Key Points
Question
Are there rural-urban and/or regional differences in the association between dual sensory loss (concurrent hearing and vision loss) and depression?
Findings
This cross-sectional study included 27 927 respondents to Longitudinal Aging Study in India and found that the odds of depression with dual sensory loss (vs no loss) were significantly higher (odds ratio [OR], 3.16) in urban compared with rural residents (OR, 1.73) and in the West (OR, 5.10) compared with the North (reference) region (OR, 1.38).
Meaning
These findings suggest that interventions for sensory loss should prioritize older adults in these areas.
Abstract
Importance
Investigating rural-urban and regional differences in the association between dual sensory loss (concurrent hearing and vision loss) and depression may highlight gaps in sensory loss research and health care services, and by socioeconomic status. Whether urbanicity and region may modify associations between sensory loss and depression is unknown.
Objective
To describe the rural-urban and regional differences in the association of dual sensory loss with depression among older adults.
Design, Setting, and Participants
This cross-sectional study used data from wave 1 (April 2017-December 2019) of the population-based Longitudinal Aging Study in India (LASI). Participants were recruited from 35 states and union territories in India. LASI incorporated a multistage stratified area probability cluster sampling design to recruit participants 45 years and older and their spouses; 31 447 eligible participants 60 years of age or older were interviewed. Data analyses were conducted from May 17, 2022, to November 11, 2023.
Exposures
Sensory loss (no sensory loss, hearing loss only, vision loss only, and dual sensory loss) was determined by respondents’ self-reported perceived difficulty regarding hearing and vision function.
Main Outcomes and Measures
The Composite International Diagnostic Interview (CIDI-SF) scale was used to identify major episodic depression. Logistic regression was used to estimate the odds ratios (ORs) and 95% CIs of depression comparing participants with vs without sensory loss, adjusting for demographic and clinical covariates. Rural-urban and regional differences were assessed by including interaction terms between these variables and sensory loss.
Results
The study analysis included 27 927 participants (mean [SD] age, 68.0 [7.2] years; 14 477 [51%] females and 13 450 [49%] males). The fully adjusted models showed that the odds of depression with dual sensory loss (vs no loss) was higher in urban (OR, 3.16; 95% CI, 2.00-4.99) vs rural (OR, 1.73; 95% CI, 1.31-2.29) residents and among residents in the West (OR, 5.10; 95% CI, 1.74-14.97) vs North (OR, 1.38; 95% CI, 0.81-2.35) regions.
Conclusions and Relevance
These findings indicate that sensory loss is associated with depression in older adults, with differences by urbanicity and region. Adults with sensory loss across multiple systems may be an important group to target for intervention.
This cross-sectional study assesses the rural-urban and regional differences in the association of dual sensory loss with depression among older adults in India.
Introduction
Depression is the largest contributor to global disability, was responsible for 7.5% of years lived with disability in 2015, and is associated with 800 000 deaths by suicide per year.1 Currently, 34% of older adults (≥60 years) in India experience depression.2 Given the anticipated increase in the number of older adults living in India during the next 3 decades, the prevalence of depression will likely rise concommittantly.2,3
Hearing loss is present in 42% of adults older than 60 years and is experienced disproportionately in low- and middle-income countries (LMICs), with almost 80% of people with hearing loss living in LMICs.4 The prevalence of age-standardized hearing loss for adults ranges from 4.9% in high-income countries (HICs) to 15.7% in the sub-Saharan Africa region and 17% in the South Asian region.5 Similarly, vision loss affects 84% of adults 50 years and older globally and 90% of people living in LMICs.6 The age-standardized prevalence of moderate and severe vision loss for adults 50 years and older was estimated to be 1.6% in high-income North America to 6.4% in South Asia.7 Hearing and vision loss can adversely affect communication and may lead to social isolation, a potential pathway associating sensory loss with dementia and depression.8,9,10,11 This association may be greater for older adults with dual sensory loss (concurrent hearing and vision loss) because individuals cannot compensate for the loss by using the other sense.12
Place of residence may also affect depression prevalence. A systematic review found higher odds of depression among urban residents in HICs, although this did not hold in LMICs. In India, 71% of older adults (≥60 years) reside in rural areas, many of which have differing lifestyles and socioeconomic statuses.13,14 As such, there is a rural-urban divide in certain health outcomes, with urban areas having a greater prevalence of diabetes and hypertension than rural areas.15 There is also variation among the states in India, especially the geographically isolated northeastern states, where rugged topography may affect access to health care.16 However, conclusions on the differences in health statuses between residents living in rural compared with urban areas, and varying regions, may be skewed by the shortages of rural physicians and unaffordability and inaccessibility of health care.17,18 Whether urbanicity and region may modify associations between sensory loss and depression is unknown.
