Growing Old in the City - Health Transition Among the Elderly in North Sulawesi, Indonesia: An Anthropological Approach to Old-Age Research
Indonesia, North Sulawesi; Selected Towns: Manado, Tomohon (Minahasa), Tahuna (Sangihe-Talaud)
Old-age research in developing countries and particularly in cities is in its initial stage. This study builds on recent overviews of ageing in the Asia-Pacific Region and correlates the conceptual framework of 'health transition' (i.e. demographic and epidemiological transformation and change of lifestyle in most developing countries) with that of a 'triangle of uncertainty' for elderly persons (i.e. minimal state provision; uncertain family and community support; an unfriendly environment). Preliminary findings of our field research in Indonesia have shown that economic and social conditions rather than cultural and ethnic ascriptions affect vulnerability of elderly urban people and that signs of urban poverty show a strong gender bias. Furthermore, emerging non-communicable, chronic illnesses such as hypertension and diabetes present a serious threat for the well-being of elderly citizens; in times of decreasing family and community support in urban areas in Indonesia new strategies for long-term care of chronically ill persons are badly needed. Indonesian cities provide an unfriendly environment for the elderly, especially since the world of urban elderly people is a world of work, and many of them find it very hard to make a living.
These preliminary findings can be abstracted from our field research in North Sulawesi, but they require further scrutiny. The planned data analysis phase will focus on correlations and factors emerging from the collected field data. The five principal research objectives reflect these new foci and comprise the study of
(1) differentials in living conditions of elderly urban people,
(2) the relation between urban vulnerability and social and economic differentials among elderly people including a gender gap,
(3) perceptions, manifestations and assessments of chronic illnesses and the range of corresponding coping strategies elderly develop,
(4) experiences of and self-images of ageing in relation to well-being and illness, and
(5) health-seeking behaviour and current long-time care of chronically ill older persons.
The proposed study period will last one year; it will start in November 2002 and will end in October 2003. Data analysis will be carried out in three steps:
A) rough data analysis;
B) follow-up in the field, and
C) detailed data analysis. Step C will be carried out in Switzerland as well as in the Netherlands (as post-doctorate research fellow at the International Institute for Asian Studies/IIAS in Leiden).
This project will make a major contribution to old age research, particularly concerning elderly people's own perception and assessment of 'ageing', 'health' and 'well-being' and the influence of three main factors, namely the urban environment, the provision of services and the social support on these core phenomena. Detailed qualitative description will document that 'elderly people' are not a homogeneous age group, but rather an age cohort whose individual members vary e.g. according to education, life experience, social and economic background, health status and thus individual health needs. This innovative project will strengthen the international dimension of old age research Switzerland. It will further contribute a Medical Anthropology perspective to the development old age research in the Asia-Pacific Region. And finally, it will provide empirically grounded recommendations for Indonesian researchers, politicians and policy-makers.
The following results will be discussed by means of the five defined specific objectives of the research project in Indonesia:
Objective 1: Identify different urban household compositions and compare among them the corresponding social networks and economic environment of old people suffering from a chronic disease.
- Household composition and general vulnerability: Unmarried elderly women, widows without children or widows without any child support and without regular monetary income share the greatest risk to fall out of their (once) existing social and economic network and, as its consequence, to fall seriously ill. This gender bias is felt in a very distinctive way. People who have migrated five years ago or more recently to one of these three selected towns also share an increased health risk. Locality and the corresponding length of stay as well as the capability to adapt to a new surrounding in order to establish and maintain secure social networks ('social capital') are an important factor influencing the degree of vulnerability. Household structures which consist of intact two- or three-generation families offer a certain shield against social and economic deprivation and thus against poverty determined health disturbances (including communicable diseases).
- Economic environment: It is a given fact that older persons in urban areas in North Sulawesi have to continue to generate monetary income and/or to contribute to the daily household needs. Even after formal retirement as civil servant and endowed with a monthly old-age pension, these persons have to look for an occupation mostly in the informal service sector. In one third of our sample households, the elderly family member contributes an important share in household income. We may generally derive from our data that poorer older urban citizens (based on weekly expenditure) share a higher incidence of illness episodes, however, not only in old age, but also during their lifetime (for example due to unhealthy environment). Nevertheless, this fact had not a significant effect on longevity, that is on life expectancy.
