Southern Demographic Association

A Comparative Study of Successful Aging in Three Asian Countries

Author(s): Vicki L. Lamb and George C. Myers
Reviewed work(s):
Source: Population Research and Policy Review, Vol. 18, No. 5 (Oct., 1999), pp. 433-449
Published by: Springer in cooperation with the Southern Demographic Association
Stable URL: http://www.jstor.org/stable/40230242 .
Accessed: 15/02/2012 06:01

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .
http://www.jstor.org/page/info/about/policies/terms.jsp

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of
content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms
of scholarship. For more information about JSTOR, please contact support@jstor.org.

Springer and Southern Demographic Association are collaborating with JSTOR to digitize, preserve and
extend access to Population Research and Policy Review.

http://www.jstor.org
 andPolicyReview18: 433-449,1999.
Research
^L Population 433
yR © 1999KluwerAcademic Printed
Publishers. intheNetherlands.

A comparativestudyofsuccessfulagingin threeAsian countries

VICKI L. LAMB & GEORGE C. MYERS

Center DukeUniversity,
Studies,
forDemographic North
Durham, USA
Carolina,

Abstract.Thepurpose istoexamine
ofthisresearch aginginthree
successful Asiancountries,
SriLankaandThailand,
Indonesia, usingdatafrom theWHOregional studiesofHealthand
SocialAspectsofAging.Successful agingis definedas having no ADL difficulties,
andat
most,oneNagidifficulty. Forthemostpart,theresults aresimilar tothoseusingmorede-
velopedpopulationsinthatgender,age,nomorbid conditions, attitude
positive towardone's
ownagingandtheability tomanage money areallcorrelatedwithsuccessfulaging.Aninter-
esting is thatfortheleastdeveloped
finding country,Indonesia,beingan unskilledworkeris
associated
significantly withincreased
oddsforsuccessful aging.Thefinalsectionofthepaper
discusses
thetheoreticalimplications
regardinga disability
transition
forelderlypopulations
develop.Wealsofocuson thecurrent
as countries andeconomic
political inthe
situations
under
countries study,andconsiderthepossibleimpactsonelderly health.

Keywords: Successful
transition,
Disability aging, SriLanka,Thailand
Indonesia,

Introduction

Therehas been growingresearchattention beingdirectedto theidentific-

ationof so-called'successful'agingpersonswithinolderpopulationsand
thefactorsthatmaybe associatedwiththemaintenance of highlevelsof
functioning (Rowe & Kahn 1987, 1998). The MacArthur FoundationRe-
searchNetworkon SuccessfulAginghas been particularly responsiblefor
thisresearch focus.Buildingon theEstablished Populations fortheEpidemi-
ologicalStudiesof theElderly(EPESE) community studies,theMacArthur
group has conducted researchon high-functioning personsin threeof the
EPESE sitesintheUnitedStates(see Berkman etal. 1993).Thisresearch has
intentionallyemphasizedstudy of the of
highrange functioning, in contrast
tothestudyofthoseolderpersonsafflicted withchronicdiseases,disabilities
andotherdeficitsoftenassociatedwith'normal'aging.
Relativelylittlesystematicattention,however,has been givento stud-
ies of highfunctioning in
subpopulations developingcountries.Although
longevouspopulation groupshavesometime beenidentified (e.g.,Abkhazia,
Georgia;Vilcbamba,Ecuador)rigorous assessments of thevalidityof the
extreme longevityof thesegroupshavegenerally providedlittlesupportfor
434 VICKIL. LAMB& GEORGEC. MYERS

such claims. But longevityis onlyone aspect of a humanlife,and itgiveslittle

acknowledgmentto the quality of life and the relativewell-beingof persons
as theyage.
A recentinitiativelaunched by the World Health Organization(WHO),
entitledThe Determinantsof HealthyAging Project,is designed to increase
our knowledgeof thefactorsthatcontributeto successfulfunctioning in older
individuals(Myers 1993). The projectinvolvescoordinatedand comprehen-
sive longitudinalstudiesof persons60 yearsof age and overin two developed
and fivedevelopingnations.The HealthyAging Projecthas benefitedgreatly
froma series of earlierWHO regionalstudiesthatwere undertakenin 13 de-
veloping countriesof Asia and thePacific,the Middle East and NorthAfrica
between 1984 and 1990 (Andrews 1993, 1992; Andrews et al. 1986). Data
fromthe WHO regional studies conductedin threeof the Asian countries-
Indonesia, Sri Lanka and Thailand - are used in the analysis of well-being
and functioningreportedin this paper. The purpose of this research is to
use multivariatetechniquesto analyze the factorsassociated withsuccessful
aging.
There are some compellingreasons forsuggestingthatthe overall distri-
butionsof older persons in developingcountrieswill show quite substantial
proportionsof older individuals who functionat relativelyhigh levels, in
spiteof obviously lower levels of life expectancyand generallyhigherlevels
of morbiditycompared to more developed countries.Such reasons include
the following:One, the populations at older ages are selective in the sense
thattheyare persons who have survivedmany threatsto healthexperiences
at earlierages, and perhaps,representgeneticallymore endowed subgroups
(Chen & Jones 1989; Riley 1990). Two, high case-fatalityrates (in partdue
to poor health services) ensure that persons with diseases and disabilities
progressto death very rapidly (Myers & Lamb 1993). Three, to the extent
thatstrongsocial networks,social integrationand greatersocial esteem for
older personsfromcognitive,emotionaland
the aged play a role in buffering
physical declines, persons developingcountriesshould be favored(Cow-
in
gill 1986). Four, it is suggested that the physically productivework roles
experiencedby many older persons in developing countriesmay contribute
to greaterphysical fitnessand vitality(Tout 1989). Finally,risk factorsfor
certainchronicdiseases (e.g., smoking,alcohol use, and fattydiet) may be
less prevalentin developingcountries.
It should be emphasized thatwe are not suggestingthatthe reduced ma-
terialand healthresourcesavailable to older persons in developingcountries
do not contributeto conditions deleterious to well-being, but ratherthat
relative deprivationmay not be perceived as fully in such environments.
Moreover, thereis no gainsayingthat socioeconomic distributionsmay be
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 435