Prior work19,20 has investigated dual sensory loss and its association with mental health outcomes, including depression. However, current research19,21 has mainly focused on HICs. A prior study22 found an association between sensory loss and depression in India. The objective of this study was to describe rural-urban and regional differences in the prevalence of self-reported dual sensory loss and its association with depression in a population-based study of adults in India. We hypothesized that dual sensory loss is associated with a higher prevalence of depression and that associations differ by place of residence (rural or urban) and region in India (North, Central, South, East, West, and Northeast).
Methods
The study used data from the Longitudinal Aging Study in India (LASI). LASI obtained institutional review board (IRB) and ethical approvals from the following collaborating organizations: Indian Council of Medical Research, Delhi; IRB, International Institute for Population Sciences, Mumbai; IRB, Harvard T. H. Chan School of Public Health, Boston; IRB, University of Southern California, Los Angeles; IRB, Indian Council of Medical Research-National AIDS Research Institute, Pune; and IRB, Regional Geriatric Centres (Ministry of Health and Family Welfare). Four consent forms were used, including household informed consent, individual informed consent, consent for dried blood sample collection for storage and future use, and a consent for proxy interview. As a secondary analysis of publicly available deidentified data, this study did not require IRB approval. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Design and Participants
LASI was the first nationally representative population survey of individuals aged 45 years and older and their spouses; it obtained a substantial amount of information on the health, economic, and social factors of aging.23 LASI is a part of the Health and Retirement Study International Family of Studies, which includes large-scale surveys conducted in more than 40 countries around the world. Data harmonization has been conducted for comparability of variables across countries. The LASI baseline survey was implemented in 3 phases from April 2017 to December 2019.24
This cross-sectional study used data from the first wave of LASI, with more than 72 000 respondents in 35 states and union territories of India.23 In this analysis, we restricted the sample to individuals aged 60 years and older who had complete information available on relevant variables. We excluded 855 participants with incomplete information on depression, 53 participants with incomplete information on sensory loss, and 2642 participants with incomplete information on covariates (eFigure 1 in Supplement 1).
Study Measures
Depression
The Short Form Composite International Diagnostic Interview (CIDI-SF) is a nonclinical, diagnostic interview used to assess major depressive episodes lasting 2 weeks or longer within the past 12 months.25,26 The CIDI-SF provides a valid and reliable diagnosis of major depression and is used widely in large-scale surveys.27 The CIDI-SF contains 2 sets of questions, 1 for measuring dysphoria and the other for measuring anhedonia (respondents were only asked to answer 1 of the 2 sets).23 Participants with a score of 3 or higher, on a scale of 0 to 10, were determined to have a screening result that was positive for major depression.28
Sensory Loss
Sensory loss was determined by respondent self-report. Hearing was measured using 2 questions, with responses of either yes or no: “Have you ever been diagnosed with any hearing or ear-related problem or condition?” and “Have you been using a hearing aid to assist you in the activities of daily living?” We identified respondents as having hearing loss if they responded yes to either question.
Vision was measured using 3 questions, 1 requiring a response of yes or no, and the other 2, a rating on a scale: “Have you ever been diagnosed with any eye or vision problem or condition, including ordinary nearsightedness or farsightedness?”; “How good is your eyesight for seeing things at a distance, like recognizing a person across the street (or 20 meters away) whether or not you wear glasses, contacts, or corrective lenses? Is it very good (1), good (2), fair (3), poor (4), or very poor (5)?”; and “How good is your eyesight for seeing things up close, like reading ordinary newspaper print whether or not you wear glasses, contacts, or corrective lenses? Is it very good (1), good (2), fair (3), poor (4), or very poor (5)?” We identified respondents as having vision loss if they responded yes to having been diagnosed with an eye or vision problem or condition, or reported poor or very poor vision for either distance vision or near vision. We categorized the self-reported sensory loss into a 4-level categorical variable with mutually exclusive categories: no sensory loss (reference), hearing loss only, vision loss only, and dual sensory loss (both hearing and vision).
Covariates
Respondents’ sociodemographic information was self-reported and included age (60-69, 70-79, or ≥80 years), sex (male or female), highest educational attainment (no education, less than secondary education, or secondary education and higher), marital status (married/partnered or single), area of residence (urban or rural), and household economic status (tertiles).29 Regions included North (Jammu and Kashmir, Himachal Pradesh, Punjab, Chandigarh, Uttarakhand, Haryana, Delhi, and Rajasthan), Central (Uttar Pradesh, Chhattisgarh, and Madhya Pradesh), South (Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Puducherry, Andaman and Nicobar, Lakshadweep, and Telangana), East (Bihar, West Bengal, Jharkhand, and Odisha), West (Gujarat, Daman and Diu, Dadra and Nagar Haveli, Maharashtra, and Goa), and Northeast (Arunachal, Nagaland, Manipur, Mizoram, Tripura, Meghalaya, and Assam) regions. The North was chosen as the reference region, which aligns with prior literature.15,22,30 Per-capita consumption was used for household economic status.31 We also considered the following health-related variables: self-reported physician diagnosis of diabetes, heart disease, hypertension, or stroke; history of smoking, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared).
