Berapa umur mak cik?
How old are you, Auntie?
Aging in Malaysia: A Women's Issue
Angela Sprunger
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References
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Bennett, Rachel and Zaidi, Asghar (2016) Ageing and development: Putting gender back on the agenda. International Journal on Ageing in Developing Countries, 1 (1). pp. 5-19.
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Bernama. (2017, April 25). Malaysia needs to prepare now to address ageing population problem in 2050, says economist. Retrieved July 25, 2017, from http://www.thesundaily.my/news/2017/04/25/malaysia-needs-prepare-now-address-ageing-population-problem-2050-says-economist
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Cornman, Jennifer C. (1996). Toward Sustainable Development: Implications for Population Aging and the Wellbeing of Elderly Women in Developing Countries. Population And Environment, (2), 201.
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Goh, Z., Lai, M., Lau, S., & Ahmad, N. (2013). The Formal and Informal Long-Term Caregiving for the Elderly: The Malaysian Experience. Asian Social Science, 9(4). doi:10.5539/ass.v9n4p174
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Hamid, T., & Yahaya, N. (2008). National Policy for the Elderly in Malaysia: Achievements and Challenges. In Ageing in Southeast and East Asia: Family, Social Protection, Policy Challenges (pp. 108-133). ISEAS–Yusof Ishak Institute.
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Healthy Places Terminology. (2013, August 14). Retrieved July 30, 2017, from https://www.cdc.gov/healthyplaces/terminology.htm
Hong, P. K. (2009), Health Care in Malaysia: The Dynamics of Provision, Financing and Access – Edited by Chee Heng Leng and Simon Barraclough. Singapore Journal of Tropical Geography, 30: 144–147. doi:10.1111/j.1467-9493.2008.00355_4.x
Ibrahim, R., Abolfathi Momtaz, Y., & Hamid, T. A. (2013). Social isolation in older Malaysians: Prevalence and risk factors. Psychogeriatrics, 13(2), 71-79. doi:10.1111/psyg.12000
Kasztelan, M. (2015, February 20). Female Circumcision is Becoming More Popular In Malaysia. Retrieved from https://www.vice.com/en_us/article/4w7ja9/female-circumcision-is-becoming-more-popular-in-malaysia
Labour Force Survey Report, Malaysia, 2015).. (n.d.). Retrieved from https://www.dosm.gov.my/v1/index.php?r=column/pdfPrev&id=TFVqZ2NtWW9iNlJBV0pTQnZUUzBEZz09 Labour Force Survey Report, Malaysia, 2015
Mafauzy, M. (2000). The Problems and Challenges of the Aging Population of Malaysia. The Malaysian Journal of Medical Sciences : MJMS, 7(1), 1–3.
Mather, M. (2016). Population Reference Bureau. From http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx
Nai Peng Tey1, t., Saedah Binti, S., Binti Kamaruzzaman, S. B., Ai Vyrn, C., Maw Pin, T., Sinnappan, G. S., & Müller, A. M. (2016). Aging in Multi-ethnic Malaysia. Gerontologist, 56(4), 603-609.
Omar, Rosiah (2003). Being Old In Malaysia: Issues and Challenges of Older Women. Journal of Kroeber Anthropological Society. Papers no. 89 (90).
Wienclaw, R. A. (2015). Caring for the Elderly: Global Perspectives. Research Starters: Sociology (Online Edition)
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Women over 50 years of age account for almost one quarter of the world’s population. However, the discourse around developing economies, such as Malaysia, has given minimal attention to women beyond reproductive age.
According to the Global Age Watch index in 2015, women over 50 years of age account for almost one quarter of the world’s population. However, the discourse around developing economies, such as Malaysia, has given minimal attention to women beyond reproductive age (Bennet and Zaidi, 2016). Like other emerging economies, Malaysia is experiencing a demographic increase in its aging population. As developing countries move towards sustainable economies, mortality and fertility rates decline. This means that people live longer and fewer births are occurring, therefore the proportion of older adults in a population increases. The Malaysian government defines older persons as those 60 and up. The numbers of elderly women and the proportion of elderly who are women are significantly increasing. Healthcare is not monolithic, one size does not fit all. What impact do these demographic changes towards an aging population have on elderly women’s health and care in Malaysia?
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In Malaysia, family is the primary source of care responsible for shelter, financial well-being, health, and emotional support. Family remains at the core even in government development programs. For the most part, adult children are responsible for their parents’ well-being. While the government and the non-profit sector manage some old age homes, they are highly stigmatized as they are primarily occupied by the destitute and those without families. The importance of filial piety- the idea that one takes care of one’s parents, obeys, and respects them- is a strong cultural value among all ethnic groups in Malaysia. Co-residing- a parent or parents living with an adult child and his/her family- is common.
