Family Role in Decision Making of Health Seeking Behavior on Elderly in Tabanan Regency, Bali, Indonesia

Most countries in the world experienced a demographic transition which is a decrease in the birth rate and death rate. In addition, important changes also occurred in the age composition of the population [1]. As well as an increase in the economic level also increasing human life expectancy. This resulted in an increase in the number of elderly from year to year [2]. It predicted in 2050 the proportion of the elderly population (> 60 years) globally will increase to 100% [3].

Asian is a continent that has a large number of elderly. Half of the world's elderly population is in Asia. Indonesia is one of Asia which today received the title as the state structure of old age [2]. Indonesia is stated as country with old age structure because the proportion of the elderly have reached above 7%.

Results of a national health survey conducted in 2013 indicated an increase in the elderly population in Indonesia. 8.05% of the total population of Indonesia, or about 20.4 million people are classified as elderly. The province with the highest proportion of elderly people in Indonesia is DI. Yogyakarta is 13:20%, followed by Central Java (11.11%), East Java (10.96%) and Bali 10.07% [4].

At the time of the elderly person will tend to experience a variety of health problems due to decreased function of organs, one of is the disability. Disability that occurs in an elderly person is associated to the age, whereas the higher the age, the risk of disability is also higher [5]. Moreover, a study conducted by Lyons and Levine in the United States that the increasing age, the report on chronic diseases is also increasing and is higher in women than men [6].

In addition the physical decline and disability, mental disorders and neurological disorders are also at risk for the elderly such as dementia or depression as public health problem [7]. It shows that elderly have become as one of the vulnerable groups in society due to various physical and mental risks that it faces [8].

There are many elderly people who are able to live productively in life, however due to aging will face various limitations. The elderly tend to lose their ability to live independently due to mobility limitations, the physical and mental weakening [9]. Decline in the quality of physical and mental of the elderly it resulted the elderly need families assistance in a variety of activities (Nair [10]).

Based on the Universal Declaration of Human Rights, art. 16.3, family is the fundamental group unit and natural in the community, therefore its families right to get protection from the community and the country [11]. Family is important to someone especially if the person has entered the elderly. Family is a very important supporter in the elderly life especially in the developing countries [12,13].

Caring the elderly member of the families is constitute and an important thing for them [14]. Various support can be given to elderly people as support in economic terms (provision of funds), provision of food, up to in terms of costs and health care [13].

Many studies have been conducted concerning the elderly. However, these studies mostly about physical condition, or mental health of the elderly. Research that focuses on the role of the family in the elderly, especially in terms of decision-making related to health seeking behavior is rare.

In fact, the role of the family for elderly in Indonesia is very important. The family acts as a support system that is the most important for parents in Indonesia. Elderly tend to stay with children and other family members [15].

This is also supported by statistical data in 2013 that showed the elderly in Indonesia mostly stayed with a family of three generations or so-called extended family. Therefore, it is important to see the picture of the family's role in decision making related health seeking behavior in the elderly.

The cross sectional study was carried out in the region of Tabanan. The population of this research is all elderly in Community Health Center Kediri 1, Tabanan. A systematic random sampling with a sample size of 153 samples was used. The age of respondents ranges from 60-80 years old. Questionnaires were used to collect data.

Respondent were asked to fill out the informed consent from prior to complete the questionnaires. In a case where the respondents were illiterate, the family members’ concerned consent will be asked. Before the study conducted it ask for ethical clearance. Ethical clearance got from Udayana University.

Characteristics of respondents

The characteristics of the elderly can be seen from the age, sex, education level, and the work. Based on Table 1 it can be seen that 50.33% was in the age group 60-69 years. 50.98% was elderly women and this percentage is higher than the elderly male, which only reached 49.02%.

Table 1: Characteristics of respondents based on age, gender, education, and employment.

This is because life expectancy is higher in women than men [2,16]. Beard et al in Suyasa et.al (2014) mentioned that since two decades the proportion of elderly women are larger than males had been a debate as close to the physical decline and various loads that will be experienced by men. Therefore, it is important to give more attention in health of men [17].

The majority of level of elderly education was elementary around 39.2%. Then followed by elderly literacy was 22.88%. It shows the level of education of respondents was low.

The study conducted by Ramlah (2011) states that many elderly people are still less educated that are only finished elementary school. The level of education of the elderly will primarily affect to the health maintenance [18].

55.56% of respondents admitted that they had unworked. This is because increasing age of the elderly will be weakened or declining physical endurance [19]. However, not all elderly have a lower productivity even though they are often considered unproductive in everyday life [19]. It found that 44.44% of respondents was working mainly by themselves that was equal to 20.92%.

According to research conducted by Handayani dan Wahyuni mentioned that the reason of elderly who work as laborers and in the farming because the elderly like to live independently and do not depend on his family [20]. Those type of elderly are commonly found in developing countries who do not have social insurances [2].

Role of family in relation to health care decision making

There is no standard definition for age limit of the elderly, however, most developed countries use the age of 65 years old to define it. In this particular study, the age of 60 years old and above are used to define the elderly. It is in accordance with the cut-off approved by the UN [21,22].

Increased life expectancy supported by the improvement of health care quality and social conditions has brought Indonesia into a country of old age structure. The proportion of elderly people in Indonesia which is above 7% of the total population shows that Indonesia is among the older age structure countries where provinces in Java and Bali are proved to have the older age structure [4].