highlyskewedin developingcountries, withlargeproportions of people

foundintheeconomically disadvantaged underclass.
Whilethisanalysis,focussingon developingcountries, cannotoffera
rigoroustestof thesepropositionsin theabsence of comparabledataforde-
veloped it
countries, does offerthe of
possibility examining variationsamong
countriesthatare at differentlevelsof development themselves. Previous
researchbased on data fromfourof theearlierstudiesof countriesin the
Western Pacificregionfoundconsiderable variationin patterns
ofmorbidity
(Manton,Myers& Andrews1987). Nonetheless,
and disability as notedin
thatresearch,"some of thebasic age, sex morbidity and disabilityassoci-
ationsfoundinthefourdeveloping countrieshavesimilarcounterparts in the
elderlypopulationin a moredevelopedcountry liketheU.S." (1987: 128).

Data

The data forthisstudyare drawnfroma component of theWorldHealth

Organization's (WHO) Health and Social Aspects Agingproject.The
of
countriestobe studiedinthisresearch arefromtheSouthEastAsianRegional
Officeproject(SEARO: Indonesia,SriLankaandThailand).The WHO pro-
jects wereconductedundertheauspicesof theCentreforAgeingStudies,
FlindersUniversity of SouthAustralia,underthedirection of Dr GaryR.
Andrews. Individual leveldatawerecollectedfromnon-institutionalized per-
sonsaged sixtyyearsand olderin 1990.The WHO regionaldata setshave
been used fora largercomparative studyof depressionamongtheelderly
(Mackinnon et al. 1998),as wellas a cross-nationalexamination ofpatterns
ofelderlyfunctional andemotional disablement (Lamb 1996).Thesedataare
nowavailablethrough ICPSR.
Each WHO country-level projecthad a principalinvestigator or project
directorfroma researchinstitution or organizationwithinthecountry. This
personwasresponsible fortheconstruction andimplementation oftheappro-
priatesampling techniques andtheselectionandtraining ofinterviewers.The
interviewerswerenativeswhospokethelanguagesand/or dialectsthatwere
necessaryforaccuratedata collection.Manyinterviewers werehealthcare
suchas community
professionals, nursesandhealthcareworkers, orpersons
whohad previously participated in healthsurveys.Detailedinstructions for
theprojectdirectors andtheinterviewers wereestablished bytheCentrefor
AgeingStudiesto ensurebettercomparability of thedata collected.After
theinterviewswerecompletedandtheresponsestranslated intoEnglish,the
responsebooklets were sentto theCentre for Ageing Studiesin Australia,to
be uniformlycodedintomachine-readable datasets.
436 VICKIL. LAMB& GEORGEC. MYERS

A majoradvantageof thesedatais thatstandardized

interview
schedules
wereusedthroughout. weretranslated
The questionnaires intothenativelan-
guages,and thenback-translated
to checkforconsistency in meaningand
content.

Sampling.In all of the researchprojects,sampledesignwas intendedto

represent thepopulationdistribution of theelderlyin termsof sex,urban-
ruralresidenceandmajorethnicgroups.Efforts weremadetoage-stratify the
elderlypopulation toensureadequatenumbers ofrespondents intheolderage
groups.Within-country logisticalconsiderationsandpopulation distributions
oftheelderlyaffect therepresentativeness ofthecountry-level samples.
Indonesiais composedof morethan13,000islandsand is theworld's
fifth mostpopulouscountry, withthemajority ofelderlylivingin the"inner
Indonesian" Java
area,including (Hugo 1992). Previous studiesofIndonesian
elderlyhave been based on surveys from theJava region(Chen& Jones1989;
Evans 1985; Rudkin1993, 1994). The WHO Indonesiandataforthisstudy
weredrawnfromtheCentralJavaprovince,whichat thetimehad a pop-
ulationof 29 millionpersons.Districtswereselectedfromurbanand rural
areas.Stratifiedrandomsamplesweredrawnfromofficialvillageregisters.
Tenpeoplecouldnotbe contacted duringtheinterview periodandsubstitute
respondents were obtained. The response ratewas 100 percent.
In SriLanka,a three-stage samplingprocedure was usedin threedistricts
oftheWestern Province:Colombo,KalutanandGampaha.It is probablethat
theongoingcivil war in Sri Lanka (Singer1996) limitedtheopportunity
to conductinterviews in theNorthand East regions,homeof theTamils.
Thus,theSri Lankandatarepresent olderadultsin thepredominantly Sin-
haleseareas.Censusdatawereusedto identify 10 urbanandruraldistricts.
Clusterswererandomly selectedfromelectionwardsin urbandistricts and
fromGramaSevakadivisionsintheruralareas.Theelectoralregisters served
as thesamplingframefortherandomselectionofpersonstobe interviewed.
Therefusalratewas less than1 percent.
The Thai samplewas designedto be representative of theentirecountry,
thus,Bangkokandfourgeographical regionsweresampled.Foreachregion,
one municipalarea and threeprovinceswererandomlyselected,and then
andvillageswereselected.In Bangkok,threedistricts
districts andtwosub-
wererandomly
districts chosen.Interview subjectsweredrawnfromofficial
population Onlyone personrefusedtobe interviewed.
registers.
For all of theWHO surveys,data werecollectedthrough personalin-
terviewswiththeelderlysubjects,and whenpossible,withan informant
who livedwiththerespondent. The totalnumberof personssampledwere:
Indonesia,1202; SriLanka,1200;Thailand,1199.Sampleweightswerees-
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 437