Malaysia is multi-ethnic and multi-cultural. About half the population is ethnically Malay with large minorities of Malaysian Chinese, Malaysian Indians, and Indigenous people. Though Malaysia is a secular government, Islam is the official religion of the country. Non-Muslim nationals are free to practice their own religions such as Buddhism and Hinduism. While there are specific considerations that ethnicity and religion contribute towards attitude and care for an elderly population, this paper will look at the impacts that a changing age structure has on women system across ethnicities and religions.
Population aging is the process of changes in the age structure where proportions of people in older age groups increase and the proportions of people in younger age groups decrease. Sustainable development is coordinated with reduced mortality and fertility rates. “If sustainable development entails reducing fertility, then attaining sustainable development will lead to an aging population.” (Cornman, 1996, p. 202) Fertility and mortality are the main factors that influence the age structure of a population. Fertility is measured births per woman and mortality is a measure of the number of deaths in a particular population.
When mortality and fertility is high, a population’s age structure is young. Relatively few people live until old age and birth rates are high enough to produce and maintain a young population. Mortality begins to decline as a society experiences the epidemiological transition where in the major causes of death transition from communicable diseases to non-communicable diseases. People live longer and develop chronic diseases and conditions associated with aging. When mortality declines and fertility is still high, the age structure of a population becomes younger. More children survive through childhood which significantly increases the proportion of young people in a population as well as increasing the number of female children that live to child-bearing age who reproduce. As mortality is declining and fertility declines, a population starts to get older. When fertility levels decline, there is a significant decline in the number of births entering the bottom of the age pyramid. As that cohort reaches reproductive age, a smaller number of women are alive to have children which leads to smaller birth cohorts. In turn, that means that older age groups then constitute a larger proportion of the population. Mortality also ages the population through increased survivorship. It takes some time after initial declines in fertility and mortality to affect the aging proportion of a society.
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Malaysia’s population started to undergo demographic transition around 1969 when the fertility rate began to decline. The fertility rate in 1980 was 5.6, in 1990, 3.7, and in 2007, 2.5. The life expectancy for men in 1957 was 55.8 years and 58.2 years for women. In 2007 the life expectancy for men was 71.9 years and 76.4 years for women (Ibrahim, Abolfathi Momtaz, Hamid, 2013). Malaysians over 60 currently account for 8% of the population and are expected to account for up to 15% of the population by 2035 (Bernama, 2017). By comparison, in the US, a developed country, 15% of the population was over 65 in 2016 (Mather, 2016).
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These changes impact women in specific ways. The numbers of elderly women and the proportion of elderly who are women are significantly increasing. When fertility declines, maternal and infant mortality tends to decline which increases the number of women who survive to older ages. Women have higher life expectancies than men and, in general, lower age-specific mortality rates at almost every age. Therefore, women will comprise a larger proportion of the elderly population. As Cornman (1996) notes, these trends occur because of the greater longevity of women; because women marry men who are older; and/or because women have lower rates of remarriage than men. “Women are more likely than men to be widowed at older ages and to live longer portions of their lives in dependent states (ESCAP, 1987)” (p. 209)
Declines in fertility and mortality also change the structure of families. According to Cornman (1996) as a population transitions from high mortality-high fertility to low mortality-low fertility, family structure “verticalizes” There is a decline in the proportions of kin in each generation of a family and an increase in the proportions of families consisting of parents, grandparents, and great grandparents. This has a significant effect on size and composition of a household. Reduced family size reduces the number of people who can share in the economic, emotional and labor burden of caring for an aging parent. While children may still want to care for an aging parent, the burden may be too great. Additionally, developing economies offer more education and work opportunities for younger women so, as they enter the workforce, their ability and availability to caregive is challenged. Mobility also increases with industrialization. Children are more likely to be geographically distant from parents. Rural flight to urban centers for work create especially challenging family caregiving shortages in rural areas.
This significantly impacts single elderly women as they rely almost entirely on family support, physically and economically, in old age. Malaysia does not have a financial welfare program and many elderly women do not have savings, pensions, or properties of their own. While co-residing is common in Malaysia, due to the same pressures/opportunities, the sustainability of this tradition becomes challenging. With decreased mortality rates, co-residing is sustained over longer periods as parents live longer, increasing the financial and caregiving burden.