- Ethnic differentiation: The cliché that elderly Chinese people enjoy a relatively secured live in extended family households, was partly confirmed by the reality in the field (but with just as many exceptions). With regard to the other main ethnic groups (Minahasa, Sangihe-Talaud, and Gorontalo) in our urban study sites, we cannot derive any clear-cut socio-economic differences according to cultural-ethnic affiliation.
- Religious differentiation: We could not prove the assumption held by many people in North Sulawesi that urban Christian families are gradually loosening their solidarity obligations and that, in contrast to them, Moslem kinship bonds are - even in an urban setting - still strong. There are other prominent factors such as household economy, education, and social embeddedness, which determine social coherence on household level.
Objective 2: Explore the curative patterns (how) and cultural and system factors (why) of chronically ill elderly people when utilizing - or non-utilizing - one or several of the existing three health sectors in an urban setting.
- Curative pattern: Elderly people with access to home-gardens and fields (Tomohon and Tahuna) make widely use of herbal medicine as an initial curative resort. With persisting chronic illness, they tend to make regular use of professional biomedicine. They largely consume not only medicaments prescribed by doctors and nurses, but also drugs sold freely over the counter (of kiosks and shops). Older persons usually recognize the persisting effect of drugs and injections by stabilizing their progressive illnesses. Drug compliance is amazingly high among the elderly. Popular health measures include e.g. food and rest regulations. Nevertheless, different urban 'traditional' healers are visited as a way to cope with long lasting suffering and degenerative illnesses.
- Cultural factors: The aetiology of chronic illnesses is considered as a main cultural factor affecting health-seeking behaviour. Most old-aged individuals explain their ailment as a result from A) their personal life style in preceding years (e.g. smoking, drinking, hard physical work), from B) the on-going inevitable biological ageing process, and from C) current changing behaviours such as food habits and physical exercise. We have not yet analysed the relationship between type of aetiology and the corresponding health-seeking behaviour.
- System factors: The most frequently mentioned factors for utilizing or non-utilizing the professional health sector (e.g. nurse, district health centre, outpatients' clinic, private practice) are as follows: affordability (i.e. costs), access (i.e. within reach, transport), and accommodation (i.e. waiting period, seat). We have not yet analysed the relationship between kind of mentioned system factors and the corresponding health-seeking behaviour.
Objective 3: Identify old people's perceived health disorders and study the coping strategies of old people with chronic, mental and psychological illnesses and how they deal with their functionality ('Activities of Daily Life') and social life.
- Perceived health disorders: Elderly individuals are objectively suffering from chronic illnesses such as hypertension, eye diseases, rheumatism, diabetes, and mental disorders (e.g. dementia, confusion, anxiety). In contrast to these mentioned biomedical diagnosed sufferings, elderly people distinguish three categories of illness perception: A) disturbing (e.g. eye and dental problems), B) worrying (e.g. chest pain, persisting fever), and C) threatening illnesses (e.g. hypertension, diabetes). Disturbing illnesses (A) hinder daily household work as well as social and economic activities; worrying illnesses (B) show indistinct causes, unclear effects and an uncertain course; threatening illnesses (C) are related to further future physical and mental complications and deterioration.
- Coping strategies: We have found several coping strategies ranging from children's or grandchildren's support, intragenerational support, professional medical support by private organization to 'deportation' to hospitals, neglect, and suicide. There are strategies, which were based on individual (i.e. by the elderly person) or collective decision-making (i.e. by the social reference group of the older person). We have not yet analysed the relationship between the three categories of illness perception (A-C) and the corresponding coping strategy.
- Activities of Daily Life (ADL): Elderly people consider the carrying out of the ADL an essential gauge or mark for their personal independence and their general physical and mental fitness. ADL manifest therefore the context of action, which allows older people to assess their current functionality.
Objective 4: Investigate how old people perceive and experience 'old age' and evaluate their ageing process in the given urban setting.
