Understanding the inter-linkages between Economic Status and Subjective Health among Indian Elderly By Sanjay Kumar, Ph.D National Programme Officer (M&E), UNFPA – India 12th Global Conference on Ageing, June 10 - 13, 2014, HICC, Hyderabad, India

Outline of the presentation: Demographic Change and Population Ageing in India Beliefs about Indian Elderly Data and Methods The connection between subjective and psychological health of the elderly with their economic status Major conclusions of the Study

Demographic Changes and Population Ageing in India India has 104 million elderly population, consisting of 8.6 per cent of the total population By the year 2050, it is likely to increase by three times, around 300 million, accounting for 20 per cent of the total population Changing Size of Young and Old Population and Age Dependency in India

Well-known Beliefs about Elderly in India Indian elderly are generally considered happy as they live their children and within the family environment There has been several attempt to measure happiness around the world The studies show that happiness does not necessarily have a connection with economic status The most happier countries are not the economically advanced ones The present study examines the subjective well being of the elderly reflecting their mental status in India and its relationship with economic factors

Data and Method The data is drawn from BKPAI Survey conducted among elderly in 2011 in selected states A total of 9852 elderly from 8329 households were interviewed from seven states which have higher proportion of elderly population Gujarat Jharkhand Manipur Jammu & Kashmir Andaman & Nicobar Islands Goa Andhra Pradesh Himachal Pradesh Karnataka Chhattisgarh Assam Arunachal Pradesh Bihar Haryana Sikkim Uttarakhand Tamil Nadu Odisha Meghalaya Tripura Madhya Pradesh Nagaland Maharashtra Uttar Pradesh Rajasthan NCT of Delhi Punjab Kerala Lakshadweep West Bengal Mizoram Bi-variate and Multivariate Statistical Analyses were conducted to examine inter-linkages between subjective health status and socio-economic factors

Measures Used Self Rated Health – rating by the elderly themselves Self-rating of health is mainly influenced by physical health conditions like chronic diseases, functional disability, sensory performance, the number of sick days etc. Subjective Well-Being (Mental Health) The assessment of mental health can be done with more objectivity due to the methodology available Several efforts are made to quantify subjective well-being through various instruments. This study explored two such well known instruments: General Health Questionnaire (GHQ) Subjective Well-being Inventory (SUBI)

Self-rated Health by the Elderly The self-rated health is assessed in three ways: Current Health Status excellent, very good, good, fair, poor Health in comparison to the previous year better, same, worse Health in comparison to peers

Self Rated Health by the Elderly Self Rated Measures Men Women Total Current health Excellent 2.9 1.7 2.2 Very good 14.3 10.9 12.5 Good 30.6 28.9 29.7 Fair 37.0 37.2 37.1 Poor 15.1 21.1 18.3 Compared to 1 year earlier Better 8.5 6.4 7.4 Same 58.7 54.5 56.5 Worse 31.0 35.9 33.6 Compared to peers 18.8 14.4 16.5 50.7 47.4 49.0 25.8 31.6 28.8 Number of elderly 4,672 5,180 9,852

General Health Questionnaire (GHQ-12) GHQ is an instrument for screening psychological distress The scale asks whether the respondent has experienced a particular symptom or behaviour recently Each item is rated on a four point scale less than usual, no more than usual, rather more than usual, or much more than usual The survey used GHQ-12 , the scoring is based on the Likert scale, ranging from 0 - 36 [Scale reliability coefficient: 0.90] The accepted threshold is 12. Mean GHQ score was computed A higher score indicates a greater degree of psychological distress

Subjective Well-being Inventory (SUBI) SUBI is another instrument used for measuring mental health The SUBI is designed to measure “feelings of well-being or ill-being as experienced by an individual or a group of individuals in various day-to-day life concerns” It evaluates one’s life in terms of overall life satisfaction as well as one’s experience of pleasant and unpleasant emotions 9 questions in SUBI measure feelings of well-being through a scale ranging from one to three [Scale reliability coefficient: 0.89] The total score ranges from 9 to 27 with lower scores indicating greater well-being

