J.E. DOWDAND K.G. MANTON

PROJECTIONS OF DISABILITY CONSEQUENCES IN INDONESIA

ABSTRACT. With the populations in many developing countries growing older due to declining fertility and infant mortality, there is concern that chronic disease and disability will rapidly increase in prevalence. Such an increase could create a conflict of priorities in developing countries with scarce public health resources between, the continuing need for infectious disease and infant mortality programs, and an emerging need to deal with the health, and health related social problems of adult and elderly populations. To assess the potential magnitude of the emerging problems of chronic disease and disability - and to assess when those needs are likely to emerge - we present projections of chronic disability and its sequelae using data from a large Indonesian survey focusing on the prevalence of impairments and handicaps as envisaged in the WHO (1980) ICIDH classification. INTRODUCTION Indonesia is a country of great geographic, cultural and ecological heterogeneity. Geographically, it is a large archipelago of 13,667 islands covering an area of 1,919,000 square kilometers. The islands, which tend to be long and narrow, are typically volcanic mountains surrounded by narrow coastal plains. The climate is tropical on the coastal plains and moderate in the highlands. It has rich natural resources which include crude oil, tin, natural gas, nickel, timber, bauxite, fertile soils, coal, gold and silver. The mid-1988 population estimate was 175,000,000. The population was estimated to have grown 2.1% per annum between 1980 and 1988. Ethnically, it is predominantly Malay (74%), with Chinese and Indian groups constituting the remaining 26%. Religious affiliations are 86.9% Muslim, 9.6% Christian, 1.9% Hindu, 1.0% Buddhist and 0.6% other. There is great variation in population density between the 24 provinces, two autonomous districts, and the metropolitan region of Jakarta, which make up the Republic of Indonesia. Population density which averages 92.2 persons per square kilometer, ranges from 3.6 persons per square kilometer in Irain Jaya to 817.5 persons per square kilometer in Central Java. The urban population increased from 16% of the total in 1965 to 27% in 1988. Table I summarizes changes in economic, demographic and health indicators. Substantial change has occurred since the introduction of the first Five-Year Plan in 1969 (the fifth Five-Year Plan covers 1989 to 1994). Even with carefully planned development, Indonesia lags economically behind many other countries in the South-Eastern Asian area. Table 1I compares social indicators in Indonesia with those in five other countries in the region. Indonesia lags behind on social indicators in spite of rapid economic improvement up to the mid-1980s. In the mid-1980s, economic stagnation set in due to (a) sharp declines in the price of oil and (b) increasing external debt, and Journal of Cross-Cultural Gerontology 7: 237-258, 1992. © 1992Kluwer Academic Publishers. Printed in the Netherlands.

238

J.E. DOWDAND K.G. MAN'I~N TABLE I Demographic and vital statistical changes in the Indonesian population Number or Rate Year

Number or Rate

Characteristic

Year

Life expectancy at birth Percent Urban Percent Over 65 Years Crude Birth Rate (/1000) Crude Death Rate (/1000) Total Fertility Rate (/Women) Contraceptive Prevalence (%) Median Age (Years) Infant Mortality Rate (Per 1000 Live Births) Daily Calories Per Capita Population Per Physician Population Per Nurse Access to Safe Water-Urban (%) Access to Safe Water-Rural (%) Access to Sanitation-Urban (%) Access to Sanitation-Rural (%) Per Capita Gross National Product $ Children Immunized BCG (%) Children Immunized DPT (%) Children Immunized Polio (%) Children Immunized Measles (%) Mother Immunized Tetanus (%) (per 1000 births) Maternal Mortality Rate

1965 1965 1965 1965 1965 1965 1976 1965

44 16 3.1 43 20 5.6 19 19.6

1985 1985 1990 1985 1985 1989 1990 1990

61 27 3.8 28 9 3.4 47 21.8

1965 1965 1965 1965 1970 1970 1970 1970 1977 1985 1985 1985 1985

128 1800 31700 9490 10 1 5 4 320 65 15 13 15

1985 1985 1985 1985 1990 1990 1990 1990 1988 1990 1990 1990 1990

75 2579 9460 1260 75 60 60 40 440 81 71 74 65

24 12.8

1990 1988

41 4.5

1985 1965

Sources: World Development Report 1990. Published for the World Bank by The Oxford University Press. decreasing export profits, due to the devaluation of the U.S. dollar relative to the foreign currencies of Indonesia's creditor nations (Trends in Developing Economies 1990). Indonesia has the lowest national government expenditures on health of any country in the region expending only 2.3% of its budget for health. Other countries in the region expend an average of 5.6% on health. This represents an expenditure of 0.6% of the GDP in Indonesia compared to as much as 1.8% in other countries of the region (Budi Otomo and Gour Dasvarma 1989). There are also inequalities within the country in health service access and the adequacy of diet, due to differences in economic development between Indonesian provinces - especially urban areas and the poor Outer Islands. Expectation of life at birth and infant mortality rates range from 62 years and 29 deaths per 1000 live births in the city of Yogyakarta to 47 years and 146 deaths per 1000 live births in Nusa Tenggara Barat (NTB). The prevalence of malnutrition is 3% for children in Bali compared to 20% in NTB (World Health

440 290 1810 590 400 850

Country

Indonesia China Malaysia Philippines Sri Lanka Thailand

61 69 70 63 70 64

Life Expectancy at Birth 75 39 35 53 20 51

IMR 9460 1000 1930 6700 5520 6290

Population Per Physician 2579 2630 2730 2372 2401 2331

30 N.A. N.A. 22 28 5

14 6 9 18 28 12

Percent Percent Daily Malnutrition Babieswith Calories 2nd & 3rd Low Birth Per Capita Degree Weight

64 N.A. N.A. N.A. 90 93

Percent Access to Local Health Care

Source: Health Care in South-East Asia. World Health Organization, Regional Office for South-East Asia, New Delhi, 1989.

