpJVJ57YlF0v2HGCWnLkNtxaDGwfMpBkSmBPbJJK3AbUwJ264kcDGzItXy/Fvkj8S6oFaEsykLdvqidByvsdMgifhMFBLirExY9thwlokZ/CUSfOkHU9s43mW+LDn3PHEmT0Hm/H6hZ//+DbJHzbVif3syQcO/CgDMZoPfviIRwuDRAKUIQBkMIJTAmMDHvUgaw4gM/7gVzwKRsEoGAUjEwAAHJtTu8WaF+cAAAAASUVORK5CYII=","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chijioke","middleName":"Stanley","lastName":"Anyigor-Ogah","suffix":""},{"id":573441466,"identity":"1e04101a-c887-46c5-9746-4aa0af3a6631","order_by":1,"name":"Agatha Nkechinyere Ekechi","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Agatha","middleName":"Nkechinyere","lastName":"Ekechi","suffix":""},{"id":573441467,"identity":"b2207613-959d-49cd-a9a4-5b5eb43dfaec","order_by":2,"name":"Chukwuemeka Mbam Ovuoba","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chukwuemeka","middleName":"Mbam","lastName":"Ovuoba","suffix":""},{"id":573441470,"identity":"9f413a73-96f0-4e52-a3de-c984125e3303","order_by":3,"name":"Daniel Udochukwu Aghor","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Udochukwu","lastName":"Aghor","suffix":""},{"id":573441471,"identity":"60082176-ae9f-4819-80b0-9afae227f37a","order_by":4,"name":"Idika Mba Idika","email":"","orcid":"","institution":"David Umahi Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Idika","middleName":"Mba","lastName":"Idika","suffix":""},{"id":573441473,"identity":"342b30a0-debd-4f5e-a934-78816641b071","order_by":5,"name":"Augustina Chinweoke Anyigor-Ogah","email":"","orcid":"","institution":"Ebonyi State University","correspondingAuthor":false,"prefix":"","firstName":"Augustina","middleName":"Chinweoke","lastName":"Anyigor-Ogah","suffix":""},{"id":573441474,"identity":"4d16ac91-545a-4adf-a048-4b341c839155","order_by":6,"name":"Miracle Erinma Chukwuonye","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Miracle","middleName":"Erinma","lastName":"Chukwuonye","suffix":""},{"id":573441475,"identity":"5b2cbced-caf4-405e-ab2b-982b21240c2f","order_by":7,"name":"Ikechukwu Aloh Ogah","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ikechukwu","middleName":"Aloh","lastName":"Ogah","suffix":""},{"id":573441476,"identity":"37fc3de5-46d6-4f31-b09a-3fc45ca12499","order_by":8,"name":"Nweke Chinedu Idakari","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nweke","middleName":"Chinedu","lastName":"Idakari","suffix":""},{"id":573441477,"identity":"a8c46cf6-320d-437b-9e8f-8b7fa6fb3b56","order_by":9,"name":"Ikechukwu Henry Amazue","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ikechukwu","middleName":"Henry","lastName":"Amazue","suffix":""},{"id":573441478,"identity":"32046194-6009-4799-bcff-9bf229a6d84b","order_by":10,"name":"Benjamin Ikechukwu Umezurike","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"Ikechukwu","lastName":"Umezurike","suffix":""},{"id":573441479,"identity":"25c31954-0287-4d88-83dd-a3cbd3a9c635","order_by":11,"name":"Ndudim Ogwuegbu Okezie","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ndudim","middleName":"Ogwuegbu","lastName":"Okezie","suffix":""},{"id":573441480,"identity":"f252d6a9-e02e-4c6f-8642-2f996d2ac44a","order_by":12,"name":"Ifeyinwa Nneka Umezurike","email":"","orcid":"","institution":"Alex Ekwueme Federal University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ifeyinwa","middleName":"Nneka","lastName":"Umezurike","suffix":""}],"badges":[],"createdAt":"2025-12-10 12:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8327691/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8327691/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100206299,"identity":"58d1de95-ad62-40b2-bb3d-7f59ada6d851","added_by":"auto","created_at":"2026-01-14 06:34:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47557,"visible":true,"origin":"","legend":"","description":"","filename":"geriatricpublication2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8327691/v1/208f25c1cd222492d9e78a09.docx"},{"id":100206301,"identity":"50d7e41f-5c1e-4089-89d6-4954f54ff09e","added_by":"auto","created_at":"2026-01-14 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10:45:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1129696,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8327691/v1/d3d8fe5c-c7f5-4415-9135-50a9aa8d2118.pdf"},{"id":100206298,"identity":"12c1b2a9-992e-4199-b879-c2de7d687f54","added_by":"auto","created_at":"2026-01-14 06:34:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35349,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8327691/v1/30d9a949b9d12da0ead1df87.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Basic Activities of Daily Living and Associated Factors among the Elderly in a Tertiary Care Center, South-East Nigeria","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn recent decades, the rate of disability has declined in older adults in the developed countries. This is not the case in developing countries like Nigeria. The problems of the elderly in Africa are rapidly increasing as the societies are locked-up in diverse conflicts, economic challenges, natural and man-made disasters, diseases and deterioration in family relationships.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The society generally has negative affinity towards older people as various programs are being fashioned out for other population groups except the elderly.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The Nigerian elderly are disadvantaged in terms of support, yet the growing population of this group makes it imperative to demand for social support since majority of them live in rural areas, hence this study aimed at studying the functionality of the elderly in selected basic activities of daily living (BADLs), with a view to not only ensure proper policy formulation in providing them with essential healthcare, but also to develop appropriate support and nursing services aimed at obtaining relevant patient-centered information with respect to their individual peculiarities. The elderly in Nigeria who are mainly agricultural workers and subsistence farmers do not benefit from government grant and the retirees are hardly paid their pensions and gratuities.