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In Malaysia, most long-term health care for the elderly is informal (familial and unskilled) with some formal care for acute needs. In a survey of formal and informal long-term caregiving in Malaysia, Goh, Lai, Lau, and Ahmad (2013) defined an informal caregiver as someone who provides care for an elderly person who needs assistance in performing daily living activities. This survey found that most informal caregivers were daughters of the elderly, between 30 to 50 years old and working. In 2015, 54% of Malaysian women between 15 and 64 were now in the workforce (Labour Force Survey Report, Malaysia, 2015). This group relies heavily on maids and other siblings. Unmarried children are also providing informal care to elderly parents.
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The healthcare system in Malaysia is largely focused on short term care and hospitalization. Options for rehabilitation care and respite care are severely limited. This means that informal care systems are stressed with the responsibility, however lacking in skill, to manage the continuity of care from treatment of acute illness, injury, and disease to returning to the informal family care system for recovery. The government and non-profit sector offer some long-term care options that predominantly house those who do not have family that can care for them. Stigmatization of long-term care facilities and the pressure of filial piety dissuade adult children who are caregivers from moving aging parents to long-term care facilities, even if they cannot provide adequate care at home. Malaysia’s old age homes, known as “old folks” homes, primarily serve the poor, elderly widows, and others without family and in need of food, shelter and care who have no alternatives. Government sponsored old folks homes, such as the Rumah Seri Kenangan homes, offer two ways to become a resident: 1) Voluntary admission. Application for voluntary admission is reviewed before approval. 2) By instruction of the Department of Social Welfare: in which a person is declared unable to care for herself or himself and therefore committed. (Omar, 2003)
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The elderly surveyed had a preference to stay in their own home or a child’s home. “Current living arrangements showed that most elderly are now residing with their caregivers. Most male elderly are living with their spouse as compared to their female counterpart.” (Goh, Lai, M., Lau, and Ahmad, 2013) This indicates that men may be more likely to “age in place” at their home with wives as caregivers. Women are less likely to be able to “age in place.” The U.S. Centers for Disease Control and Prevention defined aging in place as “the ability to live in one’s own home and community, safely, independently and comfortably, regardless of age, income, or ability level.” (2013)
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Malaysia does not yet have the social safety nets of other developed countries (i.e. long-term care insurance, private pension schemes, annuity income and social security benefits,) or a skilled labor work force to provide varied levels of in home care to support “aging in place.” There is growing research, advocacy, and programs in both the government and NGOs to address the gap between public and private roles in contributing to a continuum of care from independent living to dependent living. The Malaysian government and care professionals recognize that there is a need for services which integrate family care and public assistance. “Therefore, it is imperative that government needs to review the employee provident fund, pension, and mutual fund scheme in order to support those elderly who will require formal caregiving as society becomes more competitive for their children to provide informal caregiving” Goh, Lai, Lau, and Ahmad, 2013).
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As noted earlier, when the number of elderly increase and people reach older age, chronic and disabling conditions dominate health problems. Care focus shifts away from communicable disease towards degenerative diseases such as diabetes, heart problems, and dementia. Specialized care will need to be available to support aging people, their family care providers, and professional service options.
One of the barriers to care for older women in Malaysia is that women’s healthcare is often equated with family planning and childbirth. Women’s health in many developing countries “is relegated soley to obstetrics and gynecology, and within primary health care, all women’s health needs are assumed to be met by maternal and child health programmes. This is because women are primarily seen as mothers and wives, part of rigidly defined gender roles, rather than active members of society with holistic health needs.” (Wong, 2000).
According to Hong (2009), maternal healthcare is widely available in Malaysia. Women’s access to healthcare within the conventions of marriage and family, is generally high. However, women who fall outside this norm have greater difficulty. Health care access is mediated by social, economic and cultural factors. Cultural practice and social norms that circumscribe the mobility and behavior of women may act as barriers to their seeking health care. If it is assumed that only married women need maternal healthcare, then access is dependent on marital status. For example, in trying to broaden the scope of national cervical cancer screenings: prior to 1995, the official policy was to provide cervical cancer screenings to married women only. Current policy is to include all sexually active women but in practice, unmarried women encounter more barriers. Studies show that women who never married almost never had a pap smear. (Hong, 2009)
While maternal and reproductive health care services are well developed, patriarchal constructs of what “women’s health” is form a barrier to access. Cardiovascular disease, cerebro-vascular disease and cancers are the primary causes of death in the general population and among women. However, disease models are male-centered and women may present with different indications. Institutionalized gender bias also contributes to physicians being more likely to discount complaints of women. Medical gender bias is not unique to Malaysia but it has yet to receive attention in health research in Malaysia. (Hong, 2009)
Although the 2012 United Nations General Assembly unanimously passed a resolution calling female circumcision a human rights violation, it is estimated that more than 90% of women from Muslim Malay families have undergone the practice (Kasztelan, 2015). It is widely viewed as a religious obligation and in 2009, the Fatwa Committee of Malaysia's National Council of Islamic Religious Affairs ruled that female circumcision was obligatory for Muslims. Public hospitals are prevented from performing the surgery but the procedure is not banned. It is increasingly becoming medicalized and performed by trained medical professionals in private clinics, instead of by traditional circumcision practitioners called Ma Bidans (Kasztelan, 2015). While it may be argued that such a tradition has a cultural value, it has no medical value. To medicalize the procedure may make it safer as it simultaneously institutionalizes a medically unnecessary practice. As long as women’s health remains conflated with reproductive health, women will continue to lack access to health care for their non-reproductive health needs.