tablishedforthedata,basedon aggregate age/sexdistributionsoftheelderly

populations foreach The
country. weighted data are used in themultivari-
ate analyses.However,theresultsare quite similarto analysesusingthe
unweighted data.
Table 1 presentsa numberof demographic indicatorsforthecountries
understudy.The data indicatethatIndonesiais theleast developedwhen
comparedwithSriLankaandThailand.The Indonesianinfant rate
mortality
is muchhigherthanthatof theothertwo countries, and theaveragelife
expectancy forIndonesiais approximately60 years.Lifetableestimatesalso
indicatethata smallerproportion of personsare expectedto surviveto age
65 yearsinIndonesia,as comparedwithSriLankaandThailand.Indonesia's
lowerprobability of survivingto age 65 indicatesthatgreaterselective
survivalis occurring.Giventhesedifferences,theprofileofsuccessfulaging
inIndonesiamaybe different whencomparedwithSriLankaandThailand.

Table1. Selectedaggregateindicators
ofhealthdevelopment circa 1990
bycountry,

Infant Crude Life expectancy Percentof persons Percentof persons

mortality death at birth aged 60 yearand to age 65
surviving
rate rate M F olderthatare M F
economicallyactive
~M F

Indonesia 74 9 57.6 61.8 66 34 60.6 68.5

Thailand 39 7 65.3 70.1 56 32 73.3 79.1
Sri Lanka 33 6 68.1 73.2 52 13 75.7 85.1

M = males;F = females.
Sources:UNICEF 1991; UnitedNations1988; US Department
ofCommerce1991.

Measures

The construction of the successfulaging indicatoris informedby the

MacArthur (Berkman etal. 1993)andotherstudiesof successful aging(e.g.,
Strawbridge et al. 1993; Guralnik& Kaplan 1989),and is based uponself-
reportfunctional assessments. The criterionfor'high' successfulagingis:
(1) reportingno difficultieswithanyof sevenKatzADL items(walk,bathe,
groom,dress,eat,transfer andtoilet)and(2) reporting,
atmost,onedifficulty
withthefiveitemsof theNagi scale of physicalstrength (pulling/pushing,
stooping,lifting,reaching, andhandlingsmallobjects).Table2 presents the
weighted variablepercentage ormeanscores,foreachcountry
distributions,
understudy.Indonesiahas thegreatest proportion of highsuccessfulagers,
438 VICKIL. LAMB& GEORGEC. MYERS

(or meanscore)forvariablesbycountry
Table2. Percentagedistribution

Indonesia Thailand Sri Lanka

Successfulagers 79.8 74.4 46.6

Males 45.1 45.4 51.0

Age groups
60-64 33.3 37.0 35.3
65-69 25.7 25.8 25.8
70+ 41.0 37.2 38.9

Morbidconditions
0 30.8 20.8 36.5
1 41.4 34.0 33.4
2+ 27.9 45.3 30.1

Attitude
aging(mean) 2.6 1.8 2.0

Managesmoney 88.5 85.4 69.0

Unskilledworkers 72.6 62.0 66.7

One generation
household 25.5 12.7 13.8

Source:WeightedSEARO datafiles.

80 percent,followedby Thailand with74 percent.The Sri Lankan sample has

thelowest proportionof successfulagers,less than50 percent.

Demographicfactors. There are a numberof possible domains of determin-

ants of successful aging. Gender and age are importantdemographicfactors
associated with successful aging. It is expected that males will have the
advantage. Additionally,the youngerage groups are most likely to be the
successful agers. Because of potentialproblems associated with age mis-
reporting,especially with data gatheredin developing countries,age group
intervalsare used to measure age.

Assessmentsof health. A person's state of health has been found to be an

importantconsiderationin the determinationof successfulaging. Under the
domain of health,we consider a numberof variables. Research in the USA
has indicateda strongassociation betweenthe numberof morbidconditions
withfunctionalabilities(Verbrugge,Gates & Ike 1991;
and havingdifficulties
Satariano,Ragheb Dupuis 1989; Verbrugge,Lepkowski & Imanaka 1989).
&
The findingsof Verbruggeet al. (1991) and others (Satariano, Ragheb &
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 439

Dupuis 1989) have concluded that a simple count of morbid conditionsis

sufficientforthe studyof functioning.
The respondentswere probed regardingwhetherthey had experienced
sixteenseparatemorbidconditionswithinthe past twelve months.The con-
ditionsincluded chronicconditionsas well as impairmentssuch as falls and
brokenbones. A categoricalvariablewas constructed,whichis a simplecount
of the self-reportedmorbid conditions.The elderly in Thailand reporteda
higherprevalence of morbid conditions,as compared with the samples in
Indonesia and Sri Lanka.
Besides thephysical healthof the respondent,successfulaging also may
be influencedby morale or a sense of general well-being.The revised Phil-
adelphia GeriatricCenter morale scale (Lawton 1975) is composed of a
numberof underlyingfactors,one of which,attitudetowardone's own aging,
is used in this study.The 'attitudetowardone's own aging' factor,which is
based upon fiveitems,taps views associated withaging, such as 'life keeps
gettingworse as you get older'. For thisfactor,the scores rangefromzero to
five,withhigh scores indicatinghigh levels of morale. Table 2 presentsthe
mean score by country.The elderlyin Indonesia have slightlyhigheraverage
morale scores as comparedwiththeothertwo countriesunderstudy.
An instrumental activityof daily living,theself-reportedabilityto manage
money,is includedas an indirectmeasureof cognitiveability.High cognitive
functioningis used in the MacArthurproject as partof the measurementof
successfulaging. There is a problemof bias, however,whenusing traditional
Westernmeasuresof cognitiveability(e.g., knows year,month,date,etc.) on
elderlypopulationsin the developing world. Of course, we understandthat
managingmoneycan be a gender-related activity,and thussubject to bias as
well. Nonetheless,a large proportionof all of the samples reportthatthey
have no difficulty managingmoney.