Statistical Analysis
Covariate distributions were compared by sensory loss status using 1-way analysis of variance (continuous variables) and the Pearson χ2 test (categorical variables). We estimated the prevalence of self-reported sensory loss and depression by rural and urban status and by region in populations using person-level poststratified analysis weights correcting for different nonresponse rates.
We used multivariable-adjusted logistic regression to estimate the odds ratios (ORs) and 95% CIs of major depression (CIDI ≥3) associated with self-reported sensory loss, adjusting for age, sex, education, marital status, household economic status, area of residence (urban/rural), region, diabetes, heart disease, hypertension, stroke, smoking status, and BMI. We tested for modification by urbanicity with the inclusion of an interaction term between urbanicity and sensory loss. Given the substantial regional variations in sociodemographic characteristics, culture, and geography that could affect both sensory loss and major depression, we tested whether the association between sensory loss and depression differed by region with the inclusion of an interaction term between region and sensory loss. We further included an interaction term between urbanicity and region to assess whether urban-rural differences in the association between sensory loss and depression varied by region. Urbanicity and regionality analyses were consistent with previous LASI analyses.22,27 Analyses used sampling weights corrected for the differences in nonresponse.
In a sensitivity analysis, we investigated effect modification by urbanicity, with the inclusion of an interaction term between urbanicity and sensory loss, for the independent association of hearing loss with depression (irrespective of vision), and of vision loss with depression (irrespective of hearing). Models adjusted for the same covariates as the analyses previously described.
Statistical tests were 2-tailed and P < .05 was considered statistically significant. Data analyses were performed from May 17, 2022, to November 11, 2023 using Stata, release 18 (StataCorp).
Results
The study analyses included 27 927 adults (mean [SD] age, 68.0 [7.2] years; 14 477 [51%] females and 13 450 [49%] males), of whom 63% were aged 60 to 69 years, 28% were 70 to 79 years, and 9% were 80 years or older. Overall, 9% had a screening result that was positive for major depression (Table 1). Sample participants and excluded participants were comparable (eTable 1 in Supplement 1). Of the total, 4% of rural residents and 3% of urban residents reported dual sensory loss (eFigure 2 in Supplement 1). Dual sensory loss was most prevalent in the Northern, Southern, and Eastern states, particularly in rural areas (Figure). Residents in the East and North regions had the highest prevalence of dual sensory loss (4.6% and 4.4%, respectively; eTable 2 in Supplement 1). The highest prevalence of dual sensory loss was observed among rural residents in the North, South, and East regions (Table 2). Among respondents with depression, 36% had vision loss only, 5% had hearing loss only, and 5% had dual sensory loss (eTable 3 in Supplement 1).