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Rural-urban migration of the young people in search of better economic realities has left so many of the elderly unattended to, even those who would have provided the traditional support have been limited by high mortality rates arising from this migration.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn a study done in Ondo State Nigeria, majority of the aged males reported participating in sanitization and vigilante activities to make livings while many of their female counterparts participate in market trading and fetching of sacred water to bath for longevity. Only minority of the aged reported patronizing the hospital when sick but many others make use of local herbs.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In the same study, few subjects reported lack of accommodation while economic hardship was more prevalent among the uneducated. It has been reported that no social security or policy system has ever been put in place to carter for people at their old age in Nigeria. Even the primary health care system has no special provision for enhancing the healthcare of the elderly.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Due to poverty and poor infrastructural developments, the elderly in Nigeria face lower life expectancies and live the greater part of their lives in poor health.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This poor health condition is usually aggravated by old age, being separated after marriage, visits by only male children and not receiving financial support among others. The stance of the government towards the overall health of the elderly is poor while the family structure which provided support for them in the past is almost collapsed.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies have shown that about 54% of French citizens older than 65 years reported having at least one disability while about one-third of the elderly in Califonia had at least one severe disability.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In Taiwan, over 4.4\u0026nbsp;million elders reported that their disability limits their ADLs and 6.5\u0026nbsp;million reported difficulties in attending to instrumental ADLs while about 75% of those 85 years or older need assistance with ADLs.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e With the aging population, there is an increased need for support services to augment the support from the family.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations and Consent to Participate\u003c/h2\u003e \u003cp\u003eApproval for this study was sought and obtained from the Research and Ethics Committee of the Federal Teaching Hospital, Abakaliki on 1\u003csup\u003eST\u003c/sup\u003e June, 2018, with reference number FETHA/REC/VOL.2/2018/060. This research work complied with the Helsinki declaration of 1975, as revised in 2013 on human research. All selected participants were informed about the objectives and contributions of the study and written informed consents were obtained before the questionnaires were administered. Participants were informed that they had the right to decline participation in the study. They were also informed that all data obtained from them would be kept confidential.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design:\u003c/h3\u003e\n\u003cp\u003eThis was a cross-sectional analytical study which spanned for duration of three (3) months.\u003c/p\u003e\n\u003ch3\u003e:\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eStudy Population\u003c/b\u003e:\u003c/div\u003e \u003cp\u003eThe study population comprised the elderly patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years, who presented at the Geriatric Clinic of the hospital within the period of study.\u003c/p\u003e\n\u003ch3\u003eSelection Criteria:\u003c/h3\u003e\n\u003cp\u003eThe selection of the participants was based on some inclusion and exclusion criteria.\u003c/p\u003e \u003cp\u003eIncluded in this study were patients aged 65 years and above, who gave their consent to participate in the study. Excluded from this study were the severely or terminally ill patients because the functional status might be influenced by the illness and not the patients\u0026rsquo; characteristics, patients with severe disabling conditions because this might bias the assessment of functions\u003c/p\u003e\n\u003ch3\u003eSample Size Determination:\u003c/h3\u003e\n\u003cp\u003eThe sample size (N) was determined using the Fisher\u0026rsquo;s formula thus:\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;Z\u003csup\u003e2\u003c/sup\u003epq/d\u003csup\u003e2\u003c/sup\u003e, where: n is the minimum sample size, Z is the standard normal deviate at 95% confidence level (which is 1.96), P is the prevalence of functional impairment in the elderly from previous study which is 17%\u003csup\u003e9\u003c/sup\u003e, q is regarded as 1-p (proportion of the population that does not have malnutrition, (0.83), d is the degree of precision (level of accuracy desired) and it is usually set at 0.05.\u003c/p\u003e \u003cp\u003eFrom the above figures; sample size, N\u0026thinsp;=\u0026thinsp;216.82\u003c/p\u003e \u003cp\u003eSince the study population is 606 (not up to 10,000 and above), the sample size was corrected\u003c/p\u003e \u003cp\u003eusing the formula: N\u003csub\u003ef\u003c/sub\u003e = n/[1+(n/N)]\u003csup\u003e10\u003c/sup\u003e, where N\u003csub\u003ef\u003c/sub\u003e is the corrected sample size; n is the population size (606); N is the sample size (216.83).\u003c/p\u003e \u003cp\u003eApplying the formula, N\u003csub\u003ef\u003c/sub\u003e = approximately 160.\u003c/p\u003e \u003cp\u003eHence, the sample size was 160.