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Religious Activity Participation and Self-Rated Health Among Older Population in Indonesia

A number of studies have documented a positive and robust relationship between religious activity and health outcomes. The purpose of the study was to examine the relationship between religious activity participation and self-rated health (SRH) among older population in Indonesia. Data were obtained from 2,915 respondents 60 years and older from the Indonesian Family Life Survey 4 (2007). SRH was assessed by a single-item health measure with four options: “very healthy,” “somewhat healthy,” “somewhat unhealthy,” and “unhealthy”. Logistic regression were used to examine the relationship of the religious activity participation and SRH. Bivariate analysis revealed that religious activity participation was significantly associated with SRH. Multivariate analysis shows that among participants who participated in religious activity, the likehood of a better SRH is increased (OR = 1.422; 95% CI = 1.203 to 1.682) after controlling for sociodemographic variables, socio-economic status (SES), health behaviour and number of Non Communicable Diseases (NCDs). This findings suggest that religious activity participation has an important effect on self-rated health status. Longitudinal studies are needed to help elucidate mechanisms and the order and direction of effects.


Introduction
Worldwide, the proportion of people age 60 and over is growing faster than any other age group. In 2025, there will be a total of about 1.2 billion people over the age of 60. By 2050 there will be 2 billion with 80 percent of them living in developing countries and over half of the world's older people live in Asia. 1 In Indonesia, 16.5 million persons (7.8%) are over 60, which makes it the country with the tenth largest older population in the world and the third largest in Asia in 2012. 2,3 The older population in Indonesia will reach 28.8 million (11.3%) by 2020. 2 Thus, the impact of common problems in the elderly, such as chronic illness and disability, will have profound implications for healthcare in the future.
Self-rated health (SRH) is a widely used measure for health status in public health and epidemiological research due to strong associations with other subjective and objective measures of well-being, health outcomes and mortality. 4 A large number of empirical studies have demonstrated that a single-item scale of self-rated health (SRH) has become a widely used indicator of general health and multiple studies have further supported the predictive validity of SRH in older populations concerning future health, functional decline, disability and mortality. [5][6][7][8] Research indicates that SRH is consistent with objective health status and can serve as a global measure of health status in the general population. 5 Self-rated health (SRH), generally captured by a single item inviting respondents to provide an overall assessment of their health using some form of a five-point scale (for example, very good, good, fair, poor, and very poor). 9 Activities are important for successful aging. Older adults are involved in a variety of different activities and activities have been found to be beneficial in improving the quality of life and successful aging of older adults. 10 A number of studies have documented a positive and robust relationship between religious activity and health outcomes, such as good self-rated health, 11 mental health. [12][13] Studies assessing the effects of religious attendance have also found positive correlation with survival, [13][14] and inverse correlation with mortality. [15][16] Weekly religious attendance was also associated with improving and maintaining good health behaviour, increase social relationships and marital stability. 13 The association between religious activity participation and SRH of older adults in rapidly aging nations of Asia is relatively unknown. The need to look at activity participation in late life among older Asians is recently reported. 17 Although older adults of developing Asian countries are concerned with health issues and financial and caregiving problems, activity participation in late life may have a positive impact on aging-related problems and also enhance life satisfaction. 17 As aging is a new phenomenon in Indonesia, no studies have been identified that examine the association of religious activity participation with SRH. Because religious activity has an impact on health outcomes, the knowledge about religious activity participation and SRH in Indonesian older need to be explored. The purpose of the study was to examine the relationship between religious activity participation and SRH among older population in Indonesia.

