International Journal of Integrated Health Sciences. 2019;7(1) 1 Social Determinant Factors of Elderly as an Input in Enhancing Primary Health Care in Indonesia Abstract Objective: To analyze the differences of social determinant factors among elderly according to gender, in urban and rural areas in Indonesia. Indonesia is one of the most populated countries in the world, faces an increased number of elderly. This situation leads to the increase of degenerative diseases and demands of caregivers as well. The identification of social determinant factors of elderly has an important role in enhancing primary health care. Methods: A comparative study was carried out in 33 provinces in Indonesia using secondary data from Statistics Indonesia 2013. The variables included in this study were percentage of elderly according to education, marital status, occupation, income and living arrangements, divided in gender, urban and rural areas. The normally distributed data were analyzed using unpaired T test and not normally distributed data were analyzed using Mann-Whitney test. Results: This study showed that there were differences in education, occupation and income between urban and rural areas. In urban area, most of the elderly worked in industry and trade and in rural area they worked in agricultural, indicated huge risks of occupational haxards. Most of them were poor, still married, lived with spouses and family of three generations. Conclusions: It can be concluded that there were differences of social determinant factors (education, occupation and income) in elderly who live in urban and rural areas that can contribute to the risks of disease in elderly and these situations must be considered as an input to enhance the primary health care. Keywords: Elderly, gender, rural, social determinants, urban pISSN: 2302-1381; eISSN: 2338-4506; http://doi.org/10.15850/ijihs.v7n1.1495 IJIHS. 2019;7(1):1–8 Received: December 11, 2018 Revised: January 25, 2019 Accepted: March 19, 2019 Correspondence: Sharon Gondodiputro, Department of Public Health, Faculty of Medicine, Universitas Padjadjaran Jl. Dr. Eyckman No. 38, Bandung, Indonesia e-mail: sharon_gondodiputro@yahoo.com Introduction Indonesia, which is considered as one of many countries with the biggest population in the world, faces increased of life expectancy from 70.9 years in 2015–2020 to 72 years in 2025– 2030.1 An increase of elderly population and the percentage of elderly will increase from 8.5% in 2015 to 11.8% in 2025.1 Indonesia’s success in increasing life expectancy, has many concequences, among others increase of noncommunicable diseases. The situation is worsened by the presence of multimorbidity or comorbidity.2–4 Moreover, problems faced by the elderly are not just about disease and disability, but also about social problems that can influence their health, known as the social determinants of health (SDH).5 The World Health Organization Commission on the Social Determinants of Health, defined SDH as “the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries”.6 The SDH is a complex factor consits of economic, political, social, environmental, and cultural conditions that can act as risk factors which have an impact on health.5,6 Original Article :1–8 Sharon Gondodiputro,1 Henni Djuhaeni2 1Department of Public Health, Faculty of Medicine, Universitas Padjadjaran 2Master Program of Management, Faculty of Economics and Business, Universitas Padjadjaran 2 International Journal of Integrated Health Sciences. 2019;7(1) The identification of SDH in the elderly can contribute to the development of many health preventive and promotive actions. Based on these descriptions, the aim of this study was to identify the social determinants of health of the elderly by gender, urban, and rural area. Social Determinant Factors of Elderly as an Input in Enhancing Primary Health Care in Indonesia Provinces 60–69 Years (%) 70–79 Years (%) 80+ (%) 60+(%) Aceh 3.74 1.67 0.58 5.99 North Sumatra 4.06 1.67 0.61 6.33 West Sumatra 4.99 2.36 1.06 8.41 Riau 2.98 1.09 0.38 4.46 Jambi 3.83 1.53 0.64 6.00 South Sumatra 4.16 1.75 0.70 6.6 Bengkulu 3.83 1.57 0.72 6.13 Lampung 4.53 2.10 0.87 7.5 Bangka Belitung Islands 4.04 1.63 0.66 6.32 Riau Islands 2.58 0.90 0.28 3.76 Jakarta 4.10 1.47 0.34 5.91 West Java 4.71 2.14 0.73 7.58 Central Java 6.34 3.45 1.32 11.11 Yogyakarta 6.98 4.35 1.86 13.2 East Java 6.53 3.28 1.15 10.96 Banten 3.29 1.24 0.42 4.95 Bali 6.02 2.98 1.07 10.07 West Nusa Tenggara 4.59 2.03 0.76 7.38 East Nusa Tenggara 4.44 2.12 0.85 7.4 West Borneo 4.22 1.71 0.44 6.37 Central Borneo 3.26 1.17 0.49 4.92 South Borneo 3.99 1.58 0.56 6.13 East Borneo 3.24 1.06 0.36 4.66 North Celebes 5.66 2.65 0.84 9.14 Central Celebes 4.34 2.00 0.62 6.96 South Celebes 5.14 2.53 0.88 8.54 South East Celebes 3.74 1.62 0.70 6.07 Gorontalo 4.38 1.74 0.46 6.58 West Sulawesi 3.89 1.66 0.71 6.26 Maluku 4.00 1.79 0.58 6.37 North Maluku 3.49 1.29 0.41 5.19 West Papua 2.63 0.81 0.20 3.63 Papua 1.86 0.55 0.14 2.56 Indonesia 4.91 2.31 0.83 8.05 Table 1 Percentage of Elderly Population from Total Population in Indonesia, 2012 :1–8 International Journal of Integrated Health Sciences. 