- Perception of 'old age': The perception of 'old age' (by elderly people) is represented through the individual 'control or power over body, mind and soul' and not by a concrete age limit (e.g. 60 years) or a biomedical diagnosis. The gradual reduction or deterioration of physical and mental competence and capability of an ageing person is perceived through the following transformations: decreasing eyesight and hearing, falling out of teeth, declining physical agility, and diminishing mental receptivity and memory. The assessment of these mentioned manifestations differ sometimes between the subjective perception (of the elderly person) and the perception of his/her social environment.
- Evaluate ageing process: 'To become old' is not determined by a clear-cut break or turning point such as formal job retirement. Daily productive work and social activities of elderly people continue in their common course and are only reduced in case of bodily or mental disorders. Nevertheless, a transitional period occurs in most cases of people becoming old: They retire systematically from public to domestic sphere (e.g. withdraw from formal positions in community or parish matters), they hand over household authority to the next generation, and they are more engaged in intragenerational social relations. Indeed, many elderly persons feel also overburdened by current technical progress (e.g. use of modern telecommunication, car traffic) and development in service sector (e.g. bank, post and government service). Because of this 'no longer able to cope'-attitude, many senior citizens deliberately renounce these modern processes and conditions.
Objective 5: Find out what elderly people understand by 'health' or 'well-being' and how they actively deal with maintaining health and preventing illness in their environment.
- Perception of 'well-being': The elderly persons' perspective of 'well-being' covers several differentiated fields. It comprises a broad scope of well balance, regularity, moderation, and reserve as well as independence and intactness. This attitude may be represented by behavioural measures such as living in social harmony (e.g. family, neighbourhood, quarter), not suffering from economic and financial hardships, to avoid stress situations, to conduct a sound religious life, to carry out activities of daily life, and not to be obstructed by illness in order to move free and easy. Generally spoken, it represents a cognitive concept of harmony and well balance, which is widespread all over South-East Asia.
- Maintaining health: Elderly people are very conscious of the effect of active health maintenance. As a contrast, health-maintaining actions and steps are rather performed by coincidence or by order of a health professional. Nevertheless, urban senior citizens in North Sulawesi emphasize the following health maintaining activities: daily bodily work, balanced nutrition and regular food intake, enough sleep and rest, keep body and physical environment clean, and leading a social and spiritual life in harmony. Moreover, almost every elderly person regularly consumes herbal medicine (home made or ready-to-use) as a body- and mind-strengthening step.
This research consisted of the following five general study steps encompassing different society levels:
1. Review of the recent and current literature on age, ageing, health and illness and urban health in Indonesia and especially in Province North Sulawesi was carried out to identify relevant findings and to avoid duplication.
2. Community Study in 3 towns (encompassing 7 political communities (Kelurahan) altogether) has collected background information on the selected study population on, for instance, recent history, cultural background, economic situation, demographic details/dynamics, education status, basic services and their infrastructure, political and administrative structure, ecological conditions, transport, religious life, and measured health status.
3. Household Study (50 households (Rumah Tangga) per town to be studied) has investigated the multifaceted relationship and interdependence of caregivers and caretakers in households. Furthermore, this study identifies concepts of 'ageing', 'old/aged', 'well-being/health' and 'illness' and attitudes of (healthy) elderly and sick old-aged people. Data collection also comprises information on the social, economic, ethnic, education and religious background of household members and on household income, income allocation, spatial housing conditions, and food production. Specific questions on health management (including health maintenance and prevention) and experienced illness episodes/cases have provided first basic answers on perceived medical reality in households.
4. Cohort Study (25 individuals (Perseorangan) per town to be investigated) has focused on a selected sample of chronically ill elderly individuals (>60 years old) from the household sample. The purpose of this study was to make a more detailed analysis of health seeking behaviour and treatment choice of chronically ill elderly people, of quality and scope of their social network and support system and of management of 'Activities of Daily Life' (ADL). This was achieved by observing and monitoring for example illness episodes, social interactions as well as well-being and household activities over a period of two months, and investigating perception of health risk and vulnerability of members of the same age cohort.