GNP per Capita $

TABLE II Comparative social indicators for selected countries

3.8 5.8 3.7 3.4 5.2 3.8

Years of Age

Percent Over 65

t~

240

J.E. DOWDAND K.G.MANTON

Organization 1990). The major causes of morbidity in Indonesia, in order of frequency, are diarrhoea, upper respiratory infections, dental disorders and skin infections. Forty-four percent of the morbidity reported in a 1986 household survey conducted in 7 provinces occurred in children less than 5 years of age (World Health Organization 1990). The major causes of death, in order, are lower respiratory tract infections (pneumonia and influenza), diarrhoea, cardiovascular disorders and tuberculosis (with the exception of diarrhoea, these causes are associated with adult mortality; World Health Organization 1989). The five "Five-Year Development Plans" running from 1969 through 1994, emphasized the development of health institutional structures, followed by the development of primary health care centers. The intent is to make health care accessible to the population by offering comprehensive community-based health services. Priority has been given to community-based services aimed at fertility reduction and child survival (Budi Otomo and Gour Dasvarma 1989). Services are provided through village organizations and include maternal and child health clinics, nutrition advice, immunization, diarrheal disease control and family planning. Studies of health service utilization (Budi Otomo and Gour Dasvarma 1989) show an annual rate of 0.8 medical visits per person. Rates vary by socioeconomic status, with poorer groups using less service. Higher service use rates are found in geographic areas close to health facilities. Since programs designed to improve child survival are associated with health service delivery, morbidity and mortality rates for childhood and matemal diseases vary widely over socioeconomic class and geographic area. Recent cutbacks in health funding by the central government reduced total health expenditures (in constant 1983 prices) 30.6% - f r o m 281 billion rupiah in 1984/85 to 195 billion rupiah in 1987/88. There has been little compensatory increase by regional governments. The decrease is aggravated by inequities in central government funding which imposed the greatest cuts in the most impoverished provinces. The effectiveness and quality of health services was further reduced by diverting resources from non-salary recurrent expenditures, i.e., for drugs and medical equipment (Budi Otomo and Gour Dasvarma 1989). Changes in health and demographic factors (to those of a more developed country) are occurring in Indonesia without comparable changes in the country's health services. This will, inevitably, produce competition for limited public health resources to respond to (a) demands for health and social services generated by population aging, and (b) continuing demand for programs to control infectious diseases and infant mortality. One response to the competition for resources, is to produce long term forecasts of future requirements for services in Indonesia. With accurate long range forecasts, necessary expenditures on capital equipment and manpower training can be spread over longer periods of time. Such forecasts may also allow the use of alternate strategies (e.g., primary prevention programs directed at younger populations which have not yet had significant risk factor exposure) whose implementation requires significant lead time.

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241

Measuring the prevalence of disease, especially chronic disease with lengthy natural histories and complex patterns of expression, does not satisfactorily represent disease consequences for population health and functioning at latter ages. The development of measurement technologies to accurately describe the population impact of disease is an important activity of the World Health Organization (WHO). Analyses of the "consequences" of disease show that they vary with disease severity and over social dimensions, e.g., need for curative, rehabilitative and maintenance services at the community level, diminishment of social and economic opportunities at the individual level, and extra economic and psychosocial burdens on families. Disease consequences can be increased, or moderated, by soeio-cultural factors. While the incidence of some childhood diseases is declining due to control programs (e.g., increased immunization against incidence of polio, measles, neonatal tetanus, better treatment of diarrheal diseases, improvement in the nutritional status of children), there is a substantial residual health burden in the chronic manifestation of past acute infectious and childhood disease among survivors. Table HI gives the 15 most frequent diagnoses producing chronic impairments reported in the Indonesia Disability Study. About 50% arise from diseases with a relation to infections or nutritional deficiency. In addition, chronic degenerative diseases, whose incidence is age dependent, and whose consequences include both chronic loss of function, and subsequent loss of social and economic autonomy, are likely to affect a larger segment of the population as the population ages and the Indonesian socio-economic structure evolves. There is evidence that changes in dietary and smoking patterns are already influencing risk factor levels for coronary heart disease (Boedhi Darmojo et al. 1990). The MONICA risk factor study protocol has been used in 43 sites in developed countries and in China (WHO; Tunstall-Pedoe 1988). This protocol was applied to a sample of 2,073 males and females age 25 to 64 selected randomly from three districts in Jakarta in 1988. Table IV compares risk factor levels in Jaka_na with those in Beijing, China and with risk factor averages for the 43 other MONICA sites. Smoking prevalence for Indonesian males was among the highest. About 85% of smokers in Indonesia smoke KRETEK (clove-scented) cigarettes which have an average of 58 rag/gin of tar and 2.4 mg of nicotine (Western medium tar cigarettes contain 15 and 20 mg/gm of tar and 1.0 to 1.2 mg of nicotine). Though an Indonesian male's per capita cigarette consumption is less than that of the MONICA centers (3 per day vs. 5 to 10 per day), the average daily tar and nicotine consumption is similar due to the potent nature of Indonesian cigarettes. The proportion of the population with hypertension is near the low end of the range for MONICA centers for both males and females. Body Mass Index (BMI; a measure of obesity) is below all other MONICA centers for males and all but one of other center for females. Since the Indonesian risk factor sample was restricted to an urban area, Jakarta, the BMI for the rest of Indonesia, which contains extensive rural areas may be lower still (Evans 1990; Kesteloot et al.