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSampling Techniques:\u003c/h2\u003e \u003cp\u003eParticipants for this study were selected by systematic random sampling.\u003c/p\u003e \u003cp\u003eSince sample size, N\u003csub\u003ef\u003c/sub\u003e = 160;\u003c/p\u003e \u003cp\u003eAverage number of elderly, 65 years and above seen at the Geriatric Clinic in three months in the hospital was 606, hence, the population size (n). This gave a sample interval of approximately 4.\u003c/p\u003e \u003cp\u003eThat is, for every 4 patients, one was selected as soon as they presented at the Geriatric clinic. The number of the first elderly patient included in the sample was randomly chosen by picking one out of 4 elderly patients by balloting among them. However, during the selection, any number that was selected which did not meet the inclusion criteria was dropped and the next number picked. Such a selection did not affect the next random selection.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Instruments:\u003c/h3\u003e\n\u003cp\u003eData for this research was collected by face-to-face interviewer-administered structured and pre-tested questionnaires. The pre-testing was carried out at the General Outpatient Clinic (GOPC) of a similar health facility with the aim of modifying the questionnaire and making other adjustments were necessary.\u003c/p\u003e \u003cp\u003eThe questionnaires were prepared in English language but were interpreted in Igbo language for those that could not understand English. To ensure validity, the questionnaires were transcribed from English language to Igbo language by an Igbo language lecturer of the State College of Education. This translation was back-translated to English language by an English language lecturer of the same school and was compared with the previous questionnaire. Both translations made the same sense. The questionnaire was developed using a modified Katz and Lawton\u0026rsquo;s index.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e It consisted of two parts (see the supplementary material). The first part documented the socio-demographic characteristics and social support while the second part of the questionnaire assessed the functional status of the patients (basic and instrumental activities of daily living). Based on self-reporting, an elderly who needed help in one or more items was regarded as functionally dependent.\u003c/p\u003e \u003cp\u003eResearch assistants were selected and trained. The training included discussions on the objectives of the study, consent form, contents of the questionnaires, data collection techniques and issues of confidentiality of the participants. Participants were made to understand that their participation in the study was not compulsory and that they could decide to opt-out at any point within the study period without any untoward consequences.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eAll the questionnaires were checked visually, and were exported to the statistical package for the social sciences (IBM SPSS Inc\u0026amp; Chicago, IL,USA) version 20.0 for analysis. Mean and standard deviations were estimated for numerical variables while number and percentages were estimated for categorical variables. Comparison between numerical variables was made using student\u0026rsquo;s t-test while Chi-square square test was used to compare the categorical variables. Logistic regression analysis was employed in finding the independent association between the variables. The strength of the association between the independent and dependent variables was assessed using odds ratio (OR) at 95% confidence interval. The associations were considered statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eThis study had a response rate of 100 percent, with a mean age of 76.61\u0026thinsp;\u0026plusmn;\u0026thinsp;7.87 years (76.31\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34 for males and 76.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.47 for females).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSocio-demographic Characteristics of the Respondents\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eParticipation was more among those aged above 80 years, farmers, females, the educated, those with spouse and low income. Majority of the participants had no care at their disposal or any source of social support. Only 62.5% of those who received care, had family members as source of care. Sources of social support differed among those who had them. Out of the number that had social support, only 21.2% received support from family members, and only 3% received it always. Transportation service was available to only 10% of respondents most of the time. See Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eAssociation between Socio-demographic Characteristics and Functional Status\u003c/h2\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003eSocio-demographic Characteristics and Toilet Use\u003c/h2\u003e\n \u003cp\u003eStatistically significant association existed between dependence in toilet use and age (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), female gender (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.045\u003c/strong\u003e), absence of spouse (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), higher education (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), low income level (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e) and religion (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.047\u003c/strong\u003e). The greater the distance to source of food supply, the more the functional dependence and vice versa (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.045\u003c/strong\u003e). See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eLogistic Regression on the Association between Socio-demography and Toilet Use\u003c/h2\u003e\n \u003cp\u003eThe probability of being functionally dependent in toilet use was 28 times higher in the respondents above the age of 75 years when compared to those aged 65\u0026ndash;75 years (OR\u0026thinsp;=\u0026thinsp;28.090; 95%CI\u0026thinsp;=\u0026thinsp;3.235\u0026ndash;243.940). See Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-demographic Characteristics and Functional Support (Feeding).