DOESADOLESCENCEANEMIAPERSISTOVERAWOMAN’SLIFECYCLE?

EVIDENCEFROMTHEINDONESIANFAMILYLIFESURVEY

ElanSatriawan,RanjanShrestha,FirmanWitoelar,andTakashiYamano

NO.690

ADBECONOMICS

July2023

WORKINGPAPERSERIES

ASIANDEVELOPMENTBANK

ADBEconomicsWorkingPaperSeries

DoesAdolescenceAnemiaPersistoveraWoman’s

LifeCycle?EvidencefromtheIndonesianFamilyLifeSurvey

ElanSatriawan,RanjanShrestha,FirmanWitoelar,andTakashiYamano

No.690|July2023

TheADBEconomicsWorkingPaperSeriespresentsresearchinprogresstoelicitcommentsandencouragedebateondevelopmentissuesinAsiaandthePacific.TheviewsexpressedarethoseoftheauthorsanddonotnecessarilyreflecttheviewsandpoliciesofADBoritsBoardofGovernorsorthegovernmentstheyrepresent.

ElanSatriawan(esatriawan@ugm.ac.id;

elan.satriawan@tnp2k.go.id)isanassociateprofessor

atUniversitasGadjahMadaandthechiefofthePolicy

GroupofNationalTeamforAccelerationofPoverty

Reduction(TNP2K),OfficeoftheVicePresident,

RepublicofIndonesia.RanjanShrestha

(rshrestha@)isalectureratWilliam&Mary.

FirmanWitoelar(firmanwitoelar.kartaadipoetra@

.au)isafellowattheCrawfordSchoolof

PublicPolicy,AustralianNationalUniversity.Takashi

Yamano(tyamano@)isaprincipaleconomist

attheEconomicResearchandDevelopmentImpact

Department,AsianDevelopmentBank.

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ABSTRACT

Westudythedeterminantsofhemoglobinconcentrationinwomenthroughouttheirlifecycleandaskwhetheranemiaduringadolescencepersistsintoadulthood.UsingapanelofindividualsfromtheIndonesianFamilyLifeSurvey(IFLS),wefindthatalthoughabout30%ofoursamplewasanemicduringagivensurveywave,63%experiencedanemiaatleastonceoverthefoursurveywaves,suggestingahighburdenofanemiaamongIndonesianwomen.Furthermore,thehighprevalenceofanemiaisnotlimitedtopoorwomenbutisalsoobservedinthewealthiersegmentsofthepopulation.Usingadynamicpanelframework,wefindasignificantrelationshipbetweencurrenthemoglobinconcentrationanditsmeasurementintheprecedingsurveywave,suggestingsomepersistenceofanemiastatusacrosssurveywaves.However,asmallautoregressivecoefficientsuggeststhathemoglobinconcentrationandthelikelihoodofanemiaconvergeacrosswomenovertime.Wefindafewvariablesthataresignificantdeterminantsofhemoglobinconcentration.Amongthem,householdsocioeconomicstatusandwagesofwomencomparedwithmeninthecommunityarepositivelyassociatedwithhemoglobinconcentration.

Keywords:anemia,hemoglobinconcentration,IndonesianFamilyLifeSurvey,femaleadolescenthealth

JELcodes:I15,I18

____________________________

ThegrantfundforthisstudywasreceivedfromtheJapanFundforProsperousandResilientAsiaandthePacificfinancedbytheGovernmentofJapanthroughtheAsianDevelopmentBank.

I.Introduction

Anemiaischaracterizedbylowhemoglobinconcentrationorthenumberandsizeoferythrocytes(redbloodcells),resultinginadecreasedcapacityofthebloodtotransportoxygenthroughoutthebody,andislargelyassociatedwithnutrition,infectiousdiseases,andgenetics(Balarajanetal.2011).

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Symptomsofanemiaincludefatigue,lethargy,andshortnessofbreath.Asinmanylow-andmiddle-incomecountries,thereisahighprevalenceofanemiainIndonesia—aboutaquarterofthepopulationisanemicatanygiventime,withhigherprevalenceinwomenandchildren.

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Thishighprevalenceofanemiaamongwomencouldhaveanimpactontheireducationalattainmentandlabormarketoutcomes,aswellasmaternalandchildhealth.Hence,understandingthesocioeconomicdeterminantsofanemiainwomenhasimportantimplicationsforwell-being.