242

J.E. DOWDAND K.G. MANTON TABLE HI Prevalence of 15 most frequent diagnoses associated with all physical impairments, Indonesia (all ages and both sexes)

Rank

ICD9 Code

Diagnostic Category Rubric

No. of Diagnoses

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

521.0 263.9 525.1 011.9 491.8 285.9 692.1 401.9849.0 714.0 493.9 716.9 366.1 535.1 006.1

Dental Caries 2,068 Malnutrition 850 Absence of Teeth 660 Tuberculosis 520 Chronic Bronchitis 423 Anemia 397 Dermatitis 316 Hypertension 287 Low Back Pain 279 Rheumatoid Arthritis 256 Asthma 241 Unspecified Joint Diseases 206 Cataracts 196 Gastritis 182 Intestinal Amoebiasis 181

Cumulative Percentage of All Diagnoses

% of Diagnoses*

Prevalence Per 1,000"*

18.8 7.7 6.0 4.7 3.8 3.6 2.9 2.6 2.5 2.3 2.2 1.9 1.8 1.7 1.6

92 38 29 23 19 18 14 13 12 11 11 9 9 8 8

64.1

* Denominator- Total number of diagnoses made = 10,997. ** Denominator - Total number of persons in sample = 22,568. Source: Indonesia Disability Study; unpublished report: World Health Organization, Geneva, 1978. TABLE IV Risk factors for chronic diseases as found in Jakarta (1988), Beijing (1985) and in 43 other Monica Centres between 1980 and 1987 Risk Factor

Jakarta

Beijing

Other Monica Centres (Range) 23-59% 3-50%

Smoking Prevalence

M F

60% 6%

58% 18%

No. of Cigarettes Per Day Per Capita

M F

3 0.5

6.4 1.2

Body Mass Index (kg/m2)

M F

22.6 23.6

23.4 23.9

25.0-27.5 23.5-29.2

Blood Pressure Systolic (ram Hg)

M F

123 125

126 121

121-146 118-141

Blood Pressure Diastolic (ram Hg)

M F

79 78

85 76

74-91 72-89

Total Cholesterol (retool/L)

M F

5.2 5.4

4.1 4.2

5.3--6.4 5.2-6.3

5-10 1-4

Source: Boedhi Darmojo, R. et al., 1990. A study of baseline risk factors for coronary heart disease: Results of population screening in a developing country. Rev. Epidem. et Same Publ., 38:487-491.

PROJECTIONSOF DISABILITYIN INDONESIA

243

1989; Knuiman et al. 1982). Despite the low average BMI, total cholesterol levels exceed those in China. They are close to the lower levels in the 25 developed countries but exceed the level of 4.9 rnmol/L in Japan. The average Indonesian diet in 1985 had slightly less than 25% of total calories in fat (Boedhi Darmojo et al. 1991) - similar to the currem Japanese diet. The elevated (relative to BMI) cholesterol levels might reflect dietary change in large Indonesian cities. With increasing urbanization and population aging, since cholesterol levels tend to rise with age (as do blood glucose levels) - chronic disease risks (especially CVD), will increase. For these reasons, it is important that countries experiencing demographic, socio-economic and epidemiologic transitions similar to Indonesia examine and understand the consequences of its health changes for health and other service needs. To aid this examination, projections usng data from a large crosssectional survey carried out in 14 of the 24 provinces in 1976-77, are presented. The distribution of health, handicaps and health and social service needs are projected to 2025. Since the survey was cross-sectional, the projections are based on handicap, medical condition and health utilization prevalence rates for 1976. These were applied to age and sex specific population projections prepared by the United Nations (U.N.) Office of Population Projections and Estimates for the period 1985 to 2025. METHODS

A Population Model of Disease Consequences Individuals as they age, often begin healthy and fully functional, and after passing through multiple transitional health states, end up with significant physical or mental handicaps. Correlated with health and functioning changes are reductions in the ability to fulfill social and economic roles which make individuals dependent on society or family to varying degrees until death. The passage through all intermediate states from health to death is not obligatory. Transitions may occur in both directions (i.e., persons may be cured or recover from disease; they may be rehabilitated and regain lost function) - except of course, from the absorbing death state. Thus, the goals of programs for promoting healthy aging involve prevention (or delay) of transitions from healthy to morbid or functionally impaired states, or improving health and functioning. For persons in an illness or impairment state from which return to the healthy, unimpaired state is not possible, the goal is to prevent or delay further loss of function, which could decrease autonomy, and make him (or her) more dependent upon family, community and national resources. For persons who suffer from physical or mental dependency, the goal is to remm them from dependent to autonomous states, or to prevent their dependency from increasing (e.g., from dependency on informal care in the family to institutional care). This process is portrayed in Figure 1.