2019;7(1) 3:1–8 Provinces Urban Rural Male (%) Female (%) Total (%) Male (%) Female (%) Total (%) Aceh 5.03 5.9 5.47 5.61 6.78 6.2 North Sumatra 5.61 6.73 6.17 5.72 7.26 6.49 West Sumatra 6.79 8.42 7.61 7.95 9.88 8.92 Riau 4.16 4.39 4.27 4.49 4.66 4.57 Jambi 5.8 6.13 5.96 5.89 6.14 6.01 South Sumatra 5.97 6.94 6.45 6.36 7.04 6.69 Bengkulu 5.06 5.4 5.23 6.35 6.74 6.54 Lampung 6.63 7.07 6.85 7.62 7.85 7.73 Bangka Belitung Islands 6.13 6.99 6.54 5.8 6.45 6.11 Riau Islands 3.21 3.3 3.25 6.21 6.46 6.33 Jakarta 5.66 6.17 5.91 0* 0* 0* West Java 6.52 7.26 6.89 8.46 9.42 8.94 Central Java 9.74 11.3 10.53 10.82 12.37 11.6 Yogyakarta 10.28 12.45 11.37 15.15 18.3 16.77 East Java 9.26 10.89 10.08 10.74 12.74 11.76 Banten 4.29 4.66 4.47 5.58 6.37 5.96 Bali 8.05 9.26 8.65 11.51 13.02 12.27 West Nusa Tenggara 6.92 7.4 7.17 7.38 7.69 7.54 East Nusa Tenggara 6.04 6.77 6.4 7.36 7.93 7.65 West Borneo 6.56 6.84 6.7 6.15 6.32 6.23 Central Borneo 4.65 4.73 4.69 4.95 5.14 5.04 South Borneo 5.28 6.26 5.76 5.73 7.09 6.4 East Borneo 4.54 4.4 4.47 5.1 4.82 4.97 North Celebes 7.85 9.45 8.64 8.78 10.38 9.55 Central Celebes 5.92 6.61 6.27 7.06 7.33 7.19 South Celebes 6.46 8.15 7.32 8.26 10.21 9.26 South East Celebes 4.72 5.45 5.08 6.01 6.89 6.45 Gorontalo 5.8 7.27 6.55 6.15 7.05 6.59 West Sulawesi 6.03 7.08 6.57 5.82 6.52 6.17 Maluku 5.7 6.61 6.15 6.29 6.71 6.5 North Maluku 4.61 5.13 4.87 5.36 5.26 5.31 West Papua 3.58 3.35 3.47 3.94 3.45 3.71 Papua 4.01 3.74 3.89 2.34 1.82 2.1 Indonesia 6.91 7.94 7.43 8.07 9.28 8.67 Table 2 Percentage of Elderly Population from Total Population, According to Sex and Urban/Rural Area in 33 Provinces of Indonesia, 2012 Sharon Gondodiputro, Henni Djuhaeni 4 International Journal of Integrated Health Sciences. 2019;7(1):1–8 Elderly Urban (%) Rural (%) p value Percentage of elderly 6.35 (1.90)* 6.49(0.00–16.77)** 0.172 Percentage of male elderly 5.80(3.21–10.28) 6.15(0.00–15.15) 0.147 Percentage of female elderly 6.74(2.16) 6.89(0.00–18.30) 0.308 Social Determinants of Health Urban (%) Rural (%) p value Education Never/no 13.96(9.54)* 22.86(0.00–57.90)** 0.000 Not finished elementary school 25.98(12.99–33.77) 38.35(0.00–58.57) 0.000 Elementary School 28.25(5.19) 25.66(8.24) 0.131 Yunior High School 11.41(3.73) 3.84(0.00–12.77) 0.000 Senior High School 15.30(4.82) 3.10(0.00–9.43) 0.000 Higher Education 6.39(2.37) 0.81(0.00–3.50) 0.000 Illiteracy Male Illiteracy 4.53(0.45–37.37) 19.62(0.00–60.62) 0.000 Female Illiteracy 11.98(2.82–41.90) 36.59(17.98) 0.000 Occupation Still working 36.32(4.28) 52.8(0.00–70.97) 0.000 Household 35.61(4.09) 25.52(0.00–32.17) 0.000 Agriculture 31.46(11.18) 80.32(0.00–88.86) 0.000 Industry 7.77(2.94–17.71) 4.55(2.42) 0.000 Trade 34.78(6.44) 8.64(3.17) 0.000 Services 13.62(4.48) 3.07(0.00–11.84) 0.000 Unemployed 0.23(0.00–0.71) 0.09(0.00–0.80) 0.162 Own company 34.95(6.52) 27.25(9.70) 0.000 Own company with employees 31.60(7.92) 47.29(0.00–57.74) 0.000 As employee 17.68(7.68) 4.36(0.00–14.27) 0.000 Independent worker 4.76(0.00–17.85) 4.50(0.00–20.22) 0.521 Family business, unpaid 9.66(3.80) 13.06(0.00–32.35) 0.000 Income >IDR 2,500,000 10.6(3.24–60.00) 3.70(0.00–15.82) 0.000 Table 3 Percentage of Elderly from Total Population, According to Sex and Urban/Rural Area in Indonesia 2012 Table 4 Percentage of Elderly according to Education, Literacy, Occupation, Income and Home Ownership in Urban and Rural Area, Indonesia 2012 Methods A comparative study was carried out to data of social determinants of elderly in 33 provinces of Indonesia using secondary data from Statistics Indonesia 2013. The variables included in this study were percentage of elderly according to gender, education, marital status, occupation, income and living arrangements. Normality of data was analyzed using Shapiro-Wilk test. The comparative analysis was conducted between male-female and Social Determinant Factors of Elderly as an Input in Enhancing Primary Health Care in Indonesia International Journal of Integrated Health Sciences. 