\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThere was statistically significant association between functional dependence in feeding and age above 75 years (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), absence of spouse (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), low level of education (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), low income level (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.001\u003c/strong\u003e). See Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eSocio-demographic Characteristics and Functional Status (Transfers)\u003c/h2\u003e\n \u003cp\u003eFunctional dependence in transfers was significantly associated with increasing age (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), absence of spouse (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), low level of education (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), low income level (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e), and being a Christian (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.005\u003c/strong\u003e). See Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eLogistic Regression on the Association between Socio-demographic Characteristics and Functional Status (Feeding/Transfers)\u003c/h2\u003e\n \u003cp\u003eOnly age group (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e) and marital status (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.003\u003c/strong\u003e) had statistically significant independent association with functional support in feeding when confounders were eliminated. Also, age (\u003cstrong\u003ep\u003c/strong\u003e\u0026thinsp;\u003cstrong\u003e=\u0026thinsp;0.000\u003c/strong\u003e) had statistically significant independent association with functional support in the elderly on elimination of confounders. See Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAs shown in (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), the overall response rate of 100% was recorded, with more female participants and those above 80 years. The greater participation among the respondents above 80 years in this study might have resulted from frequent hospital visits resulting from the geriatric giants as well as undifferentiated complaints from metabolic or biochemical imbalance which are common in this age group. Conversely, a comparative cross-sectional descriptive study in South-west Nigeria had most participation among those aged 58\u0026ndash;68 years.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The finding of more female respondents in this study is similar to another cross-sectional study in South-west Nigeria which demonstrated more female participation.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Similarly, in surveys on health-seeking behaviour of older people in Nigeria and Australia, women above 65 years consulted doctors more than their male counterparts.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Our study finding could be attributed to greater co-morbidities in females resulting from menopausal changes which frequently make them seek care more than their male counterparts. It has been shown that while disability in men is related to cardiovascular diseases (CVDs), it is related to osteoporosis and other problems associated with menopause in women.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlso, our study participants were mostly married, farmers, educated, low income earners and Christians. The participants had farming as the predominant occupation, had greater chances of being married, considering their ages and were mostly retirees, hence the high proportion of them receiving one form of formal education or the other. The number of low income earners as recorded could be as a result of poor policy implementation on pension among the retirees on one hand and poor socioeconomic status of others, notwithstanding the lower likelihood of having health insurance when compared with other groups. These findings in this study are similar to another cross-sectional study by Afolabi and colleagues in South-west Nigeria which showed majority of respondents to be married, farmers and low income.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e It is also in line with other studies on health-seeking behavior among the elderly, which demonstrated more participation among the married, farmers, low income earners and the educated.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e The findings from this study is expected considering that in developing countries such as Nigeria, lifestyle choices including nutrition, healthcare utilization and to a larger extent, the level of disability among the elderly depend on the financial capability of these individuals.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLevel of Support Received by the Respondents\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThere were variations in the source of care at the disposal of respondents (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The greater proportion of those who had no care at their disposal could be due to elderly neglect at all levels of care and portrayed that family care was the major source of elderly care in this locality. This was not unexpected considering the fact that culturally, in this part of the Continent, elderly welfare and care aimed at ensuring stable psychosocial health status are the primary roles of immediate family members. Animasahun and Chapman demonstrated that the psychosocial health status of the elderly in Nigeria are affected by changes in family dynamics, increased demand for healthcare, rising economic stress and decreased functional independence.