Methods
Data. The population used in these analyses is a subsample of the Indonesian Family Life Survey (IFLS). IFLS is a continuing longitudinal socioeconomic and health survey. It is based on a sample of households representing about 83% of the Indonesian population living in 13 of the nation's 26 provinces in 1993. Within each of the 13 provinces, enumeration areas (EAs) were randomly chosen from a nationally representative sample frame used in the 1993 SUSENAS of about 60,000 households. The IFLS randomly selected 321 enumeration areas in the 13 provinces, over-sampling urban EAs and EAs in smaller provinces to facilitate urban-rural and Javanese-non-Javanese comparisons. Within a selected EA, households were randomly selected based upon 1993 SUSENAS listings obtained from regional BPS office. 25 The survey collects data on individual respondents, their families, their households, the communities in which they live, and the health and education facilities they use. This longitudinal study involved data collection from 1993 to 2007 for a total of four waves. The first wave (IFLS1) was administered in 1993, IFLS2 sought to reinterview the same respondents four years later. The next wave, IFLS3, was fielded on the full sample in 2000. IFLS4 was fielded in late 2007 and early 2008 on the same 1993 households and their splitoffs; 13,535 households and 44,103 individuals were interviewed. 25 The analytic sample used for this study was restricted to those participants in the 60 years old age and over with complete data on the demographic and socioeconomic indicators, health behaviour and health status. The final sample used in the analysis was therefore n = 2,915. Self reported general health (SRH) was assessed by a single-item health measure with four options: "very healthy," "somewhat healthy," "somewhat unhelathy," and "unhealthy". SRH was elicited by asking "In general, how is your health?". The responses were categorized as healthy (very healthy and somewhat healthy) = 0, and unhealthy (somewhat unhealthy and unhealthy) = 1. The religious activity participation was operationalized by involvement in religious activities. Activity participation was measured by asking the older adults "During the last 12 months did you participate in or use …?" In addition to age (in years) and sex, we selected three sets of covariates that are known to be related to SRH outcomes and might influence the association of religious activity participation and SRH. The first set consists of indicators of socioeconomic status, represented by measures of education, employment and household income. The second set includes measures of health behaviour and the third set a measure of multimorbidity.
Eldery age was classified into two gorups (60-69 years and ≥ 70 years). Sex was categorized as male and female. Education was measured the highest grade they had complete, and education level was categorized as: Religious Activity Participation and Self-Rated Health Makara J. Health Res.
December 2014 | Vol. 18 | No. 3 121 low (no education and Primary School), middle (Junior and Senior High School) and High (Diploma and University). Employment status was categorized as unemployed and employed. The household income was categorically coded into 5 quintiles, ranging from the poorest to the richest quintile as given in the data set.
Health behaviour included information on smoking, Body Mass Index (BMI), physical activity and consumption of fruit and vegetables. Smoking status was categorized as non smoker, ex smoker and current smoker. BMI was calculated as weight (kg)/height 2 (m 2 ) and classified as underweight (<18.50 kg/m 2) ; normal (18.50-24.99 kg/m2) and overweight/obese (≥25.00 kg/m 2 ). Physical activity was assesed by using questions about how many days respondents doing activity at least 10 minutes of vigorous activity, moderately activity and mild activity. Physical activity was categorized as vigorous activity (at least 30 minutes a day and at least 3 days a week), moderately activity (at least 30 minutes a day and at least 3 days a week) and mild (all other). Consumption of fruit and vegetables was assesed by using questions on frequency of fruit and vegetable concumption with the question, "In the last week, how many times do you eat vegetables or fruit". Respons were on an eight point scale ('never' to 'seven times'). We classified participants as consuming fruit or vegetables at seven days, four to six times a week, and less than four times a week.
Multimorbidity was based on the number of respondents self-reported diagnosis of chronic Non Communicable Disease (NCDs) which was previously made by a health professional, examples of such NCDs are diabetes, hypertension, heart disease, stroke, lung diseases, asthma, cancer, arthritis and depression. There were assesed by self-reporting through answers to the question 'Has a doctor ever told you that you have any the following?' followed by a list of conditions. Multimorbidity was defined as two or more chronic NCDs.
The main characteristics of the sample were investigated through descriptive analysis and this was followed by bivariate analysis using Chi-square test to identifiy the variables significantly associated with SRH. The variables found significant in the bivariate analysis at the p < 0.25 level were entered into multivariate analysis. Logistic regression analyses were performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of SRH associated with various factors, with and without adjustment for other covariates.