244

J.E. DOWD AND K.G. MANTON

The intermediate stages of the process are described in a WHO (1980) classification of the consequences of morbidity, trauma, and congenital and other malformations; the International Classification of Impairments, Disabilities and Handicaps (ICIDH). The immediate physical consequences of disease or trauma are "impairments" (e.g., loss of an eye or cataracts), loss of physical or mental function from physical or mental impairments are "disabilities" (e.g., blindness), and the social consequences of loss of function (i.e., loss of autonomy) are "handicaps." In the ICIDH, autonomy is one of six dimensions of "survival" roles necessary for an individual to function in society. The other five dimensions are: (1) orientation; (2) mobility; (3) occupation; (4) social integration; and (5) economic self-sufficiency. The model in Figure 1 can be expanded to include contextual factors that impact transition rates and outcome. The elaborated model in Figure 2 is used to evaluate our projections. HEALTHY ~

ILLNESS ~ OR OTHER IMPAIRMENTS

LOSS OF ~ FUNCTION (PHYSICAL OR MENTAL)

(Bi-dlrectlon•l •rrows represent the possibility he•lth status.)

LOSS O F ' - - - ~ M O R T A L I T Y AUTONOMY

to move both in the direction of • better or worse

Fig. 1. Schematic representation of the states of the health dimension of the disability process. In Figure 2, passage from the health to death for an individual is implicitly represented as a function of the individual's age. At each state there are factors which may favor, retard, or reverse transitions between states. Thus, "aging" refers to a complex multidimensional and partially reversible process which is not isomorphic to chronological age. Mitigating factors might be characteristics of the individual or of his (or her) environment or culture. For persons with reduced autonomy (i.e., handicaps), consequences at the individual, family and societal level are listed. Since Figure 2 represents transitions over time, direct measurement of population stocks and flows for various states requires longitudinal data on a defined population. Since the Indonesian survey is cross-sectional, only prevalence information is available. The relation between risk factors, handicaps and their consequences was retrospectively determined using event history questions. This limits the reliability of transition rate estimates, but there are currently few surveys in developing countries which produce nationally representative longitudinal data on health and functioning. Detailed longitudinal surveys of elderly populations have been conducted in developed countries (e.g., in the USA, the 1984, 1986 and 1988 Supplement on Aging and Longitudinal Supplements on Aging to the National Health Interview Survey; National Center for Health Statistics 1987, 1989) which might provide necessary experience for the design of longitudinal

PROJECTIONS

OF DISABILITY

245

IN INDONESIA

ENABLING, DELAYING AND RESTORING TRANSITION FACTORS: • • • • • •

BIOMEDICAL BEHAVIOURAL PSYCHOSOCIAL ECONOMIC ENVIRONMENTAL CULTURAL

-

7

FUNCTION

MORTALITY

CONSEQUENCES

I

INDIVIDUAL E.G. DECREASE IN • MOBILITY • SELF-CARE • SOCIAL INTEGRATION

1

FAMILY E.G. • ECONOMIC AND SOCIAL BURDEN OF CARE GIVING • DISTURBED SOCIAL RELATIONSHIPS

1

SOCIETY E.G. • LOSS OF PRODUCTIVITY • DEMAND FOR SERVICES • DISTURBED SOCIAL INTEGRATION

Fig. 2. Generalized model of health status transitions. surveys in developing countries. There will be methodological problems in developing countries (e.g., longitudinal tracking) that will be different. Prevalence rates of handicap specific to age and sex, were cross-tabulated with the type of preventive, curative or rehabilitative treatments recommended by the examining physician and the kind of social and family actions needed to supplement these treatments. Since only prevalence data is available for risk factors and handicaps, it is necessary to assume that transition rates used in the projections are constant. Under this assumption, the rates are applied to age and sex specific population distributions projected to specific dates to see how the distribution of impairments and handicaps change as a function of demographic factors. We used the United Nations Medium Variant Age and Sex specific population projections for Indonesia as the basis for the handicap projections (United Nations 1991). The U N medium variant projections are based on the assumption that the decreases in fertility, urbanization and mortality between 1965 and 1985 presented in Table I will continue, but at slower rates between 1985 and 2025.

246

J.E. DOWDAND K.G. MANTON

The demographic rates generated by these assumptions for 1980-1985 and 2020-2025 are, Crude Birth Rate (per 1000 population): 1980-1985 31.8 2020-2025 16.3 Total Fertility Rate: 1980-1985 4.05 2020-2025 2.10 Population Growth Rate: Total Urban 1980-1985 2.06 5.37 2020-2025 0.90 2.13

Rural 1.00 --0.73

Crude Death Rate: 1980-1985 11.2 2020-2025 7.3 The medium variant population projections are combined with prevalence estimates from the Indonesian Disability Survey to produce projections of the demand for different types of health services. It is difficult to know how the prevalence rates of disability will change in Indonesia in the future - especially among the elderly. This depends upon the direction of social and economic development that occurs between 1985 and 2025. It also depends upon how future life expectancy increases are achieved. Some authors suggest that, if life is extended at advanced ages the proportion of life spent in a disabled state will increase. Others suggest that the proportion of life spent in a disabled state can be decreased with appropriate interventions. The projections presented below assume the constancy of rates because we wish to emphasize the implications of a phenomena that can be reliably predicted, i.e., the growth of the elderly population. The projections can be used to simulate the effects of hypothesized patterns of change in disability prevalence under different scenarios. Starting with these projections one could make plans (indeed one purpose of the projections would be to stimulate appropriate interventions to attempt to change the rates in a beneficial way) and then, as changes are realized, update the projections. The disability rates change slowly enough to make such an "adaptive" strategy feasible. BACKGROUND AND SAMPLE DESIGN OF THE INDONESIAN DISABILITY SURVEY The Indonesian disability survey measured the prevalence of impairments, disabilities, and handicaps in the population and examined factors which might prevent or accelerate movement from impairment to disability to handicap. The survey was conducted during 1976-1977 by the Institute of Health Research and Development, Department of Health in Jakarta with the financial support and technical collaboration of WHO.