2019;7(1) 5 urban-rural areas for each variable. The normally distributed data were analyzed using unpaired T test and not normally distributed data were analyzed using Mann-Whitney test. (α=0.05) Results The proportion of elderly population in the provinces of Indonesia was varied, but a large proportion live on the island of Java. This study discovered that provinces with the percentage of elderly population more than 10% were Yogyakarta, followed by Central Java, East Java and Bali (13.2%, 11:11%, 10.96% and 10.07%, respectively) (Table 1). From all provinces, the age of 60–69 years constitutes the largest proportion, moreover there were five provinces which have more than 1% of elders over 80 years old, namely West Sumatra, Yogyakarta, Central Java, East Java and Bali. The elderly who lived in rural area covered approximately 8.67% of the total population. This was higher than the elderly who lived in urban area. Statistically, there was no difference between the percentage of elderly population in urban and rural areas (p=0.172), In other provinces than the provinces already mentioned, two provinces i.e. North Celebes and South Celebes had more than 10% elderly female in rural area (Table 2). Overall, the elderly female who lived in rural area covered approximately 9.28% of the total population, higher than in urban area. This situation occured in the elderly male as well. Although, the proportion of elderly female and male were higher in rural compared to urban area, there was no statistically significant (Table 3). The level of education of the elderly population was still low. Most of them studied only up to elementary school (Table 4). Percentage of elderly population who never or did not finished elementary school was higher in rural than in urban area (p=0.000). The opportunity of the elderly to receive higher education in rural area was very low. This was proven by the very low percentage of the elderly who had higher education in rural area (0.81%) compared to 6.39% in urban area. Moreover, although the elderly had received basic education, the ability to read and write (literacy) was low, especially in rural female. (p=0.000) Almost half of the percentage of elderly population was still working, especially in the rural area. The main occupation in the rural area was agriculture (80.32%) and in urban area was household (35.61%), followed by trade and services (34.78% and 13.62%, respectively). Most of the elderly had their own company or had their own company with employee. There was still elderly who helped their family business, but unfortunately they were not paid, especially in the rural area. Indonesia has determined the Minimum Income Standard was Indonesian Rupiahs (IDR) 2,500,000 per person permonth. This study showed that percentage of elderly population who had an income of more than IDR 2,500,000 was very low, only 10.63% in urban area and 3.70% in rural area (p=0.000). Most of the elderly male was still married compared to the elderly female (p=0.000), but more than half of the elderly female was widowed (Table 5). Moreover, most of the :1–8 Social Determinants of Health Male (%) Female (%) p value Marital Status Still Married 81.72(2.84) 39.23(5.71) 0.000 Widow/widower 15.64(2.19) 56.04(5.82) 0.000 Living Arrangements Live alone 4.20(1.32) 11.52(4.70) 0.000 With spouses 20.35(5.45) 11.61(3.10) 0.000 With family member 36.37(7.35) 25.11(5.15) 0.000 With three generations 37.37(7.86) 47.39(6.56) 0.000 Table 5 Percentage of Elderly according to their Marital Status and Living Arrangements, Indonesia 2012 Sharon Gondodiputro, Henni Djuhaeni 6 International Journal of Integrated Health Sciences. 2019;7(1):1–8 elderly still lived with other family members, with 3 generations especially the elderly female. However, the percentage of elderly female who lived alone was higher than the elderly male. Discussion The percentage of elderly in Indonesia was quite high and varied from one province to another, some even exceeding 10% with the highest percentage of 60–69 years old. This situation showed that Indonesia’s population moves to aging population. In general, there was no difference in the percentage of elderly population between urban and rural area. The number of elderly population in rural area, was caused by the urbanization of young people looking for jobs outside the village and also to the big cities.7,8 A study conducted by Kreager8 showed that 46–75% of younger people in the village migrated from their village to another village or city, although this migration could be near or far. The impact of this situation is 12–37 per cent of elderly in the lower strata were currently vulnerable both physically and economically. Education is a foundation to build health literacy and at the end is one of the factors that determine health outcomes. In this study, almost more than 90% of the elderly population had low education, especially in the rural area. A study conducted discovered that participants with no educational qualifications were four times more likely to have low health literacy compared to