We first built model include all variables that found significantly associated with SRH (model 1) than built adjusted model for socio-demographic variables (age and marital status) (model 2). To asses religious activity participation independent effects, we then built adjusted model for socio-demographic variables, SES variables, health behaviour and multimorbidity (model 3). Data were analyzed using the SPSS software for Windows. Table 1 summarizes the distributions of individual characteristics. The majority (63%) of the sample were 60-69 years. Fifty four percent of participants were female, 82% had low education, 62% were married, more than half (55%) were unemployed. Seventy one percent of participants were categorized as non smokers, 56% had normal weight, 64% were categorized as mild physical activity, and 52% consumed vegetables or fruit at least once a day. Fifteen percent of the sample have two or more chronic NCDs (multimorbidity) and 75% were unhealthy SRH. Table 2 presents the bivariate tests, indicated that older adults who unhealthy SRH were more likely to be represented among 70 years and older group. The proportion of unhealthy SRH was significantly higher among low education level and unemployed. The distribution of unhealthy SRH related to health behavioral revealed statistically significant differences proportion. Those with unhealthy SRH was higher among among ex smoker, underweight, comsumed fruit and vegetables less than 4 times a week and mild physical activity. SRH varied by the number of NCDs, those with the number of NCDs is two or more NCDs (multimorbidity) were less likely to report unhealthy SRH. Religious activity participation were also related to unhealthy SRH, with lower proportions of those who were not participated in religious activity. This study used data from a national household survey to examine the association between religious activity participation with SRH. There was difference of unhealthy SRH among the oldest age group (32.2%) with the youngest age group (24.0%). This means that the subjective health status of the population significantly decreases with advancing age. Similar results were found in previous studies, which showed that age was a risk factor for poor SRH. 5,18 In contrast, this study found no differences of multimorbidity among women and men also among married and unmarried.

Results and Discussion
Socioeconomic position (SEP), defined by education, income, occupation, or a combination of these variables, has been linked to health outcomes in epidemiological studies carried out in many countries. 19 Present study shows that lower education is associated with higher rates of unhealthy SRH. This findings consistent with other studies which found that low educational level was statistically significantly associated with a worse SRH compared to higher educational level. [20][21] The proportion of unhealthy SRH was higher among unemployed persons compared to employed persons. There are two main reasons why unemployment could conceivably affect health. First, it is related to standards of living and the material conditions of life, and second it is a stressful event which may become chronic and deprive an individual of a social role, meaningful daily existence and contact with others. 22 Income is surprisingly unrelated to unhealthy SRH, and this finding is inconsistent with many previous studies. 5,[23][24] Present study found that being underweight, ex smokers, mild phyisical activity and consumed vegetables and fruit less than 4 times a week increases the risk of unhealthy SRH. Underweight is one risk factor observed in this study. This can be explained that underweight was linked to eating disorders such as anorexia nervosa, or consumptive diseases such as malignant tumors. 5 Our observation that health behaviour has an impact on SRH is supported by study that found associations between lifestyle factors and disease. 19 Smoking, physical inactivity, unhealthy diet, obesity and other lifestyle behaviors are associated with the development of diseases such as cancer, heart disease, stroke, and diabetes. 25 Multimorbidity was associated with self-rated health in this study. The participants without NCDs rate their health significantly better than those with one or more NCDs. This finding was similiar with another studies. [26][27][28] Consistent with prior research, this study provides evidence of the association between religious activity participation and SRH after adjusting for all variables. This finding is supported by study that found weekly religious attendance associated with improving and maintaining good health behaviour, mental health, increased relationship and marital stability. 13 Religious activity participation significantly found improved mental health in older adults. 12,[29][30][31] As was the case with social participation, that low social participation is associated with an increased risk of low leisure-time physical activity, which means that social participation can modify health-related behaviour. 11 This study have several strengths and limitations. A major strength of this study was the use of data from a large nationally representative sample. This made it posible to examine relationships between religious activity participation with SRH. The study also have some limitations. First, this study was largely based on the subjects self reports and not measured independently by an expert, which could have intorduced some bias. Furthermore, it should be stated that the chronic conditions highlighted in this study were self-reported, and therefore this could have the effect of underestimating the effect of chronic diseases on SRH.
The measure of religious activity participation was based on simply questions whether the participants participated in religious activity or not during the last 12 months. There was no assessment of the frequency of the activity, nor of the time spent on activity. Second, because the data are cross-sectional, so ability to understand the direction of the relationships among the