Life's work.A strongpredictorof healthand longevityin theUSA and other

developed countriesis higherSES, as measured by occupation and/oredu-
cation (e.g., Preston & Elo 1995; Preston & Taubman 1994; Guralnik et
al. 1993; Pappas et al. 1993). In the developed world it has been argued
thatdifferentials in education levels resultin distinctpatternsof behaviors
thathave directeffectson health,functioningand successful aging (Pincus
& Callahan 1985). However, as noted in the introduction,physicallypro-
ductive work roles in less developed countriesmay contributeto physical
vitalityin laterlife (Tout, 1989). As countriesbecome moredeveloped,there
may be a greaterhealthadvantageto have workedin skilled or professional
occupations.
440 VICKIL. LAMB& GEORGEC. MYERS

In the SEARO interviewsthe respondentswere asked what typeof work

they did most of theirlives. The responses were coded in categories that
are more useful for developed countries (i.e., professional, white collar,
ArmedForces, skilledlabor,unskilledlabor,housewife/husband). The largest
category of cases is coded as 'unskilledlabor'.
For the presentstudy,we are interestedin the effectsof physical labor
and, indirectly,educational status.Thus, we created a dichotomousvariable
indicatingthata person workedin unskilledlabor or as a housewife/husband
('unskilled worker'), to be contrasted with the occupations that require
more trainingor education (professional throughskilled labor). House-
wives/husbandswere included with the unskilled laborersbecause it is our
belief that the formergroup engages in physical labor around the house,
in tending family gardens and other activities. Additionally,contingency
tables of years of education and occupational categories indicate that the
unskilledlaborersand housewives/husbands have significantlyless education
as comparedwiththeoccupationsin thecontrastgroup.
We consideredincludingadditionalvariablesthatwould depictthecurrent
living situation,such as rural/urban location, and the availabilityof house-
hold facilities,such as toilet,cooking and bathingfacilities.We rejectedsuch
covariates,however,because therewere concerns about causal orderingof
currentliving standardsand location,and currenthealthstatus.Additionally,
some of thevariables were ratherhighlycorrelatedwiththe typeof workthe
respondentengaged in duringhis or herlifetime.Given thepotentialproblems
withtemporalordering,we decided to retainthe"unskilledworker"indicator
variable.

Household composition.Patternsof household compositionare, in part,in-

fluencedby culturalnorms.However,it should be usefulto examinepatterns
of coresidence and successful aging. A study of cross-nationalhousehold
composition trendsby Hashimoto (1991) found that in Singapore, South
Korea and India, elderlywithhighlevels of disabilitylive in multi-generation
households. However,thisassociation was not foundto be significantforthe
disabled elderlylivingin Brazil, Thailand, Zimbabwe or Egypt.
A dichotomousvariable was created to testwhetherliving in a one gen-
erationhousehold is negativelyassociated withsuccessfulaging. As Table 2
indicates,veryfew of therespondentslive in thistypeof arrangement, which
reflectsculturalnormsin Asia regardinglivingarrangements.
 STUDYOF SUCCESSFULAGINGIN THREEASIANCOUNTRIES 44 1
A COMPARATIVE

Table3. Logisticregression of highsuccessfulaging:Indone-

resultsfordeterminants
sia,Thailand,and Sri Lanka,1989

Indonesia Thailand SriLanka

Variable ""CoeS" (Odds) "CoeS (Odds) Coeff. (Odds)
Male 0.982*** (2.67) 0.444** (1.56) 0.508** (1.66)

Agegroups
60-64 1.560*** (4.76) 0.883** (2.42) 0.698*** (2.01)
65-69 1.245*** (3.47) 0.622** (1.86) 0.611*** (1.84)
[70+]
Morbidconditions
0 0.608* (1.84) 0.672** (1.96) 1.651*** (5.21)
1 0.143 (1.15) 0.112 (1.12) 0.664*** (1.94)
[2+]
Attitude
onaging 0.415*** (1.51) 0.137* (1.15) 0.351*** (1.42)

Managesmoney 2.855*** (17.38) 1.756** (5.79) 1.441*** (4.23)

Unskilled
worker 0.590* (1.80) -0.269 (0.76) -0.272 (0.76)
Wild
Onegener. 0.038 (1.04) -0.011 (0.99) -0.133 (0.88)
Constant -2.453*** -0.398 -1.938***
Model-2LL 767.74*** 1073.063 1197.396
N 1176 1149 1160

Note:*p ^ 0.05; **p ^ 0.01; ***/>^ 0.001.

Source:WeightedSEARO datafiles.

Results

To determine the associationof the explanatory variableswithhighsuc-

cessfulaging,a logisticregressionprocedureis used. Separatemodelsare
estimatedforeachofthethreecountries to discoverpatternsthatarepresent
Table3 reports
cross-nationally. thecoefficients foreach of theexplanatory
shouldbe interpreted
variables.The coefficients as theeffectsofthevariable
onthelogoddsofbeinga highsuccessful agerversusnot.Thedirection ofthe
coefficients, or
positive negative, indicates whether the variablehas a direct
or inverseinfluence on highsuccessfulaging.The odds columnindicates
themultiplicativeeffectof theexplanatory variablecategory,in contrastto
theexcludedcategory, on theresponsevariable,controlling forall theother
in themodel.
correlates
442 VICKIL. LAMB& GEORGEC. MYERS

In all of thecountries,being male increasestheodds of aging successfully.