PROJECTIONSOF DISABILITYIN INDONESIA

247

The Institute of Health Research and Development (IHRD) used 70 locally recruited physicians as interviewers/assessors. An epidemiologist from I H in charge of the survey conducted two-week training courses for interviewers in each area. In the training session, pretests of the questionnaire were conducted and field procedures finalized. Physicians were chosen as interviewers, rather than lay health workers, because of their presumed ability to assign an International Classification of Diseases (ICD) diagnostics category to reported or observed impairments and to identify needed treatment and service. The 9th revision of the ICD was used. Diagnoses were made on the basis of impairments reported by subjects and the physician's interpretation of those reports. They are not based on a clinical examination or on laboratory or other diagnostic tests. In some cases superficial examinations permitted diagnoses to be made, even if a complaint was not stated, e.g., malnutrition. The diagnoses were conditions that were either easily discernible (dental and skin disease), entailed obvious functional loss (arthritis, cataracts), or produced symptoms of which the patient was aware (tuberculosis, malaria, intestinal worms, asthma). The diagnosis reflect the training, customs, coding procedures and disease patterns appropriate to environmental and socioeconomic conditions in Indonesia. The sample was selected by the IHRD and the Indonesian Central Bureau of Statistics. It included the major Indonesian islands constituting 14 of the 24 provinces. The ten provinces excluded were either parts, or groupings, of outlying islands, including Sulawesi, where travel was difficult. The final sample consisted of 4,604 households in provinces from the main islands of Sumatra, Java and Bali, including the two special regions Aceh and Yogyakarta, and the Indonesian Capital Region of Jakarta. Each province, or special region, was divided into an urban and rural domain, which, along with the provinces, served as sample strata. There were a total of 27 strata (the Indonesian Capital Region of Jakarta was a single urban domain). Within stratum, a five-stage sample design was used based on population counts from the 1971 Indonesian Census. The first three stages of sampling were districts, subdistricts, and villages each selected with probability proportionate to their 1971 population size. One census enumeration unit was selected with equal probability within each selected village. From within each selected enumeration unit a systematic random sample of households was selected to give a self-weighing sample of approximately 1/4,800 on a household basis. The occupants of each household were listed and information was obtained for each person in the household. The interviewer was required to see everybody in the household. From the 4,604 households, information on 22,568 persons was obtained. Data on 22,546 of these persons for whom age, sex and health information was available are used in the analyses. Since the study was carded out during 1976-1977, the fmaI version of W H O ' s International Classification of Impairments, Disabilities, and Handicaps flCIDH) was not available (WHO 1980). The impairment, disability, and handicap definitions used were derived from an early draft of the ICIDH. In the

248

J.E. DOWD AND K.G. MANTON

draft "disability" was called "functional limitation" and "handicap" was called " d i s a b i l i t y . " T a b l e V c o m p a r e s t h e d e f i n i t i o n s u s e d in t h e 1976--1977 I n d o n e s i a s u r v e y a n d t h o s e u s e d in t h e 1980 I C I D H . TABLE V Comparison of definitions used in the Indonesian disability study (1976-77) and in the W H O ICIDH (1980) Definition

IMPAIRMENT

DISABILITY

HANDICAP

Indonesian Disability Survey

WHO ICIDH

(Page 2 - Questionnaire)

WHO ICIDH p. 47

"An impairment is a permanent or "In the context of health experience, transitory psychological, physiological an impairment is any or abnormality or anatomical loss and/or abnormality." of psychological, physiological or anatomical structure or function." (Page 2 -

Questionnaire) (called Functional Limitation)

WHO ICIDH p. 143

"Impairment may cause functional limitations which are the partial or total inability to perform those activities necessary for motor sensory or mental functions within the range and manner of which a human being is normally capable,..."

"In the context of health experience, a disability is any restriction or lack (resulting from an impalrmen0 of ability to perform an activity in the manner or within the range considered normal for a human being."

(Page 2 - Questionnaire) (called Disability)

WHO ICIDH p. 183

"Disability in which functional limitation and/or impairment is a causative factor, is defined as an existing difficulty in performing one or more activities which, in accordance with the subject's age, sex and normative social role, are generally accepted as essential, basic components of daily living, such as self-care, social relations, and economic activity."

"In the context of health experience, a handicap is a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual."