Table 1. Participant Characteristics by Sensory Loss Status Among Adults 60 Years and Older.
| Characteristic | Total, No. (%) | No. (%)a | |||||||
|---|---|---|---|---|---|---|---|---|---|
| No sensory loss | Hearing loss only | Vision loss only | Dual sensory loss | ||||||
| Rural | Urban | Rural | Urban | Rural | Urban | Rural | Urban | ||
| Total participants, No. | 27 927 | 11 860 (64.4) | 6692 (72.0) | 1095 (5.6) | 649 (6.4) | 4907 (26.4) | 1706 (18.7) | 724 (3.6) | 294 (2.9) |
| Age, mean (SD), y | 68 (7.2) | 68 (6.6) | 68 (6.6) | 70 (7.6) | 71 (7.6) | 70 (8.0) | 69 (7.7) | 72 (9.0) | 73 (8.8) |
| Age, y | |||||||||
| 60-69 | 17 167 (63.0) | 7891 (68.0) | 4406 (66.9) | 561 (53.8) | 312 (46.8) | 2644 (55.4) | 949 (58.3) | 286 (42.8) | 118 (40.0) |
| 70-79 | 8048 (27.7) | 3135 (25.5) | 1840 (26.8) | 371 (31.4) | 254 (39.8) | 1551 (30.5) | 532 (28.6) | 261 (34.7) | 104 (36.5) |
| ≥80 | 2712 (9.3) | 834 (6.6) | 446 (6.3) | 163 (14.8) | 83 (13.4) | 712 (14.1) | 225 (13.1) | 177 (22.5) | 72 (23.5) |
| Sex | |||||||||
| Female | 14 477 (50.6) | 5873 (48.1) | 3488 (51.2) | 476 (44.4) | 325 (48.6) | 2774 (55.0) | 999 (58.4) | 377 (53.3) | 165 (53.5) |
| Male | 13 450 (49.4) | 5987 (51.9) | 3204 (48.8) | 619 (55.6) | 324 (51.4) | 2133 (45.0) | 707 (41.6) | 347 (46.7) | 129 (46.5) |
| Education | |||||||||
| None | 14 898 (60.0) | 7241 (66.5) | 2130 (37.2) | 615 (62.9) | 186 (33.2) | 3388 (74.2) | 744 (51.5) | 464 (70.4) | 130 (57.2) |
| Less than secondary | 8848 (26.0) | 3478 (24.5) | 2512 (31.8) | 349 (25.9) | 239 (29.2) | 1284 (21.3) | 649 (29.9) | 214 (24.3) | 123 (28.3) |
| Secondary or more | 4181 (14.0) | 1141 (9.0) | 2050 (31.1) | 131 (11.1) | 224 (37.6) | 235 (4.5) | 313 (18.5) | 46 (5.3) | 41 (14.5) |
| Marital status | |||||||||
| Single | 9878 (35.3) | 3779 (32.0) | 2249 (34.3) | 408 (38.3) | 238 (38.4) | 1953 (38.6) | 780 (46.0) | 320 (43.9) | 151 (52.0) |
| Married | 18 049 (64.7) | 8081 (68.0) | 4443 (65.7) | 687 (61.7) | 411 (61.6) | 2954 (61.4) | 926 (54.0) | 404 (56.1) | 143 (48.0) |
| Economic status | |||||||||
| Low | 9902 (38.8) | 4947 (44.5) | 1472 (23.7) | 396 (37.2) | 113 (19.9) | 2179 (47.6) | 445 (30.4) | 271 (39.4) | 79 (32.4) |
| Middle | 9497 (33.7) | 3966 (32.9) | 2353 (36.3) | 361 (33.7) | 221 (33.5) | 1645 (32.6) | 593 (33.9) | 258 (34.6) | 100 (36.4) |
| High | 8528 (27.5) | 2947 (22.6) | 2867 (40.0) | 338 (29.2) | 315 (46.6) | 1083 (19.9) | 668 (35.8) | 195 (26.0) | 115 (31.2) |
| Region | |||||||||
| Central | 3791 (22.4) | 1913 (24.7) | 551 (15.6) | 118 (17.1) | 43 (13.8) | 862 (28.0) | 187 (20.5) | 95 (20.4) | 22 (15.8) |
| North | 5205 (13.7) | 2122 (12.8) | 1174 (14.2) | 253 (15.5) | 167 (18.8) | 897 (12.7) | 341 (16.4) | 173 (16.3) | 78 (21.9) |
| South | 6663 (24.8) | 2388 (22.8) | 2156 (30.5) | 355 (37.0) | 214 (35.6) | 783 (17.2) | 485 (28.0) | 180 (27.0) | 102 (36.7) |
| East | 5207 (21.4) | 2399 (22.1) | 808 (14.3) | 180 (19.7) | 70 (13.6) | 1241 (28.3) | 298 (20.5) | 166 (32.0) | 45 (20.0) |
| West | 3720 (14.9) | 1423 (14.6) | 1438 (23.6) | 79 (8.2) | 99 (16.9) | 417 (9.9) | 220 (12.0) | 27 (2.5) | 17 (4.0) |
| Northeast | 3341 (2.8) | 1615 (3.0) | 565 (1.9) | 110 (2.5) | 56 (1.2) | 707 (3.8) | 175 (2.6) | 83 (1.8) | 30 (1.6) |
| Presence of chronic diseases | |||||||||