Regardingage, being in the youngeraged categoriesis positivelyassociated
withhighsuccessfulaging. This is particularlytrueforpersonsaged 60 to 64
yearsin contrastto personsaged 70 yearsand older.Indonesia has thehighest
estimatedodds forsuccessfulaging forthe youngerage groupsas compared
withthecontrastgroup.
Regardingthepresenceof self-reported morbidconditions,clearlyhaving
no morbidcondition,as compared with two or more, increases the odds of
successfulaging.This effectis strongestforelderlyin Sri Lanka. For theaged
in Indonesia and Thailand, thereis no significantdifferencebetweenhaving
one versus two or more morbid conditions in predictingsuccessful aging.
However,forSri Lanka, havingonlyone morbidconditionalmostdoubles the
odds forsuccessfulaging,as comparedwithhavingtwo or moreconditions.
'Attitudeon aging' representsmorale scores fromthe PhiladelphiaGeri-
atricCenterMorale Scale (Lawton 1975), such thatthe higherthe score the
highertherespondent'smorale. The elderlyin Indonesia and Sri Lanka have
increased odds for successful aging of 51 and 42 percent with each unit
increase in thisscore. The effectis not as greatforthe aged in Thailand.
The self-reportedability to manage one's money is stronglyassociated
with successful aging for all of the countriesstudied. It is particularlyas-
sociated with successful aging in Indonesia. If this item is considered a
proxymeasurementof cognitiveability,it followsthatintactcognitiveability
predictsthose who are successfulagers.
An interestingfindingfromthis cross-nationalcomparisonof successful
aging is theeffectof one's lifework.For Indonesia,thosewho were unskilled
workersor housewives/husbandsare 80 percentmore likelyto be successful
agers. For Thailand and Sri Lanka, such life's work results in 24 percent
decreased odds forsuccessfulaging, howeverthe resultsare not statistically
significant.The nonsignificant effectsmay indicate thatas Thailand and Sri
Lanka are processingthroughthe demographicand epidemiologic transition
thedirectbenefitsof workingin skilledoccupationsare notyetrealized at the
aggregatelevel.
The effectof livingarrangements had no association withsuccessfulaging
when controllingfor the other variables in the models. In all of the cases
the standard errors were much larger than the estimated coefficients.Of
course, successful aging is the result of effectsand factorsoccurringover
a person's life course. Thus, currentlivingconditionsmay have littleassoci-
ation withbeing a successful ager. Culturalexpectationsand normsmay be
more influentialthanhealthin dictatingliving arrangementsin the countries
studied.
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 443

Discussion

This researchrepresentsan early step in the examinationof successfulaging

across selecteddevelopingcountries.A numberof thefindingsare consistent
withthe resultsof previous studies of elderlyhigh functioningin developed
countries.The most constantcross-nationaltrendsindicate that age group
and genderare associated withsuccessfulaging. Also, the abilityto manage
one's money,a proxyforcognitivehealth,increasesodds forsuccessfulaging
by a substantialproportion.Having higherlevels of morale shows a trendof
association withsuccessfulaging.
The findingsfromthis study presentinterestingconsiderationsfor the
studyof populationdevelopmentand elderlyhealth.Myers and Lamb (1993)
have suggested that thereis a 'disability transition'that accompanies the
demographicand epidemiologic transition(Omran 1971, 1983). Disabilities
are definedin termsof functionalactivitylimitations,and the definitionof
'successfulaging' representsan absence of such disabilities.
Several of the propositionsregardinga disabilitytransitioncan be ex-
aminedwiththeresultsfromthisstudy.It is informative to contrastIndonesia
withSri Lanka and Thailand. As Table 1 showed,Indonesia is further behind
Sri Lanka and Thailand in termsof demographicindicators.
The firstproposition(Myers& Lamb 1993, p. 112) indicatesthatdisability
prevalenceratesare lower in less developed countries,and propositionthree
(p. 114) says thatearlyin thetransitiontheprevalencerateswill be lower for
theolderages as comparedwiththeyoungerages. The Indonesiansample had
the largestproportionof high successful aging among the countriesstudied,
80 percent.Also life table estimates,presentedin Table 1, indicate thatfor
Indonesia a smaller proportionof the population survivesto age 65. Thus,
selective survival and high case-fatalityrates could work to leave greater
proportionsof theIndonesianelderlyin excellenthealth.
Population-basedmeasures in Table 1 indicatethata largerproportionof
older adults, particularlymales, continue to be economically active in In-
donesia. As notedin the introduction, physicallyproductiveworkroles may
contributeto greaterphysicalfitnessand vitalityforelderlyin less developed
countries.Our resultsoffersupportforthispropositionin thatforIndonesia
theunskilledworkershave increasedodds forbeing successfulagers. This is
not trueforThailand and Sri Lanka. The resultsforThailand and Sri Lanka
are notstatisticallysignificant,butcould proveusefulin theunderstanding of
the shiftin the effectof SES on healthoutcomes as countriesmove through
thedemographictransition. Myersand Lamb (1993, p. 115) hypothesizedthat
SES differentials in disabilityprevalence would increase throughthe trans-
ition. Clearly more systematiccomparativeresearch of countriesat varied
levels of developmentis needed to confirmthistrend.
444 VICKIL. LAMB& GEORGE
C.MYERS