In a 2016 article in the International Journal on Ageing in Developing Countries, Bennett and Zaidi state:
The female survival advantage has frequently been observed alongside a paradoxical finding that women have poorer self-rated health than men (Oksuzyan, Peterson, Stovring, Bingley, Vaupel, & Kristensen, 2011). This manifests into a greater length of time spent in poor health amongst women. Indeed the female survival advantage itself extends the length of time women spend in poor health (Luy & Minagwa, 2014) and can mean females need extra care, especially during the late stages of their lives. As women outlast their male partners in most instances, they are also less likely to have access to informal care from their partners and may be at higher risk of social isolation. (p. 10)
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In 2013, Ibrahim, Abolfathi Momtaz, and Hamid conducted a study on social isolation in older Malaysians to understand the prevalence and risk factors. One of the indicator of healthy aging and healthy communities is social integration. Social integration can be defined by both objective and subjective measures. Quantifiable measures of social integration include the composition and size of an individual’s social network and the frequency of meaningful interactions. Subjectively, social integration is about the perception of one’s connectivity or isolation. Social isolation is therefore the objective measures of how socially integrated a person is and the feeling of being separated from others, being an outsider, loneliness. Both objective and perceived social isolation have been found to negatively impact older person’s health. Consequences can include depression, lower immune response, elevated blood pressure, and increased risk of suicide.
Women have higher life expectancies than men and, in general, lower age-specific mortality rates at almost every age. Therefore, women will comprise a larger proportion of the elderly population.
As long as women’s health remains conflated with reproductive health, women will continue to lack access to health care for their non-reproductive health needs.
Women are at higher risk of social isolation.
The research by Ibrahim, Abolfathi Momtaz, and Hamid (2013) was sampled from a national survey, “Patterns of Social Relationships and Psychological Well-Being among Older Persons in Peninsular Malaysia.” All respondents were 60 years of age or older. About half of respondents were women and 47% of all respondents were single reported as due to divorce, widowhood, or never married. Results showed that nearly half of those surveyed were at risk for social isolation. Factors that were shown to increase social isolation included, gender, household size, self-rated health, place of residence, and homeownership. The sex of respondents was a significant determinant of social isolation risk with older women being more likely to be socially isolated than men. As Ibrahim, Abolfathi Momtaz, and Hamid (2013) note, social isolation was a function of respondent sex and marital status, but only sex (i.e. being a woman) independently increased the likelihood for social isolation.
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Marital status did not emerge as a significant predictor of social isolation probably because marital status among survey takers differed significantly by sex. 77.8% of older women were unmarried, divorced or separated compared to 22.2% of older men. This result may also imply that being a woman, rather than being unmarried, puts an individual at a higher risk for social isolation given the fact that in almost every country women normally outlive men, and the chances that older women remarry following a divorce or widowhood are lower than for older men. (Ibrahim, Abolfathi Momtaz, and Hamid, 2013, p.77)
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The informal system of family caregiving and prevalence of co-residing with family do not independently prevent social isolation among older adults. There’s clearly a need for family and community support programs to help address this issue. Identifying risk factors for social isolation is important in developing policy and practice as socially isolated people are not easily detected until the event of a crisis.
In conclusion, aging in Malaysia is a women’s issue. Women make up a larger percentage of the elderly population and will continue to do so as the population ages. Women are more likely to be dependent on their children as informal caregivers. The family care system will continue to be stressed by population aging changes resulting in smaller families and more working and geographical mobile children, potentially resulting in less familial care for dependent elderly women. Women’s specific health needs outside of reproductive health need to be addressed such as their increased risk of social isolation and self-rated perception of poor health. As the Malaysian government and NGOs are working to address the gaps between familial, community, and institutional support for the aging, it will be fundamental to consider the specific needs of women in order to equitably care for all of its aging citizens.