T h e o p e r a t i o n a l d e f i n i t i o n o f d i s a b i l i t i e s a n d h a n d i c a p s w e r e a d j u s t e d to r e f e r e n c e c o n d i t i o n s c o m m o n in I n d o n e s i a n d a i l y life a n d w o r k e x p e r i e n c e s . S i m i l a r l y , q u e s t i o n s o n t h e s o c i o - e c o n o m i c status o f t h e h o u s e h o l d , e d u c a t i o n , o c c u p a t i o n , a n y w e l f a r e p a y m e n t s a n d m e d i c a l facilities w e r e d e s i g n e d f o r Indonesian conditions. The operational definitions described conditions recognizable by the respondent. Each household member reported on physical i m p a i r m e n t s (21 items), m e n t a l i m p a i r m e n t s (11 i t e m s ) , d i s a b i l i t i e s (8 i t e m s ) ,

PROJECTIONSOF DISABILITYIN INDONESIA

249

handicaps in daily living (4 items), or work, household or social handicaps (16 items). For each handicapped person, the physician assessed the medical and rehabilitative care needed to ameliorate (if possible) the severity of the handicap, or to avoid further degeneration. The interviewer estimated "need" at the time of the survey and in the context of his knowledge of medical and other services, that might (or "should," in the Indonesian context) be available in the local area. Thus, the projections are based upon the need for services, estimated by a trained physician, given his assessment of the services in that area. The projections do not represent the introduction of new services and technologies but the estimated 1976-77 current level of service in the local Indonesian context. The categories of care were: 1. Surgical intervention; 2. Protheses or braces; 3. Visual aids; 4. Special rehabilitation services; 5. Social counselling and aid; 6. Drug treatment; 7. Job training. More than one service option could be recommended by the interviewing physician for each handicapped person. SURVEY RESULTS Figures 3(a-d) give the proportion of males and females in the survey falling into the impaired, disabled and handicapped classifications by five year age groups from birth to age 80 and above. The prevalence of chronic (of greater than 3 months duration) impairment, disabilities, and handicaps are all age-dependent with no consistent male/female differences. Physical impairment (3a) increases from a 25 to 30% prevalence for those under five, to nearly 80% above age 80. Mental impairment (3b), in contrast, is more prevalent at young ages. Female rates are higher between 20 to 45 years of age. The prevalence of disabilities (3c) increases from about 2% to nearly 35% between birth and age 80 - with more rapid increases after age 35. Handicaps (3d) increase more slowly with age with some acceleration above age 50. The four components of the handicapping process: inability to care for oneself on a daily basis, inability to carry out simple household activities (e.g., an important household activity in rural Indonesia is fetching water from distant sources), work activities (which, in rural areas, involves bending and squatting, or walking long distances to fields), and social activities (including participation in community projects and religious ceremonies), were examined separately. The prevalence of handicaps rose with age for self-care, household and work handicaps. The prevalence of social handicaps declined with age - possibly because community expectations are higher for young persons. In table VI, we list the impairments and the frequency with which they were reported. Indonesian respondents identified a large number of complaints of low

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251

PROJECTIONS OF DISABILITYIN INDONESIA TABLE VI Self-reported severity of 21 physical impairments, Indonesia

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Impairment

Does Not Bother Subject At All %

Bothers A Little Bothers Bit or A Lot or OccasionallyO f t e n % %

Not Able to Express Makes Opinionor Life UnbearableUnknown % % Total

Cough ChestPain Breathlessness Headache Backache Pain in Arms, Hands Pain in Legs, Feet AbdominalPain Diarrhea Eye Symptoms Ear Symptoms SkinSymptoms Troublewith Teeth RecurringFever MissingLimbs Fracture,Dislocation Lame,Weak Muscles UrinaryTract Symptoms Gynae.Symptoms Malnutrition Accidents,Injury

22.1 15.8 12.0 20.3 22.5 18.1 18.7 21.9 21.9 29.9 21.8 37.0 30.7 22.5 15.0 28.6 9.1 15.7 19.0 51.7 27.4

50.4 56.0 50.3 58.2 57.5 54.8 49.3 53.5 53.5 37.8 50.6 47.4 53.1 58.5 30.0 45.7 44.2 41.4 38.0 36.8 35.5

1.1 1.6 1.8 1.0 0.3 2.5 2.3 1.1 0.8 4.5 0.8 0.4 0.4 0.3 15.0 1.4 7.9 5.7 1.3 0.2 1.6

24.5 25.3 34.5 19.9 17.2 23.1 28.8 26.6 19.1 23.2 23.6 12.3 14.4 17.0 40.0 18.6 36.4 35.7 41.8 49.0 29.0

1.8 1.3 1.3 0.6 2.5 1.6 0.9 0.7 4.7 4.5 3.1 2.8 1.5 1.6 5.7 2.4 1.4 6.3 6.5

1305 613 815 1069 790 321 444 444 256 598 326 951 2652 306 20 70 165 70 70 688 62

Source: Indonesian Disability Study; unpublished report: World Health Organization, Geneva, 1978.

severity. They rated only 2,580 (or 21.4%) of 11,809 complaints as severe, i.e., impairments which "bother a lot or often" or "make life unbearable." These included cough, chest pain, breathlessness, pain in legs and feet, missing limbs, and lameness or weak muscles which restrict mobility and body flexibility. Less severe impairments included skin and teeth problems and malnutrition. These latter symptoms are more prevalant in children and, while their chronic nature is apparent, they are not regarded by the respondent (usually their mother) as severe nor yet representing disability or handicap. PROJECTIONS In Figures 4(a-b) we present projections, for every 10 years between 1985 and 2025, of the age specific numbers of handicapped males and females for the Indonesian population. These were generated by multiplying the projected population in each 5 year age interval for males and females by the prevalence of handicaps for that age

252

J.E. DOWD AND K.G. MANTON

4(a)

Population projections for handicapped males, 1985-2025 .o. OF pEnso.s(ooo's}

1600,-

,200

0

\ A

/

5

10 16 20 28 30 3 6 4 0 4 5 SO 58 60 65 70 76 eO

AGE IN YEARS 11988 ~

~

~

2008 -"-- 2018 ~

2026

Population projections for handicapped females, 1985-2025

4(b)