participants with degree level qualifications (21.3% v 4.9%).9 This situation affects the complexity of decision making in all areas including health, unawareness of the need for health, does not know where to seek treatment and gap in health information, such as reading of drug prescription, how to take medicine and how to prevent diseases. Lower health literacy was associated with a higher prevalence of depressive symptoms, physical limitations, chronic diseases, higher prevalence of smoking and physical inactivity.9,10 Presumably, this occurs because of lack of access to and use of health care services, ineffective patient- provider communication, self care behaviours, and less health information seeking.9,10 This study revealed that almost half of the percentage of elderly population was still working, especially in rural areas. The main occupation in the rural area was agriculture. Elderly people who worked in agriculture area were vulnerable to a variety of disease because of heat/sunlight exposure, pesticides, traditional farm tools, musculosceletal problems, animals (snake) or insect bites. Exposure to sunlight has advantages and disadvantages. One of the advantage is metabolism of vitamin D which have an impact to bone metabolism and prevent malignancies.11,12 Long-term exposure to sunlight is known to be associated with the development of skin cancer, skin aging, immune suppression, and eye diseases such as cataracts and macular degeneration.13,14 Exposure to pesticides can cause poisoning and malignant diseases such as lymphoma.15 Furthermore, like other traditional farmers in other countries, most of the Indonesian farmers are using agricultural hand tools for cutting, digging and scrapping.16 Those mechanical hazards are the risk factors of development of musculosceletal problems because of bowing, bending at the knees, squatting or kneeling and constant hand grip.17 In accordance with economic status, this study discovered that poverty was higher in rural than in urban area. A report by Priebe and Howell stated that with increasing age, the percentage of poverty among the elders was rising.17 Aware of this fact, the government needs to develop income security programs for the elderly so that they will not depend financially on their family and can live properly. This study discovered that more elderly women were widowed compared to elderly men and lived alone. A report by Witoelar, using data from Indonesian Family Live Survey in 1993–2007, discovered that elderly men who lived with an adult child was as much as 68.7% in 1993 and decreased slightly to 65.1%, whereas the elderly women was 75.2% in 1993 and decreased to 63.8%.18 Furthermore, the elderly man who lived alone was of 0.4% in 1993 to 2.5% in 2007, whereas the elderly women was 3% in 1993 to 11.1% in 2007.18 The change of living arrangement can cause the need of caregiver. Caregiver is the person who supports and assists disabled person or provides care for elders.19 The study had limitations since the secondary data did not provide all components of the social determinants of health such as availibility and accessibility to health care services, local culture that can affect the health outcomes, cognitive impairment status and living conditions which can be a source of hazard. Although most of the elderly lived with their family, the secondary data could not identify whether the family member stayed almost all day with the elderly or worked the Social Determinant Factors of Elderly as an Input in Enhancing Primary Health Care in Indonesia International Journal of Integrated Health Sciences. 2019;7(1) 7 whole/part of the day. The provided data could not identify who was the caregiver for the elderly as well. It can be concluded that the Indonesian population moves to aging population with varied percentage across provinces. Most of the elderly have low education and income especially in the rural area. There were various occupational hazards among elderly population according to their occupation that could contribute to the emergence of occupational disorders. This situation has to be a concern for primary health care providers. Most of the elderly had low economic status which led to the need for financial support either from members of their family or from the government to develop an income security plan. Moreover, if needed, their spouses or other family members could be their caregivers. References 1. Statistics Indonesia. Population projection 2010–2035. Jakarta: Statistics Indonesia; 2013. 2. Wang HH, Wang JJ, Wong SYS, Wong MCS, Li FJ, Wang PK et al. Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in Southern China. BMC Med. 2014;12(188):1–12. 3. 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