| Diabetes | 4290 (14.3) | 1174 (9.5) | 1712 (24.9) | 138 (12.8) | 177 (26.9) | 493 (9.8) | 432 (23.3) | 86 (11.5) | 78 (29.5) |
| Heart disease | 1402 (4.9) | 377 (3.2) | 502 (7.9) | 63 (5.6) | 59 (7.2) | 182 (3.7) | 136 (7.6) | 49 (7.2) | 34 (9.4) |
| Hypertension | 9687 (32.4) | 3236 (25.7) | 2945 (42.4) | 401 (35.2) | 337 (53.5) | 1518 (28.7) | 816 (46.3) | 285 (35.8) | 149 (48.6) |
| Stroke | 631 (2.4) | 188 (1.8) | 162 (2.5) | 27 (2.3) | 27 (4.0) | 127 (3.1) | 59 (3.6) | 27 (4.6) | 14 (4.5) |
| Smoking behavior | |||||||||
| None or past smoker | 23 948 (85.2) | 9864 (82.7) | 6122 (91.1) | 929 (84.2) | 587 (90.8) | 4055 (82.8) | 1522 (89.5) | 608 (84.0) | 261 (90.4) |
| Current smoker | 3979 (14.8) | 1996 (17.3) | 570 (8.9) | 166 (15.8) | 62 (9.2) | 852 (17.2) | 184 (10.5) | 116 (16.0) | 33 (9.6) |
| Body mass index | |||||||||
| Underweight | 6484 (26.0) | 3230 (29.4) | 658 (11.1) | 74 (27.2) | 74 (12.9) | 1681 (37.0) | 284 (18.9) | 250 (39.3) | 53 (20.2) |
| Normal weight | 14 640 (51.6) | 6470 (53.4) | 3292 (49.1) | 305 (54.8) | 305 (44.9) | 2549 (50.3) | 871 (50.7) | 373 (49.2) | 156 (54.1) |
| Overweight | 6803 (22.4) | 2160 (17.1) | 2742 (39.8) | 270 (17.9) | 270 (42.2) | 677 (12.6) | 551 (30.4) | 101 (11.5) | 85 (25.7) |
| Major episodic depression | 2075 (9.0) | 795 (53.0) | 296 (55.7) | 85 (5.2) | 32 (6.0) | 580 (36.9) | 167 (31.9) | 81 (4.9) | 39 (6.3) |
No. refers to unweighted sample; % refers to weighted numbers.
Figure. Prevalence of Dual Sensory Loss Among Adults 60 Years and Older in the States, by Urbanicitya.
NCT indicates National Capital Territory.
aMaps were created using Stata programs. India state boundaries provided by DataMeet India community.
Table 2. Prevalence of Hearing, Vision, and Dual Sensory Loss by Urbanicity and Region Among Adults 60 Years and Older.
| Sensory loss, %a | No. (95% CIs) | |||||
|---|---|---|---|---|---|---|
| Rural | Urban | |||||
| Hearing only | Vision only | Dual | Hearing only | Vision only | Dual | |
| Region | ||||||
| Centralb | 3.9 (3.2-4.7) | 29.6 (27.8-31.4) | 3.0 (2.4-3.7) | 5.4 (4.0-7.3) | 23.4 (20.5-26.7) | 2.8 (1.8-4.3) |
| North | 6.7 (5.9-7.6) | 25.7 (24.1-27.4) | 4.5 (3.9-5.3) | 8.0 (6.6-9.7) | 20.3 (18.1-22.7) | 4.2 (3.2-5.5) |
| South | 9.4 (8.4-10.5) | 20.3 (18.9-21.8) | 4.4 (3.7-5.2) | 7.5 (6.3-8.8) | 17.2 (15.5-19.0) | 3.5 (2.7-4.5) |
| East | 4.6 (4.0-5.4) | 31.1 (29.6-32.7) | 4.9 (4.2-5.7) | 5.6 (4.4-7.0) | 24.6 (22.2-27.2) | 3.7 (2.8-5.0) |
| West | 3.7 (2.8-4.9) | 20.9 (18.7-23.2) | 0.7 (0.4-1.3) | 5.3 (4.1-6.8) | 11.1 (9.3-13.1) | 0.6 (0.3-1.3) |
| Northeast | 4.4 (3.3-5.8) | 31.8 (29.0-34.7) | 2.1 (1.4-3.0) | 4.0 (2.4-6.5) | 24.6 (18.8-31.4) | 2.4 (1.2-4.7) |
Prevalence values are estimated using survey weights.
Central: Uttar Pradesh, Chhattisgarh, and Madhya Pradesh; North: Jammu and Kashmir, Himachal Pradesh, Punjab, Chandigarh, Uttarakhand, Haryana, Delhi, and Rajasthan; South: Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Puducherry, Andaman and Nicobar, Lakshadweep, and Telangana; East: Bihar, West Bengal, Jharkhand, and Odisha; West: Gujarat, Daman and Diu, Dadra and Nagar Haveli, Maharashtra, and Goa; Northeast: Arunachal, Nagaland, Manipur, Mizoram, Tripura, Meghalaya, and Assam.