Currentand futuretrends.As countriesmove throughthe demographicand

epidemiologic transition,thereis a shiftin patternsof morbidityand mor-
tality.Major causes of death shiftfrominfectiousand parasiticdiseases to
chronicconditions(Omran 1983, 1971), and life expectancyincreases such
that the majorityof a country'spopulation is survivingto old age. Such
trendsresultin population aging (Myers 1990). The developing world will
experiencepopulationaging throughgreatincreases in the numberand pro-
portionof elderlyin the twenty-first century(Kinsella & Taeuber 1993; US
Departmentof Commerce 1996; Kinsella 1988).
Indonesia, Thailand, and Sri Lanka will be partof thetrendof population
aging, as demonstratedin Table 4. As fertility and mortalitylevels decline
thesecountriesare predictedto have large increases,from191 to 169 percent,
in the numberof persons aged 60 years and older between the years 1996
and 2025. For Indonesia, the median age is expected to increase from24 in
1996 to 33 in 2025, whereasthemedian age forbothThailand and Sri Lanka
is expectedto increasefromthelate 20s to thelate 30s duringthesame period.

Table4. Selectedindicators
ofpopulationagingand development
bycountry

Percentof Percentincrease Medianage Percapita PercentofGDP

population in 60+ population, 1996 2025 GDP(US$) spenton health,
aged 1996-2025 1991-1995 1991-1995
60+, 19%

Indonesia 6.3 191 24 33 740 2.8

Thailand 8.7 176 28 39 2110 3.6
Sri Lanka 8.8 169 27 38 600 5.5

ofCommerce1996; WorldBank 1997.

Sources:US Department

Both Thailand and Sri Lanka exhibit similar indicators of population

aging. The countriesdiffer,howeverin per capita GDP, which forThailand
was more thandouble thatforSri Lanka in the firsthalf of the 1990s. Until
1997 Thailand was an example of SoutheastAsian 'tiger' economic growth
and development,withincreasedexpansion in the industrialand service sec-
tors (Heller 1998; MacDonald 1998). Health expenditureshad been on the
increase for several decades, and were assisted frominternationalsources,
such as the WHO and the United Nations (WHO 1997c). Thailand is in the
thirdstage of theepidemiologictransition(Omran 1971, 1983), withthemain
causes of deathsattributedto chronicand degenerativediseases, and theHTV
infectionratewas witnessinga slow decline (WHO 1997c).
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 445

The recent economic crisis in Asia, however was triggeredby Thail-

and's currencydevaluationand economic collapse in 1997 (Levinson 1998;
MacDonald 1998). Nevertheless,Thailand also appears to be leading the
economic recoveryefforts(MacDonald 1998; Tanzer 1998). Studies of the
healthand well-beingof the elderlyin Thailand point to the importanceof
familyand intergenerational transfers(Knodel, Chayovan & Siriboon 1992).
It is expectedthatthesupportof theelderlywill notsuffergreatlythroughthe
economic crisisin Thailand if therecoveryeffortscontinue.
As notedearlier,thecountryof Sri Lanka has been experiencingcivil war
for some time (Singer 1996). The effectsof the strifehas taken its toll on
segmentsof the populationand the provisionof healthcare forall (Steven-
son 1998). Many of thepopulation's disabilitiesare the resultof war-related
injuries due to bullets, land mines and bombings (Stevenson 1998; WHO
1997b).
In 1993 the Sri Lankan governmentestablished a national healthpolicy
with the governmentprovidingthe major funds for health care, which is
provided free of cost (WHO 1997b). The prioritiesfor the government-
providedhealthcare are services forthepoor, and maternaland child health.
Reports indicate that there has been little improvementin the nutritional
status of children,however,therehave been declines in the prevalence of
infectiousand parasiticdiseases, and increases in average life expectancyes-
timates(WHO 1997b). Yet, outbreaksof infectiousdiseases such as cholera,
are exacerbatedby thelack of safe drinkingwater,particularlyin ruralareas
(WorldDisease WeeklyPlus, 1998). There have been greateffortsto address
thehealthproblemsin Sri Lanka. However,the healthof the elderlyis likely
to sufferin thenear future.
Indonesia continuesto be in the epidemiologic transition'ssecond stage
of 'recedingpandemics' (Omran 1971, 1983). A large proportionof deaths
are due to communicable diseases. While the controlof directlytransmit-
ted diseases (e.g., pulmonarytuberculosis,leprosy,diarrhealdiseases) has
improved,the vectorborne diseases (e.g., malaria, rabies, schistosomiasis,
anthraxand plague) remaina problem(WHO 1997a, p. 7). Internationalaid
continuesto be instrumental in supplementingIndonesia healthservices and
healthresources(WHO 1997a). Still,themajor focus of thehealthinitiatives
is on child and maternalhealth.
Table 4 shows thatIndonesia's estimatedper capita GDP was quite low
in the firsthalf of the 1990s, withrelativelylittlespentforhealth.The GDP
forIndonesia had been increasingsteadilyover the decade, primarilydue to
growthin oil and othernaturalresources(WorldBank 1997). The 1997 Asian
economic crisis and the 1998 political upheavals in Indonesia have resulted
in growingpovertyand chaos, which bodes ill forall (The Economist 1998;
446 VICKIL. LAMB& GEORGEC. MYERS

Hajari 1998; MacDonald 1998). It is estimatedthathalfof theIndonesian

population arenowlivinginpoverty (Runyan1999).Theelderlyareina par-
ticularly vulnerable
positionwiththegovernment unableto provideneeded
services,andtheirfamilieshurtbythedirectandindirect effectsofthesocial
turmoil.
It is increasingly
importantto considertheimpactsof development on
populationhealthand disablement, at older ages. Population
particularly
agingis a worldwidephenomenon thatmustbe addressedin thecontextof
politicaland economicdevelopment and change.Scholarsalreadyare con-
sideringimportant issuesregarding agingin Asian countries(Heller1998;
Hermalin1995;Westley1998).A majorquestionis howthecurrent political
and economicsituations will affectthesuccessfulagingof Asian popula-
tions.