Inthisstudy,wetrackagroupofwomenfromadolescencethroughadulthoodtoexaminetheextenttowhichpoorhealthinadolescencehasconsequencesthroughoutthelifecycle.Theadolescentyearsareanimportantformativeperiodinwhichindividualsdevelopcapabilitiesthataffecttheirhealthandwell-beingthroughoutthelifecycle(Pattonetal.2016).Duringtheseyears,individualsdevelopthefoundationsofhumancapitalthatenablethemtosuccessfullytransitiontoindependent,healthylifestyles.Theresultsofthisstudywillthereforeprovidepolicy-relevantinsightsintowhethergreaterinvestmentinadolescenthealthisneeded.

ThelongitudinalaspectoftheIndonesianFamilyLifeSurvey(IFLS)alongwiththeextensivehealthandsocioeconomicinformationcollectedinthesurvey,allowsustostudythedeterminantsofanemiainwomenthroughouttheirlifecycle.BecausetheIFLShasmeasuredrespondents’hemoglobinconcentrationssincethesecondroundofthesurveyin1997(IFLS2),thelongitudinalnatureofthesurveyallowsustoexaminetheprevalenceofanemiaovertimeforthesamegroupofindividuals.Wefollowwomenwhowereadolescents(10–19yearsold)inIFLS2intoadulthoodandthroughthelatestroundofthesurveyin2014(IFLS5).

WefindahighburdenofanemiaamongIndonesianwomenindifferentincomegroups.Theprevalenceofanemiainoursamplerangedfrom23%to34%ineachsurveywave.However,trackingthesamewomenoveralongerperiodsuggestsahigherburdenofanemia,asabout65%ofoursamplewasanemicatleastonceinthefoursurveywavesconductedbetween1997and2014.Furthermore,anemiaisnotlimitedtothepoorordisadvantagedgroups,butisalsoprevalentinhigherincomegroups.

1Thenormalhemoglobinlevelsvaryaccordingtoage,gender,andstageofpregnancy.Weusethefollowingcutoffvaluesforhemoglobinconcentration(WHO2001)toclassifywhetherapersonisanemic:childrenyoungerthan5years:11.0g/dL;children6–11years:11.5g/dL;children12–14years:12.0g/dL;adultmen:13.0g/dL;adult(nonpregnant)women:12.0g/dL;adult(pregnant)women:11.0g/dL.

2Inthe2014IndonesianFamilyLifeSurvey(IFLS)sample,40%ofchildrenaged5–12yearsareanemic,while32%ofnonpregnantwomenand42%ofpregnantwomenareanemic.

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Weuseadynamicpanelframeworktomodelthesocioeconomicdeterminantsofhemoglobinconcentrationanditspersistencethroughoutthelifecycleofwomen.Weestimateadynamicconditionalhealthdemandfunctioninwhichcurrenthemoglobinconcentrationisafunctionoflaggedhemoglobinconcentrationalongwithindividual,household,andcommunitycharacteristics.Thecoefficientonlaggedhemoglobinconcentrationprovidesinformationontheextenttowhichanemiapersiststhroughoutthelifecycle.Thedifficultyinestimatingthisspecificationisthatlaggedhemoglobinconcentrationislikelytobecorrelatedwithunobservedcharacteristicssuchasinnatehealth,parentalpreferences,andcommunitycharacteristics,makingitdifficulttoobtainunbiasedestimates.Weusethedifferencegeneralizedmethodofmoments(GMM)andthesystemGMMapproachestoaccountfortheendogeneityoflaggedhemoglobinconcentration.

Wefindasignificantrelationshipbetweenthelaggedhemoglobinconcentrationandthecurrenthemoglobinconcentration,suggestingsomepersistenceofanemia.However,asmallcoefficientonlaggedhemoglobinconcentrationsuggeststhatwomen’shemoglobinconcentrationandanemiariskconvergesovertime.Onlyafewvariablesinourempiricalspecificationareabletopredicthemoglobinconcentration.Amongthem,wefindthathemoglobinconcentrationhasapositiverelationshipwithhouseholdsocioeconomicstatusandwomen’swagescomparedwithmen’sinthecommunity,suggestingthatwomen’sincomepotentialandeconomicstatusinthecommunitymayberelatedtotheprevalenceofanemiainwomen.