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Family members were said to be providing up to 90% of home care for the elderly in Nigeria and this is attributed to lack of institutionalized centers or private home care as practiced in some developed nations.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Similar to our study, another study in Nigeria by Mudiare reported significant proportion of elderly neglect in all aspect of care as result of decline in family and societal values.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The total absence of care as recorded in significant number of respondents in this study agreed with a similar study in North-central Nigeria which demonstrated high proportion of low care (well-being) among the elderly with age, marital status, financial support and children living with the elderly as predictors of poor well-being.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, the absence of social support among the greater proportion of the respondents might be due to the abysmal level of investment in elderly social benefit programs by the government at all levels, probably in the belief that children would always take care of their aged parents. Inadequate healthcare programs such as the establishment of elderly care centers and social security system which would have ensured holistic and continuum of care among this group of citizens might be another explanation. The obvious lack of social support as recorded in this study agreed with a cross-sectional study by Mayston and colleagues among dependent older people which showed that the government was largely not involved in care and support of this population, leaving family members to negotiate the welfare of the older people with a marked stretch on family finances.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Majority of the participants could access their food supply with difficulty, which could have been due to poor road network, distant market sources, low income or frailty. An ethnographic-based study in Western Spain demonstrated major difficulties among the elderly in accessing their food supply, attributed to barriers in distance, physical limitations of the elderly, limitations of rural public transport and the remoteness of their living areas as were observed in our study.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic Characteristics and Toilet Use\u003c/h2\u003e \u003cp\u003eRespondents above 75 years, females gender, absence of spouse, low income and higher education level and far distance to source of food supply were statistically and significantly more functionally dependent in the use of toilet (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, only age group had statistically significant independent association with functional status (in toilet use) when confounders were eliminated with the probability of being functionally dependent in toilet use about 28 times higher in the respondents above the age of 75 years when compared to those aged 65\u0026ndash;75 years (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This finding could have resulted from poor grip strength due to sarcopenia and frailty associated with aging, instability and menopausal-related changes in bone minerals which affects bone and muscle strength in females, lack of companion and social support in those without spouse, increased co-morbid conditions such as CV-related diseases among those with higher education who might have better employment with sedentary lifestyle as well as poor socio-economic conditions usually associated with low income level which imparts on nutrition and overall healthcare. It has been shown that poor health condition is usually aggravated by old age, being separated after marriage and not receiving financial support among others while the family structure which provided support for them in the past is almost collapsed.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Our finding is in keeping with a cross-sectional study by Lestari and colleagues in six middle income countries which demonstrated that at age 80 years and above, being a female and low income were statistically and significantly associated with functional decline in toilet use. This is not different from a study done by Ahmed and colleagues which revealed statistical significant association between increasing age, female gender, low income, not being married and dependence in toilet use and attributed their findings to sedentary lifestyle among the respondents.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSocio-demographic Characteristics and Functional Support (Feeding).\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere was statistical significant association between functional status in feeding and age, marital status, educational status and income level, with functional dependence in feeding having statistically significant association with age above 75 years, being without a spouse, poor education and low income level (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, only age group and marital status had statistically significant independent association with functional support in feeding when confounders were eliminated with the probability of being functionally dependent in feeding about 8 times higher in respondents above the age of 75 years when compared to those aged 65\u0026ndash;75 and the probability of being functionally dependent in feeding about 4 times higher in respondents without spouse when compared to those with spouse (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The findings here could be due to increased incidence of Parkinsonism in the elderly with poor handgrip strength, possibly aggravated by lack of partner support and poor socio-economic well-being which imparts on the overall health status of the elderly such as cerebrovascular accident (CVA) and osteoarthritis. Low handgrip strength has been shown to be associated with multiple morbidity, cognitive impairment and disability.