After full adjustment, effect estimates did not vary by urbanicity for hearing loss only, but the magnitude of the association between vision loss only and depression was higher in urban areas (OR, 2.15; 95% CI, 1.68-2.76) compared to rural areas (OR, 1.70; 95% CI, 1.48-1.94; P for interaction [P-interaction] = .10; Table 3). Similarly, dual sensory loss (vs no loss) was more strongly associated with depression in urban areas (OR, 3.16; 95% CI, 2.00-4.99), compared to rural areas (OR, 1.73; 95% CI, 1.31-2.29; P-interaction = .03; Table 3). The associations between vision loss only (vs no sensory loss) and dual sensory loss (vs no sensory loss) and depression were higher in the West than in the North (vision only OR, 2.80 [95% CI, 1.98-3.94] in the West vs OR, 1.57 [95% CI, 1.27-1.93] in the North; P-interaction = .01; and dual sensory loss in the West OR, 5.10 [95% CI, 1.74-14.97] vs OR, 1.38 [95% CI, 0.81-2.35] in the North; P-interaction = .09; Table 4).
Table 3. Odds Ratios and 95% CIs of Association of Sensory Loss and Depression by Rural or Urban Status Among Adults 60 Years and Oldera.
| Sensory status | No. | Odds ratio (95% CI) | P for interaction | ||
|---|---|---|---|---|---|
| Total | Depression | Rural | Urban | ||
| No loss | 18 552 | 1091 | 1.0 [Reference] | 1.0 [Reference] | NA |
| Hearing loss only | 1744 | 117 | 1.26 (0.96-1.65) | 1.27 (0.80-2.05) | .96 |
| Vision loss only | 6613 | 747 | 1.70 (1.48-1.94) | 2.15 (1.68-2.76) | .10 |
| Dual loss | 1018 | 120 | 1.73 (1.31-2.29) | 3.16 (2.00-4.99) | .03 |
Models adjusted for age, sex, education, marital status, economic status, region, hypertension, diabetes, stroke, heart disease, and smoking status.
Table 4. Odds Ratios (ORs) and 95% CIs of Association of Sensory Loss and Depression by Region, Among Adults 60 Years and Oldera.
| Status | OR (95% CI) | |||||
|---|---|---|---|---|---|---|
| North | Central | South | East | West | Northeast | |
| Major depressive episode (CIDI ≥3) | ||||||
| No loss | 1.0 [Reference] | 1.0 [Reference] | 1.0 [Reference] | 1.0 [Reference] | 1.0 [Reference] | 1.0 [Reference] |
| Hearing loss only | 1.24 (0.77-2.02) | 1.13 (0.69-1.86) | 1.08 (0.66-1.74) | 1.02 (1.08-2.64) | 1.41 (0.68-2.90) | 0.40 (0.12-1.36) |
| P for interaction | Reference | .79 | .77 | .24 | .63 | .12 |
| Vision loss only | 1.57 (1.27-1.93) | 1.51 (1.14-2.01) | 1.99 (1.48-2.69) | 1.63 (1.30-2.05) | 2.80 (1.98-3.94) | 2.50 (1.40-4.47) |
| P for interaction | Reference | .85 | .19 | .68 | .007 | .13 |
| Dual loss | 1.38 (0.81-2.35) | 1.83 (1.12-2.99) | 2.87 (1.83-4.50) | 1.72 (1.09-2.71) | 5.10 (1.74-14.97) | 3.12 (0.93-10.49) |
| P for interaction | Reference | .44 | .18 | .86 | .09 | .42 |
Abbreviation: CIDI, Composite International Diagnostic Interview.
Model adjusted for age, sex, education, marital status, economic status, urbanicity, hypertension, diabetes, stroke, heart disease, and smoking status; includes interaction between sensory and region.
The rural-urban differences in the association between dual sensory loss and depression differed by region, with the biggest differences in the Northeast and South regions (Northeast urban OR, 3.14 [95% CI, 2.01-4.89]; P-interaction < .001 vs OR, 1.76 [95% CI, 0.73-4.21] for Northeast rural; P-interaction = 0.25; and South urban OR, 3.14 [95% CI, 2.01-4.89]; P-interaction < .001 vs OR, 1.82 [95% CI, 1.12-2.97] for South rural; P-interaction = .03) ( eTable 4 in Supplement 1).
In sensitivity analyses that modeled hearing loss irrespective of vision loss, the association between hearing loss (vs no hearing loss) with depression had a stronger effect estimate in urban areas (OR, 1.50; 95% CI, 1.08-2.07) compared to rural counterparts (OR, 1.25; 95% CI, 1.03-1.52; P-interaction = .34; eTable 5 in Supplement 1). This was also true for vision loss modeled independently (vs no vision loss) in urban vs rural areas: OR, 2.39 (95% CI, 1.90-2.99) vs OR 1.75 (95% CI, 1.54-1.98), P-interaction = .02 (eTable 5 in Supplement 1).