The increasing of age in the elderly is certainly brings an impact on physiological functions. Degenerative disease in the elderly appears due to the aging process in the body. Besides, they are also susceptible to infectious diseases which are caused by low physical conditions or endurance [2]. A drop off of their physical conditions and lower productivity compared to the productive age naturally led to the assumption that the elderly are considered as a burden [19]. Moreover, a decrease in physical quality experienced by the elderly make them need assistance from their families in a variety of activities as mentioned by Nair [10].

For an elderly, family is crucial because the family is the sponsor in maintaining the health of the elderly [8]. The family itself is formed naturally in the community and become fundamental. The definition is based on the Universal Declaration of Human Rights, art. 16.3 [11]. There are some roles played by family in taking care of the elderly, such as maintaining mental status, anticipating changes in both economic and social and motivation [23].

A study conducted by Sutikno et al. showed that there is a correlation between the growing of age and the decline in life quality of the elderly. This relationship proved to be noteworthy. Therefore, the role of the family is salient to improve the life quality of the elderly in their old age. Besides, the results of these studies also showed a strong relationship and statistically significant correlation between roles/ support from family to the life quality of the elderly [24].

This research found that most respondents (96.08%) live with both large family and nuclear family, while the rest are either living alone or with their husbands. It is certainly in line with the BPS Susenas Kor BPS (2013) which states that the majority of elderly people in Indonesia are living with extended family and the nuclear family. This condition is likely because many elderly people do not work.

Thus, they need the help from their family. In addition, due to the weakening of the body or mental condition, the elderly need to be supported by the younger generation [19]. It can be seen from this study where 69.28% of respondents said that the family is the first place they consult about their condition. It also shows that the family plays an important role in improving the quality of life as well as the health status of the elderly [22,25].

A decline in cognitive, memory, and intellectual ability in the elderly results in the difficulties of interacting with others. There is also a tendency of difficulties in responding to the stimulus given to him that may lead to a unconnected responses/reactions a given stimulus [23]. In addition, the decline in the condition experienced by the elderly also resulted in the decline of the degree of their independence [26].

These are the possible reasons why the elderly handing over the responsibility to the children or his successors, including also in terms of decision-making related to health services they will receive.

It can be seen from the results of studies where 81.05% of respondents said that the family is the decision maker or having a share of kind of health services received. Most of the elderly also are not the decision maker in health care costs. Family, especially by children, has taken most of the decision which amounted to 56.21%. This can be seen in the Table 2.

Table 2: Role of family in relation to health care and health cost decision for the elderly

Determinants of kinds of health services based on job status of the elderly

Weakening physical condition accompanied by a decrease in productivity of the elderly would make them difficult to work, although it is not experienced by all the elderly [19]. Therefore, the results of this study indicated that most of the elderly do not work (55.56%). It is also in line with the statement of Wijayanti which states that due to the weakened physical or retirement, the elderly tend to stop working.

Nevertheless elderly in Indonesia is considered as the person who should be respected and occupy high social class Yag [19,26].

Indonesia as one of the countries that uphold social norms so that elderly people in Indonesia earn dependents as well as the affection of the family, in this case, especially their children (Yasa [26]).

Therefore, this study is meant to see how the role of family in decision-making related to health care services, especially the health services the elderly received. This study also wanted to prove whether or not there is a share of the family in the decision-making related to the employment status of the elderly. The results of the analysis of the relationship can be seen in Table 3.

Table 3: Determinants of kinds of health services based on job status of
the elderly.

Table 3 above shows that from the 85 respondents who did not work, there are 70 respondents (82.35%) whose health care is determined by the family. While for the respondents who are still working, there are 54 people whose health care is determined by the family.

As for PR generated at the ratio of 1:03, which means the ratio of proportion of health services determined by family for the elderly who do not worked was 1:03 times higher than those who still work. However, when it is seen from the p-value which is more than α and 95% CI that passes through 1, then these results were not statistically significant.

The absence of a significant relationship between work status and whether or not there is the family contribution as a determinant of the type of health care received by the elderly may be because the type of services is largely determined by families, both for those who work and not. In addition, when it is viewed from the level of education of the elderly which are mostly low educated and lack of the knowledge they have, this condition will likely require the elderly to seek for assistance from their family to make a decision regarding their health. This is because there is a positive correlation between a person's level of education and knowledge about the health as well as the analytical ability [27].

Decision-making related to health care of the elderly are largely determined by their families both for the elderly who have not and do not work is likely due to the local culture. Indonesia is one of Asian country where it is well known that Asia is very strong with kinship system. The family has an important role in making a decision, one of which related to the choice of health care [28].

This culture is also applied to the elderly who tend to depend on the family, especially their children. The elderly, especially women, are more dependent on their children in terms of health care [29]. Moreover, due to the physical limitations, the elderly especially in Asia who live alone needs assistance from family or others to carry out their daily activities (IFA/, Far, Lat [30,31]).

Elderly have become part of the vulnerable groups within the society due to various physical and mental risks that they encounter [8]. One of the risks that often threaten the elderly with increasing age is dementia that cause the elderly to depend on others [32,33]. This is due to a decline in various cognitive functions of the elderly. A study conducted by Jennifer Moye and Daniel C. Marson reveals that there is a disruption in the ability to make consent of a patient suffering from dementia [34].

The family has an important role to the make the decisions related to health care received by the elderly. So it is advisable to health workers in this particular clinic to provide counseling and education to the families of the elderly regarding the health of the elderly. It is expected that by educating the families of elderly, the family can decide appropriate health care for them.

Thanks to the Community Health Center Kediri I and all those who have helped in completing this study.