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The finding in this study is in line with a study in South-South Nigeria by Morgan and colleagues.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e This did not differ from the work of Kagawa and colleagues in Brazil.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e On the contrary, a study by Ajayi and colleagues in South-west Nigeria showed no statistical significant association between age, gender, income level and ADL in feeding and attributed this to the fact that independence in feeding is usually the last set of activities to be lost.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Our findings also slightly varied from other studies which also showed no statistical significant difference between age, gender and functional dependence in feeding.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic Characteristics and Functional Status (Transfers)\u003c/h2\u003e \u003cp\u003eThe association between socio-demographic characteristics and functional status in transfers revealed statistically significant association between ADL (in transfer) and age, marital status, educational level, level of income and religion with respondents above 75 years, absence of spouse, low level of education, low income and non-Christians being functionally dependent in transfers.\u003c/p\u003e \u003cp\u003eMoreover, there was no statistical significant association between functional dependence in transfers and gender, employment status, availability of care, social support and distance to source of food supply (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The significant findings in this study could be explained on the basis of reduced grip strength and arthritis associated with aging, lack of partner-motivated physical exercise, inadequate knowledge of self-care and poor nutritional status from inadequate income which affects the overall psychosocial and cognitive function in the elderly. It has been shown that reduced grip strength, socioeconomic, psychosocial and cognitive impairment affect quality of life in the elderly.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e However, the probability of being functionally dependent in transfers was about 12 times higher in respondents above 75 years when compared with those aged 65\u0026ndash;75 years (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The findings in our study is similar to a study in South-west Nigeria by Ajayi and colleagues who deposited that overall functional disability in transfers among the elderly was statistically and significantly associated with age above 80 years, poor education and low income level and attributed this to poverty, malnutrition and poor health services in this age group.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This is also in keeping with some findings in studies done in Brazil and India.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eLimitations of the Study:\u003c/h2\u003e \u003cp\u003eThis is a hospital-based cross-sectional study, hence its findings may not particularly portray adequate representation of the elderly in the study area. A population-based study of a larger sample of the elderly will show more generalizability. Furthermore, the presence of co-morbidities was not assessed, hence their impact on the overall functional status were not ascertained. Data collection on the nutritional and functional status was done in retrospect with the possibility of a recall bias. However, the available options made in the questionnaire were constructed to aid recall.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe functional status of the elderly in the various ADL was affected by various socio-demographic factors. Functional dependence in toilet use and transfers had age as the only independent risk factor, with age and marital status as the independent risk factors for functional dependence in feeding. These findings portray the wide gap in disability management in the elderly between developed and developing countries, and explicitly underscore the fact that an improvement in the biopsychosocial, biomedical and economic well-being of the elderly will ameliorate the impact of decline in functional status in the ADL.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003eWe sincerely, thank the management of Alex Ekwueme Federal University Teaching Hospital for their support. We also appreciate the staff of Geriatric Clinic, in the Department of Family Medicine for their support. Special appreciation goes to our tutors and supervisors, for their kind support and continued advice throughout the duration of this research. The cooperation and willingness of the participants all through the study is appreciated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e: Approval for this study was obtained from the Research and Ethics Committee of the study institution on 1\u003csup\u003est\u003c/sup\u003e June, 2018 with approval number: FETHA/REC/VOL.2/2018/060. This study complied with the Helsinki declaration 2013 on human research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e: Written informed consents were obtained from all respondents before the questionnaires were administered. Participants were informed that they had the right to decline participation in the study, and that all data obtained from them would be kept confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCriteria for Authorship\u003c/strong\u003e: The authors contributed equally in the design, data acquisition/analysis/interpretation, article drafting and revision and gave approval for the final version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e: CS Anyigor-Ogah, AN Ekechi, DU Aghor (conceptualization, methodology, data analysis, writing