Thispaperisorganizedasfollows.Thenextsectiondiscussesthedynamicpanelframeworkusedtoestimatethesocioeconomicdeterminantsofhemoglobinconcentration.ItisfollowedbyadiscussionoftheIFLSsampleusedfortheanalysis,whichconsistsofwomenwhowereadolescentsin1997andweretrackedinsubsequentwaves.Next,wediscusstheresultsoftheanalysisonthepersistenceofhemoglobinconcentration.Finally,weconcludewithpossiblepolicyimplicationsforaddressinganemiaamongwomen.

II.EmpiricalMethodology

FollowingStraussandThomas(2008),adynamicconditionalhealthdemandfunctioncanbederivedusingalife-cycleoptimizationproblemwhereindividualsmaximizeutilitysubjecttoabudgetandtimeconstraint,aswellasadynamichealthproductionfunction.Theempiricalrepresentationofthedynamicconditionalhealthdemandfunctioncanbeexpressedasfollows:

RS

Hit=F0+F1Hit?1+xFjXjit+xFZji+eit

j=2j=1

Thedependentvariable,Hit,isthehealthstatusoftheindividualattimetwhilethelaggeddependentvariable,Hit?1,isthehealthstatusoftheindividualintheprecedingperiod,t?1.Inourcase,anindividual’shealthstatusistheirhemoglobinconcentration.TheXvalues

3

aretime-varyingregressorsthatcaptureindividualcharacteristicssuchasage,educationlevel,householdpercapitaexpenditure,andcommunitycharacteristicssuchaspricesandinfrastructuredevelopment.TheZvaluesaretime-invariantregressorssuchasthemother’seducationandhouseholdandcommunitycharacteristicsthatdonotchangeovertime.

Thecoefficientonthelaggeddependentvariable(F1)providesuswithanestimateofthepersistenceofhemoglobinconcentrationthroughoutthelifecycle.IfF1isclosertozero,thenthereislowpersistenceofhemoglobinconcentration.Awomanwithalowhemoglobinconcentrationinoneperiodisunlikelytohavealowhemoglobinconcentrationinthenextperiod,implyingthatanemiaisnothighlypersistentoverthelifecycle.Ontheotherhand,highervaluesofF1thatareclosertoonewouldimplyahighdegreeofpersistence,soawomanwithlowhemoglobinconcentrationinoneperiodwillalsohavelowhemoglobinconcentrationinthenextperiod.

Theerrorterm,eit,hastwocomponents:thefixedeffects,ui,andtheidiosyncraticshocks,vit,whichareassumedtobeuncorrelatedacrossobservations.

eit=ui+vit

Thefixedeffects,ui,capturetime-invariantunobservedfactorsthatincludeindividual-specificfactorssuchasinnatehealthandgeneticendowments,household-specificfactorssuchaspreferencesanddiscountrates,andcommunity-specificfactorssuchasgeographiccharacteristicsandculturalinstitutions.

Becausethelaggeddependentvariableiscorrelatedwiththefixedeffectsintheerrorterm,ordinaryleastsquares(OLS)estimateswillbebiased.Furthermore,fixedeffectsestimationwillbebiasedbecausethewithin-grouptransformationofthelaggeddependentvariableisstillcorrelatedwiththetransformationoftheerrorterm(Nickell1981;Bond2002).

ThedifferenceGMMapproach—basedonHoltz-Eakin,Newey,andRosen(1988)andArellanoandBond(1991)—involvestakingthefirstdifferencewhichremovesthefixedeffects.

R

Hit?Hit?1=F1(Hit?1?Hit?2)+xFj(Xjit?Xjit?1)+(vit?vit?1)

j=2

Althoughtheindividual-specificfixedeffectisnolongerpresentinthedifferencedequation,itsestimationiscomplicatedbythecorrelationofthedifferenceinthelaggeddependentvariable(Hit?1?Hit?2)withthedifferencederrorterm(vit?vit?1),asHit?1iscorrelatedwithvit?1.Inthiscase,theOLSestimationisinconsistent.However,(Hit?1?Hit?2)canbeinstrumentedbyHit?2orhigher-orderlagsofthedependentvariable.