Levels of Subjective Well-being Scores Among Elderly GHQ and SUBI Mental Health Measures Men Women Rural Urban Total GHQ-12 (Score 0-36) % of elderly reported scores <= 12 56.4 47.6 49.4 58.1 51.7 Mean score 13.1 14.6 14.1 13.3 13.9 Number of elderly 4655 5145 5109 4691 9800 Subjective Well-being Inventory (SUBI) (Score 9-27) 18.5 19.4 19.2 18.6 19.0 4541 5033 4977 4597 9574 With mean score around 14 and 52% of the elderly having below the threshold level in GHQ, indicates a good mental health status for the half of elderly population. The other half requires further investigation for psychological distress Men and urban elderly seem to be faring better in mental health compared to their counterparts SUBI with mean score of 19, higher among women and rural elderly, indicating relatively poor mental well-being among them

Self-Rated Health Status and Subjective Well-being The mean scores of both GHQ and SUBI increases with deteriorating self rated health The results indicate a strong positive relationship between physical and mental health

Subjective Well-being by Age and Sex Age is an important factor determining mental health status, GHQ and SUBI mean scores are higher for higher ages Male elderly have marginally better mental health than women

Subjective Well-being by Wealth Index and Education Mean GHQ and SUBI scores decreases with higher wealth quintiles and educational status, indicating better mental health among well off elderly

Subjective Well-being by Marital Status and Living Arrangements Currently married elderly and those living with spouse have better mental health status

Subjective Well-being by Work Status and Place of Residence Elderly working by choice have better mental health status as compared to not working at all. Urban elderly have slightly higher mental health compared to their rural counterparts

Multivariate Analysis Dependent variables Mean GHQ scores Mean SUBI scores Independent variables Age Sex Marital status Education Religion Caste Employment Living arrangements Wealth Index (based on 30 assets and housing characteristics)

Association between Subjective Well-being Economic Status – Regression Analysis   GHQ SUBI  Background variables Beta coefficient Sig. Age 60-69 (Ref) 70-79 1.14 0.000 0.51 80+ 2.38 1.09 Sex Male (Ref) Female -0.13 0.394 0.05 0.566 Marital status Currently married (Ref) Widowed 0.56 0.001 0.36 Others -0.35 0.388 0.42 0.074 Education No formal education (Ref) <5 yrs -1.03 -0.55 5-7 yrs -1.07 -0.73 8+ yrs -2.14 -1.36 Religion Hindu (Ref) Muslim 0.37 0.109 0.34 0.013 Sikh -2.82 -0.75 -1.10 -1.13 Caste Others (Ref) SC/STs 0.25 0.140 0.10 0.297 OBC 0.88 -0.09 0.301 Coefficients with negative value indicate better mental health status. Increasing age is negatively associated with GHQ and SUBI Sex of the elderly does not show a significant impact on their mental health Widowed and less educated categories of the elderly had significantly higher levels of distress

Association between Subjective Well-being Economic Status – Regression Analysis   GHQ SUBI  Background variables Beta coefficient Sig. Employment Not working (Ref) Working by choice -2.57 0.000 -1.21 Working for economic need or compulsion -0.96 -0.03 0.776 Wealth index Lowest (Ref) Second lowest -1.56 -0.90 Middle -2.58 -1.77 Second Highest -3.59 -2.47 Highest -4.44 -3.76 Living arrangements Living alone (Ref) Living with spouse -0.97 0.003 -0.23 0.227 Living with others -0.28 0.301 0.13 0.409 Residence Rural (Ref) Urban 0.18 0.180 0.47 R squared 0.1718(N=9792) 0.2121(N=9566) Living with spouse has significant better effect on their mental health, but this is true only for GHQ and not for SUBI Elderly working by choice had significantly better off in terms of their mental health Economic status has significant impact on the well being of the elderly. The subjective well being significantly improves with each higher wealth quintile

Conclusions Both the measures of mental health indicate high positive relationship with work status (working by choice) The elderly living in households in higher wealth quintile have better subjective health The role of economic factors are found to be true event controlling for other socio-demographic variables Thus the assumption that merely living with children and in a family environment is not entirely true in the Indian context This has profound implications for the economic security of the elderly

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