initial draft and revision, reading and approving final version); CM Ovuoba, CN Idakari, IH Amazue (methodology, data collection, supervision, reading and approving final version); AC Anyigor-Ogah, IM Idika, IA Ogah, ME Chukwuonyeye \u0026nbsp;(validation, data curation, supervision, reading and approving final version); BI Umezurike, NO Okezie, IN Umezurike (data analysis, data curation, revisions, project leadership)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship Statement\u003c/strong\u003e: We affirm that this manuscript has been read and approved by all the authors, requirement for authorship has been met and each author believes that the manuscript represents honest work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e: The sets of data generated and analyzed in this study are available from the corresponding author on reasonable request through the e-mail address of [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e: The authors declare that there is no financial or non-financial competing interest in this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: There was no source of external funding to this research\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdeleke JO. 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J Community Med Health Edu. 2013;3:224. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4172/2161-0711.1000224\u003c/span\u003e\u003cspan address=\"10.4172/2161-0711.1000224\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elderly, malnutrition, functional status, disability","lastPublishedDoi":"10.21203/rs.3.rs-8327691/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8327691/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn Nigeria, the elderly is neglected and much attention (if any) is not given to them in terms of their overall health and well-being, thus making them vulnerable. The process of aging is affected by variety of factors (including family dynamics). The various changes that occur as a result of these factors increase the vulnerability of individuals to life threatening diseases, dysfunction and possible death. Elderly population is said to be decreasing in Africa compared to more developed nations. This is probably due to the absence of clear policy or functional social security service for the elderly.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study focused on the effect of socio-demographic characteristics and family support on the functional status (toilet use, feeding and transfers) in the elderly.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a hospital-based cross-sectional analytical study of 160 elderly aged between 65\u0026ndash;98 years selected through systematic random sampling. Chi square test, t-test and logistic regression were used for analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was 100 percent response rate in this study. The respondents had mean age of 76.31\u0026thinsp;\u0026plusmn;\u0026thinsp;8.34 years for males and 76.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.47 years for females. There was statistically significant association between age, absence of spouse, poor education and functional dependence in all activities of daily living. Age independently predicted dependence in activities of daily living, while marital status predicted dependence in feeding.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe high level of functional decline recorded in this study explicitly underscore the fact that an improvement in the biopsychosocial, biomedical and economic well-being of the elderly, as well the incorporation of family-centered approach in the elderly care, will ameliorate the functional decline in the activities of daily living.\u003c/p\u003e","manuscriptTitle":"Basic Activities of Daily Living and Associated Factors among the Elderly in a Tertiary Care Center, South-East Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-14 06:34:40","doi":"10.21203/rs.3.rs-8327691/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-17T16:25:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T04:51:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-07T07:26:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131101611744949355397686509505945214070","date":"2026-02-07T05:08:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233065150545013224424566244839853989197","date":"2026-02-04T07:45:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86183649606408241146323534417250504754","date":"2026-02-02T05:13:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176703570456090432450753702366688096303","date":"2026-02-02T01:51:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218340310406875127701075938576643337498","date":"2026-01-30T14:39:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T12:06:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302745740657637351727971495938123149181","date":"2026-01-30T11:08:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248352166046433307046759567299290902188","date":"2026-01-29T20:36:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T21:09:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10115984911609247312397191648421381661","date":"2026-01-14T19:26:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T16:31:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T06:45:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-02T11:42:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-01-02T11:33:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"299718b2-4aea-4dc2-9e17-b515fa3f5df9","owner":[],"postedDate":"January 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T11:25:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-14 06:34:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8327691","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8327691","identity":"rs-8327691","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}