Discussion
In our study of 27 927 adults, we investigated rural-urban and regional differences in the association between self-reported dual sensory loss and depression among adults 60 years and older in India in a large, nationally representative population study. Having both hearing and vision loss was associated with 1.98 times elevated odds of depression, and this association was higher among urban dwellers (vs rural dwellers) and residents in the West region (vs the North region). Our findings are consistent with targeting dual sensory loss in LMICs as a potential risk factor for mental health outcomes such as depression, with a focus on specific demographic characteristics of the older adult population. Our study innovates on a previous report from LASI22 using adults aged 45 years and older that reported a significant association between vision, hearing, and dual sensory loss with depression, by focusing on older adults (≥60 years) and further focusing on rural-urban and regional differences. A 2014 systematic review19 of dual sensory loss and mental health outcomes in older adults found 7 studies that determined an association between dual sensory loss and depression or depressive symptoms; however, to our knowledge, no study has investigated this topic in LMICs or rural-urban or regional disparities. Our study bridges gaps in the understanding of sensory loss and mental health in LMICs, providing new insights into rural-urban and regional disparities. Our findings have important policy and clinical implications, highlighting the need to prioritize older adults with dual sensory loss, particularly those living in specific regions, to improve mental health outcomes.
Our study found that the prevalence of vision loss only and dual sensory loss was higher among rural residents (26.4% and 3.6%, respectively) compared to their urban counterparts (18.7% and 2.9%, respectively). This finding is consistent with the results from the 2011 Indian Census, which showed that rural citizens aged 60 years and older had a higher prevalence of vision disability—described in terms of hindrance in performing activities of daily living—compared with urban dwellers.32,33 Our findings are also supported by a study on low vision and blindness in South India.34 A probable explanation may be that rural areas have less access to health care services compared to urban areas.35 A study conducted in Assam (India)36 described low utilization of health services among older adults in rural areas compared to urban dwellers.
For participants reporting hearing loss only, there was a comparable prevalence among adults in urban (6.4%) vs rural (5.6%) areas. Contradicting this finding is a study37 on self-reported hearing difficulty in Western Australia, which found that rural residents were more likely to experience hearing loss compared to urban residents. One possible reason for this disagreement in findings is our differences in definitions of self-reported hearing loss, with the other study not including hearing aid use as part of hearing loss unlike our study.37 Low hearing-aid adoption (0.5%) may have affected our findings. Rates of hearing aid prevalence were different between rural (9.1%) and urban (15.6%) residents in the Western Australia study.37 Although there are no prior studies, to our knowledge, on the rates of hearing-aid adoption and hearing help-seeking in India, an estimate calculated is approximately 1% to 2%.38 Multiple prior studies39,40 have reported a gap in socioeconomic status and health care utilization between people living in rural residences and their urban counterparts in India. Nevertheless, our current analysis showed that there is a greater prevalence of hearing loss only among older urban adults than their rural counterparts. This difference could be explained by urban residents’ greater access to health care services for diagnosis.41 The prevalence of hearing loss only may reflect the degree of health care utilization, rather than the level of actual hearing loss. Another explanation may be high levels of daily exposure to noise in urban areas that may come from motor vehicle traffic and construction work.42
The association between vision loss only (vs no loss) and depression was higher among older adults in urban areas than in rural areas. The same was true for the association between dual sensory loss and depression between urban and rural residents. A possible reason may be the presence of stronger social ties among rural residents compared to their urban counterparts.43 Henning-Smith et al44 reported rural residents were more likely to rely on friends and family compared to urban residents. Similarly, a US study on the National Social Life, Health, and Aging Project45 found that rural residents had more social relationships and less social isolation compared to urban residents. A potential mechanism associating sensory loss with depression is that sensory loss may negatively affect social ties by hindering communication, which may lead to social isolation.9,10,11 Vision loss only and dual sensory loss may have a smaller influence on the pathway from communication to social isolation to depression among rural residents compared to their urban counterparts. Several studies46,47 have identified associations between depression and poorer self-rated health outcomes that may extend to self-reported hearing and vision loss. However, a meta-analysis of 35 studies48 found that the association between hearing loss and depression was not influenced by the type of hearing loss measure used, whether self-reported or measured. Ultimately, further research is needed to understand the rural-urban impact on the association between both vision loss only and depression and dual sensory loss and depression.
Stigmatization of sensory loss and depression in India may be exacerbated by the rural-urban divide. Older adults may not recognize hearing loss and consulting physicians for depression may have a negative stigma.49 Although literature suggests that rural populations have a more open attitude toward mental health disorders compared to urban populations, some studies report opposite findings.50,51,52 A study investigating rural adults in South India found that 36% of the general population believed employers would be less willing to hire those with mental health disorders, compared to 71.6% of people in urban Mumbai.53 In contrast, another study51 found that rural people in India compared to urban people had a more stigmatizing attitude toward severe mental disorders.