NO. OF PERSONS(O00'S)

1600r 1400t1 1000P 800 I-

2

0

0

~

0 0

5

10

18 20 25 3 0 38 40 48 80

55 6 0 68 70 711 8 0

AGE IN YEARS 1988 - - 1998 - - 2005 -,-e--2018 - - 2028

Fig. 4. interval (see Figure 3(d)). Figures 4(a) and 4(b) show increasing numbers of handicapped persons due to population aging between 1985 and 2025, i.e., the age and sex specific prevalence rates were not changed from the values estimated from the 1976-1977 survey. The increase in handicapped persons is rapid above age 45 because of the interaction of higher prevalence rates at those ages with population growth. For example, the number of handicapped females over 50 grew almost fourfold, to 7.1 million persons in 2025 - double the entire handicapped population in 1985. The projections demonstrate the effects of age structure on the future size of the handicapped population. There were also significant sex differences in type of handicap (e.g., a higher prevalence of work-related handicaps in males; or in the impairment(s) giving rise to handicap(s)).

253

PROJECTIONS OF DISABILITY IN INDONESIA

Figures 5(a-b) show the projected age specific numbers of males and females for which surgical care is needed for 1985 to 2025.

Projected need for surgery handicapped males 1985-2025

5(a)

NO. OF PERSONS(O00'S) 350 r 300 ,'I 280 ~ 200 [ 160~

100 P SOP -

o;

10

0

,

gO

2O

.

40

,

SO

:

,

60

_

70

90

AGE IN YEARS 200~

- " - 2015

~

2025

Projected need for surgery handicapped females 1985-2025

5(b)

NO. OF PERSONS(O00"S) 250 r 200 [ 1110} 100 [ 60_j.op-

_.

0

I0

. 20

30

40

80

80

70

90

AGE IN YEARS --

1988

--

1999

2008

~

2018

~

2025

Fig. 5 There are significant differences in the types of health care recommended by the physician for males and females. In Figure 5 more surgical care (which includes dental surgery) is recommended for males than females - especially above age 50. A substantial amount of surgical care was required for females in their 30s probably for reproductive health problems (e.g., hysterectomy, sterilization). Special rehabilitative and social services were most often required by handicapped male and female populations. They are usually recommended in combination with other services. The projected need for rehabilitation is presented in Figures 6(a-b).

254

J.E. DOWD AND K.G. MANTON

The age distribution is bimodal with demand being high for male children, young female adults, and the elderly of both sexes. This reflects the different health problems affecting age groups and suggests that the treatment and rehabilitative services that will be required will vary over age. The need for rehabilitative services was nearly twice as high for males as for females up to age 60. In Figure 7 we present the projected demand for protheses of all kinds, except vision or heating aids.

6(a)

Projected need for rehabilitation handicapped males 1985-2025 NO. OF PERSONS(000'S)

! 000 r 800 t-

2OO 0 I''-~ 0

,

~

10

20

i

i

i

i

i

SO

40

80

80

70

80

AGE IN YEARS ~11988

~I1~16

'--="2008

"e--2018

~2028

Projected need for rehabilitation handicapped females 1985-2025

6(b)

1200

NO.OF PERSONS(000'S)

1000" 800 60O ~40O F 20010 1 ~ 0

10

~:~33!:=~ 20

__ 40

30

80

60

70

AGE IN YEARS 1988

~

1998

~

2008

Fig. 6

--e- 2018

~

2028

80

PROJEC'HONSOF DISABILITYIN INDONESIA

255

Projected need for prostheses: handicapped males 1985-2025

7(a)

NO.OF PERSONS(000"S)

700 r

5 0 0 t-

4OO r 800 r ; 2 0 0 t-

lOO; O: 0

10

20

30

40

60

80

70

80

AGE IN YEARS 11988

1998

~

2008

"It-- 2018

~

2025

Projected need for prostheses: handicapped females 1985-2025

7(b)

800

~

NO.OF PERSONS (000'S)

700 600 40O 500 3OO

S

2O0 100 0

10

20

30

40

80

60

70

80

AGE IN YEARS 1985

~

1996

~

2008

--e- 2OI8

~

2028

Fig. 7

The largest demand occurs at the oldest ages in females and in the penultimate age group in males. This might represent survival to later ages of females in frail condition who require use of braces, canes, crutches, etc. Though the need for different classes of services was estimated and projected, how the health service system could be re-organized to meet the increasing needs of the population was not considered by the physician interviewer. Without information on the age and sex specific rates of transition between the health states in Figures 1 and 2, it is difficult to estimate the benefits of primary and secondary prevention and of curative and rehabilitative services for the future numbers of persons with need for specific health and social services. However, with quantitative estimates and projections of need, health planners can be made aware of the magnitude of the service burden resulting from