References

Andrews,G. R. (1993). Healthyaging:The Asia/Oceaniaexperience, Aging: Clinicaland

Experimental Research5: 148- 151.
Andrews,G. R. (1992). Researchdirections in theregion:past,presentandfuture,pp. 22-35,
in: D. R. Phillips(ed.),Ageingin East and South-eastAsia. London:EdwardArnold.
Andrews,G. R., Esterman, A. J.,Braunack-Mayer, A. J.& Rungie,C. M. (1986). Agingin the
Western Pacific:a fourcountry study.Manila:WorldHealthOrganization.
Berkman,L. E, Seeman, T. E., Albert,M, Blazer, D., Kahn, R., Mohs, R., Finch,C,
Schneider,E., Cotman,C, McClearn,G., Nesselroade,J.,Featherman, D., Garmezy,
N., McKhann,G., Brim,G., Prager,D. & Rowe, J. (1993). High, usual and impaired
functioning in community-dwelling oldermenand women:finding fromtheMacArthur
foundation researchnetworkon successfulaging,Journalof ClinicalEpidemiology 46:
1129-1140.
Chen, A. J. & Jones,G. (1989). Ageingin ASEAN. Pasir Panjang,Singapore:Institute for
SoutheastAsian Studies.
Cowgill,D. O. (1986). Agingaroundtheworld.Belmont,CA: Wadsworth.
TheEconomist(1998). Deja vu in Indonesia,TheEconomist,21 November1998: 20.
Evans,J. (1985). The development of handicapwithageingin Australiaand Indonesia,pp.
27-33, in: Proceedingsof the20thannual conference of theAustralianGerontological
Association.
Guralnik,J. M. & Kaplan, G. A. (1989). Predictorsof healthyaging: prospectiveevid-
ence fromthe Alameda Countystudy,AmericanJournalof Public Health 79: 703-
708.
Guralnik,J. M, Land, K. C, Blazer,D., Fillenbaum,G. G. & Branch,L. G. (1993). Edu-
cationalstatusand activelifeexpectancyamongolderblacks and whites,New England
JournalofMedicine329: 110-116.
Hajari,N. (1998). Shotsin thedark:troopsopen fireon students in Jakarta
as violentprotest
spreadsand Indonesia'shaltingjourneyto democracytakesanotherbloodyturn,Time
International23 November1998: 20.
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 447

Hashimoto, A. (1991). Livingarrangements oftheagedin sevendevelopingcountries, Journal

ofCross-Cultural Gerontology 6: 359-381.
Heller,P. S. (1998). AgingintheAsiantigereconomies,Financeand Development 35: 26-29.
Hermalin, A. I. (1995). AginginAsia: setting theresearchfoundation, Asia-PacificPopulation
ResearchReportNo.4 (April).
Hugo,G. (1992). Ageingin Indonesia:a neglectedareaofpolicyconcern,pp. 207-230, in: D
R. Phillips(ed.),Ageingin East and South-EastAsia. London:EdwardArnold.
Kinsella,K. (1988). Aging in the thirdworld.International PopulationReportsP95179,
Washington, DC: US BureauoftheCensus.
Kinsella,K. & Taeuber,C. M. (1993). An aging worldII. International PopulationReports,
P95/92-3,Washington, DC: US BureauoftheCensus.
Knodel,J.,Chayovan,N. & Siriboon,S. (1992). The impactof fertility declineon familial
support fortheelderly:an illustration fromThailand,Populationand Development Review
18: 79-103.
Lamb,V. L. (1996). A cross-national studyof qualityof lifefactorsassociatedwithpatterns
ofelderlydisablement, Social Scienceand Medicine42: 363-378.
Lawton,M. P. (1975). The PhiladelphiaGeriatricCentermoralescore:a revision,Journalof
Gerontology 30: 85-89.
Levinson,M. (1998). The worldeconomyin turmoil, Dissent45: 5-6.
MacDonald,S. B. (1998). Transparency in Thailand's1997 economiccrisis:thesignificance
ofdisclosure, AsianSurvey38: 688-702.
Mackinnon,A., McCallum,J.,Andrews,G. & Anderson,I. (1998). The centerforepidemi-
ologicalstudiesdepressionscale in oldercommunity samplesin Indonesia,NorthKorea,
Myanmar, SriLanka,andThailand,JournalofGerontology: PsychologicalSciences53B:
P343-P352.
Manton,K. G., Myers,G. C. & Andrews,G. R. (1987). Morbidityand disabilitypatterns
in fourdevelopingnations:theirimplications forsocial and economicintegration of the
elderly, JournalofCross-Cultural Gerontology 2: 115-129.
Myers,G. C. (1990). Demographyof aging,pp. 19-44, in: R. H. Binstock& L. K. George
(eds.),HandbookofAgingand theSocial Sciences,3rdedn.New York:AcademicPress.
Myers,G. C. (1993). International researchon healthylifeexpectancy, pp. 33-4, in: M. Fein-
leib(ed.),Proceedingsofthe1991 international symposium on data on aging.Hyattsville,
MD: NationalCenterforHealthStatistics.
Myers,G. C. & Lamb,V. L. (1993). Theoreticalperspectives on healthylifeexpectancy, pp.
109-119,in: J-M.Robine,C. D. Mathers,M. R. Bone & I. Romieu(eds.), Calculationof
healthexpectancies. Montrouge, France:JohnLibbey.
Omran,A. R. (1971). The epidemiologic transition:
a theory oftheepidemiology ofpopulation
change,MilbankMemorialFund Quarterly 49: 509-538.
Omran,A. R. (1983). The epidemiologictransition theory:a preliminary update,Journalof
TropicalPediatrics29: 305-316.
Pappas,G., Queen,S., Hadden,W. & Fisher,G. (1993). The increasing disparityin mortality
betweensocioeconomicgroupsintheUnitedStates,1960and 1986,NewEnglandJournal
ofMedicine329: 103-109.
Pincus,T. & Callahan,L. F. (1985). Formaleducationas a markerforincreasedmortality and
morbidity in rheumatoid JournalofChronicDiseases 38: 973-984.
arthritis,
Phillips,D. R. (ed). (1992). Ageingin east and south-east Asia. London:EdwardArnold.
Preston,S. H. & Taubman,P. (1994). Socioeconomicdifferences in adultmortality andhealth
status,pp. 279-318, in: L. Martin& S. H. Preston(eds.), The demography of aging.
Washington, DC: NationalAcademyPress.
448 VICKIL. LAMB& GEORGEC. MYERS