5. 'Tracer Illness' Study (15 individuals (Perseorangan) per town to be investigated) has emerged out of the Cohort Study as a result of the executed biomedical and (medical) anthropological research on elderly people. The above-mentioned Cohort Study was the research scope for this study, which focuses its scope in a very narrow sense on one selected chronic illness of elderly people. The purpose of this study was to gain a broader biomedical and anthropological understanding of the suffering, the expression, and the perception of elderly people concerning one special illness and its socio-economic impact on old persons' daily life. This 'tracer illness' was an illness of perception (i.e. vision and hearing problems including dental illness) or another non-communicable ailment such as diabetes, hypertension or rheumatics. As a first step, we had to identify elderly people suffering from this specific illness (according to our present biomedical files on our cohort study group) and to carry out a more accurate biomedical diagnosis of the concerning older persons. The next step has comprised of interviewing these elderly people, for instance, on their experience and their perception of this tracer illness, of observing their daily life such as 'Activities of Daily Life' (ADL) and social life, and of monitoring their health related behaviour such as food intake, bodily activities or biomedical compliance.
The following research methods ought to be applied to achieve the five defined objectives:
Objective 1. Identify different urban household compositions and compare among them the corresponding social networks and economic environment of old people suffering from a chronic disease. è Methods: semi-structured interviews with questionnaire; direct participant observation; focus group discussion with the chronically ill people; group discussion with visualizing techniques; biomedical screening of sick elderly (with their consent)
Objective 2. Explore the curative patterns (how) and cultural and system factors (why) of chronically ill elderly people when utilizing or non-utilizing one or several of the existing three health sectors in an urban setting. è Methods: direct participant observation; EMIC and semi-structured interviews with questionnaire; comparison of interview records and medical files (with their consent); key informant interviews Objective
3. Identify old people's perceived health disorders and study the coping strategies of old people with chronic, mental and psychological illnesses and how they deal with their functionality ('Activities of Daily Life') and social life. è Methods: social network analysis; participant observation; EMIC and semi-structured interviews with questionnaire; self-reporting (of the sufferer) with diaries; scaling and ranking methods; measuring functional activities; focus group discussion with caregivers and caretakers cohorts; group discussion with visualizing techniques
Objective 4. Investigate how old people perceive and experience 'old age' and evaluate their ageing process in the given urban setting. è Methods: EMIC and structured interviews with questionnaire; focus group discussion with age cohorts; informal discussions; multiple in-depth interviewing; life history interviews
Objective 5. Find out what elderly people understand by 'health' and 'well-being' and how they actively deal with maintaining health and preventing illness in their environment. è Methods: EMIC and structured interviews with questionnaire; direct participant observation; focus group discussion with age cohorts; key informant interviews; informal discussions
Main Scientific Methods Applied in the 'Field' and their Main Topics to be Investigated
1. Semi-Structured Questionnaires (on household level) Household composition and their economic condition Housing situation and infrastructure/physical environment Supporting network when fallen ill Health behaviour and preventive measures
2. Structured Interviews (on individual level) Self-anamneses Knowledge on health and sickness Attitude towards health and social environment Health and illness behaviour 3. In-Depth Interviews (with selected key persons) On specific themes (i.e. local culture and traditions, community history, special events)
4. Direct Participant Observation Social and economic activities of elderly persons Everyday life in households with elderly people Health and illness behaviour of elderly persons
5. Case Studies Everyday course of elderly people Illness episodes and courses of elderly persons
6. Initial Biomedical Diagnosis and First Extensive Check-ups plus Monthly Follow-up during 4 Months inclusive Monthly Medication (on strength of Informed Consent'-form; on individual level) Anamneses and general check-ups Current health status Previous illnesses/symptoms Blood test in laboratory Drug medication and following drug compliance
7. Diary of Elderly People during 4 Months (on individual level) Way of life in everyday life Physical and mental state of health Social and economic activities
8. Life Course History-Interview (on individual level) According to 4 prominent life stages Chronological life course (i.e. education, work, family/household) Health related experiences and perceptions Assessment and judgement past-present'
9. Focus Group Discussion/FGD (on individual level) Knowledge, attitude und measures of elderly people concerning health and illness Life experience and everyday problems of elderly people
10. Photo and Film Documentation Social and economic activities Physical environment and housing Community portraits
11. Verbal Autopsy Interviews (with families of deceased elderly persons) Cause of death from their point of view Interventions and therapies before death Course of dying (the last days, hours and minutes) Reactions of social environment
Methods of Investigation/Activities:
Data Analysis Procedures
This proposal asks for support of Phase 3 (see Point 2.2.) of the research process: the data analysis. Since the field methods are primarily qualitative - although our research has also generated quite a lot of quantitative medical data -, the collected data are to a great extent texts, statements and narratives. When we ask for example about health care of chronically ill elderly persons or the impact of illness on their daily economic activities, the responses come in sentences, not in figures. Similarly, our observations of interactions between members of the households or activities undertaken to restore, improve or maintain health of elderly people, they take the form of a description of actions and events; again we deal with texts or stories of people. These data have become known as 'qualitative'; a better term might be 'textual' or even 'contextual'.