The association between hearing loss only and depression remained the same between urban and rural areas. This is inconsistent with the preliminary findings from a US study54 of 80 adults who were 60 years or older that suggests rural residents with hearing loss experience fewer positive social interactions, and thus, more symptoms of depression compared to their urban counterparts. The differing findings could be influenced by their measurement methods given that our study used self-reported hearing measurements and the US study54 used pure-tone audiometric assessments. Another possible reason may be the underreporting of both hearing loss only and depression from rural residents because they have less access to and utilization of health care access compared to urban residents.36,41 There is limited research on the rural-urban differential in the association between hearing loss only and depression, and more research is needed to elucidate the basis of urbanicity not having an impact.
Those living in the West of India had higher associations between vision loss only and dual sensory loss and depression compared to those living in the North. One possibility is that disparities in wealth that exist among regions may play a role. A study55 suggests there are regional inequalities in average wage rates, with the Northern and Northeast regions ranking first and second and the West region ranking fourth (of 6 regions). Wealth gaps exist among the different states, with a large gap between the richest state and poorest state in gross state domestic products (GSDP).56 However, in our data, median household economic status was similar between the North and West regions. One study classified states into category A (highest), B, and C (lowest) based on their health care expenditures and identified 2 category A states (Maharashtra and Goa), 1 category B state (Gujarat), 2 category C states (Dadra and Nagar, Haveli, and Daman and Diu) in the West region, 2 category A states (Punjab and Chandigarh), and 6 category B states (Jammu and Kashmir, Delhi, Uttarakhand, Haryana, Himachal Pradesh, Rajasthan) in the North region.57 Furthermore, cultural factors such as trust in the health care system, which can be influenced by high-resource and low-resource settings, may also play an important role. One study58 highlighted governance failures in India’s health care system that have resulted in a loss of trust in these institutions. Future studies are needed to confirm our findings of regional disparities.
Limitations
This study had limitations, starting with hearing and vision acuity being assessed through self-reported measures. Although self-reported sensory measures may not reflect the full range of pathologic changes affecting sensory function and do not account for personal beliefs, they do evaluate self-perception of sensory function within the participant’s physical and social environment, which is important for clinical practices and research. Self-reported measures are also easy to administer in low-resource settings. Second, our study is cross-sectional; therefore, we could not assess whether sensory loss preceded the onset of depression to establish temporality or examine how sensory loss and or may be associated with trajectories of depressive symptoms. Third, although confounders were chosen based on prior literature and theoretical models, the potential for residual confounding cannot be eliminated. Other factors—cultural beliefs and lifestyle variables—that may influence depression were not collected in the LASI study.23 Despite these limitations, a substantial strength of our study is that the LASI data are representative at the national level, allowing us to present relevant findings regarding rural-urban and regional differences in sensory loss and depression.
Conclusions
The findings of this cross-sectional study indicate that vision and/or hearing loss may be a risk factor for depression in adults aged 60 years or older in India. The association was strongest for those with dual sensory loss in urban areas or in the West region, suggesting that adults with sensory loss across multiple systems may be an important group to target for intervention and that disparities may exist by urbanicity and geographic region in India. Further studies should investigate mediating factors of living in urban areas or in the West region, including health care access, and the association between sensory loss and depression.
eTable 1. Characteristics of participants included and excluded from the analytic sample
eTable 2. Prevalence of hearing, vision, and dual sensory loss among adults 60 years and older
eTable 3. Participant characteristics by sensory loss among adults 60 years and older
eTable 4. Odds Ratios and 95% Confidence Intervals of the Association of Sensory Loss and Depression by Urbanicity and Region Status, among Adults 60 years and older
eTable 5. Odds Ratios and 95% Confidence Intervals of the Association of Individual Sensory Loss (Irrespective of Other Sensory Loss) and Depression by Rural/Urban Status among Adults 60 years and older
eFigure 1. Flowchart of participant selection
eFigure 2. Weighted prevalence of sensory loss by area of residence among adults 60 years and older
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Characteristics of participants included and excluded from the analytic sample
eTable 2. Prevalence of hearing, vision, and dual sensory loss among adults 60 years and older
eTable 3. Participant characteristics by sensory loss among adults 60 years and older
eTable 4. Odds Ratios and 95% Confidence Intervals of the Association of Sensory Loss and Depression by Urbanicity and Region Status, among Adults 60 years and older
eTable 5. Odds Ratios and 95% Confidence Intervals of the Association of Individual Sensory Loss (Irrespective of Other Sensory Loss) and Depression by Rural/Urban Status among Adults 60 years and older
eFigure 1. Flowchart of participant selection
eFigure 2. Weighted prevalence of sensory loss by area of residence among adults 60 years and older
Data Sharing Statement