Preston,S. H. & Elo, I. T. (1995). Are educationaldifferentials

in adultmortalityincreasing
in theUnitedStates?,JournalofAgingand Health7: 476-496.
Riley,J. C. (1990). The riskof being sick: morbidity trendsin fourcountries,Population
Development and Review16: 402-432.
Rowe, J. (1993). Healthyaging,pp. 5-7, in: M. Feinleib(ed.), Proceedingsof the1991 in-
ternationalsymposium MD: NationalCenterforHealth
on data on aging. Hyattsville,
Statistics.
Rowe,J.W. & Kahn.R. L. (1987). Humanaeine: usualandsuccessful.Science237: 143-149,
Rowe,J.W. & Kahn,R. L. (1998). Successfulaging.New York:PantheonBooks.
Rudkin,L. (1993). Genderdifferences in economicwell-beingamongthe elderlyof Java,
Demography30: 209-226.
Rudkin,L. (1994). Dependencystatusand happinesswithold age in Java,TheGerontologist
34: 217-223.
Runyan,C. (1999). An unfinished revolution,WorldWatch12: 34-38.
Satariano,W. A., Ragheb,N. E. & Dupuis, M. H. (1989). Comorbidity in older women
withbreastcancer an epidemiologicapproach,pp. 71-107, in: R. Yancik& J.W. Yates
(eds.), Cancer in theelderly:Approachesto earlydetectionand treatment. New York:
Springer.
Singer,M. R. (1996). Sri Lanka's ethnicconflicthave bombs shattered hopes forpeace?,
AsianSurvey36: 1146-1155.
Stevenson,P. (1998). Warsurgery continuesin Sri Lanka,TheLancet351: 1039.
Strawbridge, W. J.,Cohen,R. D., Shema,S. J. & Kaplan,G. A. (1996). Successfulaging:
predictors and associatedactivities,AmericanJournalofEpidemiology 144: 135-41.
Tanzer,A. (1998). Firstin,firstout,Forbes,November16: 53.
Tout,K. (1989). Agingindevelopingcountries.Oxford:OxfordUniversity Press.
UNICEF (1991). Statisticson childrenin UN1CEF assistedcountries.New York:United
NationsChildren'sFund.
UnitedNations(1988). Mortality of childrenunderage 5: worldestimatesand projections,
1950-2025 (ST/ESA/SER.A/105). New York:UnitedNations.
US Departmentof Commerce,Bureau of the Census (1991). Global aging: comparative
indicatorsandfuturetrends.Washington, DC: Author.
US Departmentof Commerce,Bureau of the Census (1996). Global aging intothe 21st
century. Washington, DC: Author.
Verbrugge, L. M., Lepkowski,J. M. & Imanaka,Y. (1989). Comorbidity and its impacton
disability,MilbankQuarterly 67: 450-484.
Verbrugge, L. M. (1991), Survivalcurves,prevalencerates,and darkmatters therein,Journal
ofAgingand Health3: 217-236.
Verbrugge, L. M., Gates,D. M. & Ike, R. W. (1991). Risk factorsfordisabilityamongUS
adultswitharthritis,JournalofClinicalEpidemiology 44: 167-182.
Westley,S. B. (1998). Asia's nextchallenge:caringfortheelderly, Asia-PacificPopulation
and Policy,No. 45.
WorldDisease WeeklyPlus (1998). Doctorswarnof outbreakin Sri Lankancapital,World
Disease Weekly Plus, 1 December1998.
World Health Organization(1997a). Analysisof national reporton the thirdevaluation
strategyfor HFA [healthfor all]: Indonesia. Retrievedfromthe world wide web
[http://www.who.int/whosis/hfaAndex.html], January 1999.
World Health Organization(1997b). Analysisof national reporton the thirdevaluation
strategy for HFA [healthfor all]: Sri Lanka. Retrievedfromthe world wide web
[http://www.who.int/whosis/hfa/index.html], January 1999.
 A COMPARATIVE STUDY OF SUCCESSFUL AGING IN THREE ASIAN COUNTRIES 449

WorldHealth Organization(1997c). Analysisof national reporton the thirdevaluation

for HFA [healthfor all]: Thailand. Retrievedfromthe world wide web
strategy
January
[http://www.who.int/whosis/hfa/index.html], 1999.

Addressforcorrespondence:VickiL. Lamb,CenterforDemographicStudies,Duke Univer-

sity,2117 CampusDrive,Durham,NC 27708-0408,USA
Phone:(919) 684-6126;Fax: (919) 684-3861;E-mail:vlamb@cds.duke.edu