Qualitative data analysis is an iterative process. It begins during data collection and continues at the writing desk until the final report has been written. After leaving the field, the data analysis process usually passes through three phases: 1) a rough analysis to check for inconsistencies and gaps in the data material, 2) a follow up visit to the field to clarify inconsistencies and to fill gaps, and 3) a detailed analysis which leads to a systematic and insightful description of the phenomenon under study and, finally, to theoretical propositions for connections of observed patterns.
Data analysis follows the procedure known as Grounded Theory. The detailed data analysis begins by looking at the textual data line by line for 'empirical indicators', that is for observed or described actions or events. A provisional code name is given to the empirical indicator, usually a conceptual category that seems to fit the data (e.g. perception of well-being held by elderly people). These categories will be generated from my research questions, from the key concepts developed in previous studies and from the data themselves, for instance Indonesian or local language terms and corresponding English terms.
Once l have coded all the textual data, l shall examine all the texts belonging to each particular category. By systematic comparison, similarities and contrasts in the documented events and actions will be identified. These categories are not fixed once they have been developed; they may be rearranged, dropped or refined as the analysis unfolds.
In a next step, cumulative knowledge will be gained by studying relationships between categories and sub-categories. Throughout the process of generating categories, l will pay particular attention to configurations in the narrative data, which suggest that, from an emic or etic point of view, pieces of data belong together, or that an individual piece is an instance of a more general class of events or ideas. These emerging analytical notes will be written down as they occur, in the form of memos. From these memos, l shall begin to identify emergent themes, patterns or explanations and thus generate ideas for further data analysis or data collection.
Once a considerable number of analytic memos have been accumulated, l will start to draw conclusions. This will eventually lead to the formulation of theoretical propositions that l develop from my data.
Erhebungsverfahren: Akten- und Dokumentenanalyse offen, Beobachtung teilnehmend, Beobachtung nicht teilnehmend, Gruppendiskussion, Qualitatives Interview, Standardisierte Befragung face to face, Standardisierte Befragung schriftlich, Sekundäranalyse von Individualdaten
Erhebungseinheiten: In 3 towns (representing 600'000 people) with totally selected 7 political communities
Auswahlverfahren: Stratified Random Sampling; Purposive Sampling
Anzahl Untersuchungseinheiten: 7 Communities; 50 Households and 25 Individuals in each town
Community Study: collecting data in 7 political urban communities, Household Study: Study Visit every 6 months (during 2 years);
Individual Study: Observation and Reporting during 1 year plus Medical Intervention lasting 6 months;
Tracer Illness Study: research on selected people out of the Individual Study sample with vision, hearing, dental and motion problems
Durchführung der Feldarbeit: Project Main Collaborators and Trained Field Assistants (i.e. students); the researchers live themselves in one the 3 selected cities.
Weiter relevante Präzisierungen: Political, economical and security situation in Indonesia not a favourable research frame!
|Ethical approval||No||Study type||
|Start - End date||01.01.2003 - 28.12.2003|