256

J.E. DOWDAND K.G. MAN-TON

population aging and changes in the mix of services that will be required. Tables HI and VI list the diseases which produced the impairments reported in the survey. The opportunities for preventive, curative and rehabilitative actions need to be appraised while considering the health, social and community based services to implement those interventions in Indonesia. SUMMARY The projections used rates estimated from a large Indonesian disability survey to show the increase in the demand for social and health services that will emerge due to population aging. These projections are based on the assumption that age and sex specific prevalence rates for impairments, disabilities and handicaps will be constant. The projections show that the largest increase in the demand for services occurs at the oldest ages - despite the larger size of the younger population. This is fact for which social and health service planners in developing countries, at either the local or national level, are not prepared. In addition, in contrast to developed countries, males, rather than females, have a greater medically determined need for services. We did not attempt to simulate interventions to determine how the future demand for services might be altered. The projections suggest that the greatest increase in the demand for services occurs in two broad age groups - the young and the elderly - due to different medical conditions. For the young population impairments result from childhood diseases and external causes (i.e., accidents). The need for services among the elderly is a result of age related chronic degenerative diseases. Handicaps of the young could be prevented by medical actions directed at preventing childhood diseases (e.g., nutritional deficiency) or by preventing work-related accidents. In contrast, handicaps at later ages are the result of long-term and complex degenerative processes whose prevention is difficult unless interventions are started at young ages. The risk of these diseases may increase if the Indonesian economy produces more disposable income for the purchase of alcohol and cigarettes. Changes to a Western diet (i.e., with higher levels of fat and protein consumption), as has occurred in Japan, may also increase the risk of chronic degenerative diseases. To prevent chronic degenerative diseases from increasing in prevalence, and compounding population aging with an adverse epidemiological transition, interventions should now be started at the country level. Individual life styles are more difficult to change after behavior has become habituated. Boedhi Darmojo et al. (1990) indicate that, in Jakarta, prevention efforts are underway with plans to extend those efforts to other areas of the country. In other analyses (e.g., Manton, Dowd and Woodbury 1986), we evaluated profiles of disability and impairment using multivariate procedures though we did not use those profiles in our projections. In those analyses we analyzed the chronic functional and health state of the population aged 65 and over in terms of the covariation of multiple impairments, disabilities, and handicaps. That

PROJECTIONSOF DISABILITYIN INDONESIA

257

analysis was used to select the impairments and handicaps which were projected. In future years as the over age 60 population increases Indonesia can expect a significant increase in the need for health services. Importantly, these needs were determined as "typical" in the Indonesian context by local physicians. Thus, the projections do not imply raising the standards of care to arbitrarily high standards from developed countries, but, to what is expected by local physicians and their assessment of current conditions. ACKNOWLEDGEMENTS This research was supported by NIA grant nos. 5R37AG07025, 1R01AG07469, and 5R01AG01159. Mr. Dowd's efforts were supported by funds from NIAs BSR program. REFERENCES Boedhi Darmojo, R. et al. 1990 A Study of Baseline Risk Factors for Coronary Heart Disease: Results of Population Screening in a Developing Country. Rev. Epidem. et Sante Publ., 38:487-491. Budi, O. and G. Dasvarma 1989 An outline: Development of Health Programs and Improvements of Community Health Status in Indonesia. Presented at the New Order Conference, Australian National University, Canberra. Evans, J. 1990 The Economic Status of Older Men and Women in the Javanese Household and the Influence of this upon their Nutritional Level. Journal of CrossCultural Gerontology 5:217-242. Kesteloot, H., V.O. Oviasu, A.O. Obasahan, A. Olomu, C. Cobbaert and W. Lissens 1989 Serum Lipid and Apolipoprotein Levels in a Nigerian Population Sample. Atherosclerosis 78:33-35. Knuiman, J.T., C.E. West and J. Burema 1982 Serum Total and High Density Lipoprotein Cholesterol Concentrations and Body Mass Index in Adult Men from 15 Countries. American Journal of Epidemiology 116(4):631-642. Manton, K.G., J.E. Dowd and M.A. Woodbury 1986 Conceptual and Measurement Issues in Assessing Disability Cross-Nationally: Analysis of WHO-Sponsored Survey of the Disablement Process in Indonesia. Journal of Cross-Cultural Gerontology 1:339-362. National Center for Health Statistics, Fitti, J. and M.G. Kovar 1987 The Supplement on Aging to the 1984 National Health Interview Survey. Vital and Health Statistics Series 1, No. 21. DHHS Pub. No. (PHS) 87-1323. Public Health Service. Washington, DC: USGPO. National Center for Health Statistics, Kovar, M.G. 1989 National Health Interview Survey: 1988 Longitudinal Study of Aging Public Use File Version 2, 1988 Release Public Use Tape. Public Health Servive, Hyattsville, MD, Jan. 12. Trends in Developing Economies 1990 The World Bank, Washington, DC. United Nations 1991 World Population Prospects 1990 Population Studies No. 120. United Nations, New York. United Nations Family Planning Agency 1991 State of the World's Population. UNFPA, New York. WHO MONICA Project (prepared by Tunstall-Pedoe, H.) 1988 Geographical Variation in the Major Risk Factors of Coronary Heart Disease in Men and Women Aged 35-64 Years. World Health Statistics Quarterly 41:115-140.

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World Health Organization 1980 International Classification of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequences of Disease. Geneva. World Health Organization 1990 Health Sector Analysis Indonesia - the Economy, Health Strategy and Development Cooperation. WHO Unpublished Document ICO/HSA/89.4. World Health Organization 1989 Health Care in South-East Asia. WHO Regional Publications, South-East Asia series no. 14, New Delhi.

World Health Organization Geneva, Switzerland and Center for Demographic Studies Duke University Durham, North Carolina U.S.A.

Projections of disability consequences in Indonesia.

With the populations in many developing countries growing older due to declining fertility and infant mortality, there is concern that chronic disease...
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