However,thelaggedlevelsmaybeweaklycorrelatedwiththefirst-differencedlaggedvariables,especiallyiftheendogenousvariableispersistent.ThesystemGMMapproach,basedonBlundellandBond(1998)andArellanoandBover(1995),improvesefficiencyoverthedifferenceGMMapproachbyaddingadditionalmomentrestrictionsbasedon

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instrumentingthelevelsoftheregressorswithlaggeddifferencesoftheinstruments.WhilethedifferenceGMMapproachdifferencestheregressorstoremovethefixedeffects,thesystemGMMapproachaugmentsthedifferenceGMMapproachbydifferencingtheinstrumentstomakethemexogenoustothefixedeffects.

III.Data

TheIndonesianFamilyLifeSurvey(IFLS),anextensivelongitudinalsurveythatprovidesuswithinformationattheindividual,household,andcommunitylevels,istheprimarydatasetweuseforouranalysis.Thefirstwave(IFLS1),conductedin1993,surveyedover7,000householdsfrom13ofthe27provinces,representing83%ofthepopulation.SubsequentwavesinterviewedtargetmembersoftheoriginalIFLS1householdsaswellassplit-offhouseholdswithrecontactratesabove90%,andwereconductedin1997,2000,2007,and2014(Straussetal.2004;Straussetal.2009;Strauss,Witoelar,andSikoki2016).

Wetrackfemaleadolescentsages10–19duringthesecondwaveoftheIFLS,whichwasconductedin1997.WebegintrackingadolescentsfromthesecondwavebecausetheIFLSonlybegancollectinghemoglobinconcentrationusingapinprickbloodsampleduringthiswave,sowecanonlydetermineanemiastatusstartingfromthissurveywave.Thebloodsamplewascollectedalongwithotherhealthmeasurementsbytrainedmedicalpersonnel,usuallynursesorrecentlytrainedparamedics,sowecanbeconfidentwiththeseobjectivehealthmeasurements,which,unlikesubjectivehealthmeasures,arenotaffectedbyrespondentrecallbias.

Inthe1997wave,theIFLSinterviewed3,365femaleadolescentsbetweentheagesof10and19.Fortheanalysis,wefurtherrestrictthesampletothosewhowereinterviewedinallsubsequentIFLSwavestocreateabalancedpanel.Inaddition,wedropindividualswhowerepregnantduringanyofthesurveystoreduceconfoundingduetopregnancy-relatedissues.Afterexcludingsomeadditionalobservationswithinconsistentagesandbirthyearsandwithmissingvalues,thefinalanalysissampleconsistsof1,453adolescents.

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[Table1here]

Table1presentsthedescriptivestatisticsforthisbalancedpanelforeachofthesurveyyears.Oftheadolescentsinterviewed,57%areinthe10-to14-year-oldagegroup(hereafterreferredtoasearlyadolescents)and43%areinthe15-to19-year-oldagegroup

3Comparingthedescriptivestatisticsofadolescentsinthe1997balancedpanelwiththoseofadolescentsnotincludedintheanalysisbecauseofattritioninsubsequentrounds,wefindthatalthoughslightdifferencesexistinlogpercapitaexpenditureandeducationbetweenthesetwogroups,suggestingslightlyhigherattritionamongthebetter-offadolescents,thehemoglobinconcentrationandanemiaprevalencearesimilarinthesetwogroups.

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(lateadolescents).Oftheseadolescents,29%wereanemicatthetimeofthe1997survey.TrackingtheanemiastatusofthesewomeninsubsequentyearsindicatesaveryhighprevalenceofanemiaoverthelifecycleofanIndonesianwoman,as63%ofthesamplewasanemicatleastonceinthefourwavesofthesurvey.Prevalencehasalsochangedovertime;itwashighestin2000,when34%ofthesamplewasanemic,possiblyreflectingthepersistentnegativeeffectsofthe1998financialcrisis,anditwaslowestin2007,when23%wereanemic.Anothernotableobservationisthatprevalencehasinfactincreasedinrecentyears,from23%in2007to27%in2014.

Descriptivestatisticsforvarioushouseholdcharacteristicsindicatesignificantimprovementsinlivingconditionsbetween1997and2014.Theshareofhouseholdswithelectricityincreasedfrom86%to99%,theshareofhouseholdswiththeirowntoiletincreasedfrom60%to84%,andtheshareofhouseholdswithatelevisionincreasedfrom60%to94%.Significantchangeswerealsoobservedintheownershipofhouseholdappliancesthatcouldplayaroleinfoodpreparationandnutrition,suchasownershipofrefrigeratorsandelectricorgasstoves.Theshareofthosewhoreportednotowningarefrigeratordecreasedfrom73%in1997to30%in2014,whiletheshareofthosewhoownedagasorelectricstoveincreasedfrom6%to78%overthesameperiod.

[Table2here]

Table2presentsdescriptivestatisticsfortheadolescentsseparatedbyanemiastatusin1997.Themeancharacteristicslooksimilarforthetwogroups,exceptforslightdifferencesinlivingconditionsthatsuggestthatthenonanemicadolescentshaveslightlybetterlivingconditions,withslightlyhighereducationalattainmentofhouseholdheadsandslightlylowerincidenceofpoverty(definedashavinghouseholdpercapitaexpenditureinthebottom30%)andlivingincement/brickhouses.Thehighprevalenceofanemiathroughoutthelifecycleisalsoreflectedinthefactthatthosewhowerenotanemicduringadolescencehaveahighchanceofbecominganemiclaterinlife;48%oftheadolescentswhowerenotanemicin1997wereanemicinoneofthesubsequentsurveyrounds,whichreinforcesthefactthattheburdenofanemiaiswidespreadinthefemalepopulation.

[Table3here]

Table3showsthetransitionmatrixofanemiastatusforourpanelrespondentsfromonesurveyyeartothenext.Forstate1,whichisnon-anemic,andstate2,whichisanemic,wenotesignificantmovementfromonestatetotheother.Forexample,theprobabilitythatapersonbecameanemicin2000was0.28ifheorshewasnotanemicin1997.Ontheotherhand,theprobabilitythatapersonwhowasanemicin1997remainedanemicin2000was

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0.49,suggestingsomepersistenceinanemiastatus.Whilethetransitionprobabilityofmovingintoananemicstatefromanon-anemicstateandthatofremaininginananemicstatebothfellfor2000–2007(0.16and0.35,respectively),theseprobabilitiesonceagainrosefor2007–2014(0.22and0.46).

[Figures1and2here]

Figures1and2plotlocallyweightedmeanvaluesforanemiaandforhemoglobinconcentrationinrelationtohouseholdpercapitaexpenditure(PCE).Becausehouseholdsarelikelytosmooththeirconsumption,PCEisaproxyfortheirpermanentincome.Wefindthatthehighprevalenceofanemiaisnotrestrictedtowomenfromlow-incomehouseholds,butthatprevalenceishighamongwomenacrossthePCEdistribution.In1997,theprevalenceofanemiainearlyadolescentshasaclearnegativerelationshipwithPCE;theincidenceofanemiadecreaseswithincreasingPCE,whereashemoglobinconcentrationincreaseswithPCE.Amonglateadolescents,however,prevalenceishighestinhouseholdswiththehighestPCE.Insubsequentsurveyyears,asadolescentsgrowolder,prevalenceremainshighacrosstheentirePCEdistribution.

[Figures3to6here]

Figures3–6presentlocallyweightedmeanvaluesofthelikelihoodofanemiaandhemoglobinconcentrationlevelsovertimeforthe1997adolescentswhowereanemicandforthosewhowerenotanemic.Allfiguresshowsomeconvergenceinthelikelihoodofanemiaandhemoglobinlevelsovertimeforthesetwogroups.Theconvergenceovertimeisstrongerfortheearlyadolescents.However,aslightgapinthelikelihoodofanemiaandhemoglobinlevelspersistsinthelateryearsforthesetwogroups,withalargergapremaininginthelateadolescents.

IV.Results

Wefirstpresenttheresultsforourfullsampleof1997femaleadolescents(10–19yearsold)inTable4.Wethenpresentresultsseparatelyforthosewhowereinearlyadolescence(10–14yearsold)in1997inTable5andthosewhowereinlateadolescence(15–19yearsold)in1997inTable6.ThefirstcolumnofalltablescontainstheOLSestimates.TheOLScoefficientsforlaggedhemoglobinconcentrationarelargeandsignificant:0.30forthefullsample,0.26fortheearlyadolescentsample,and0.37forthelateadolescentsample.However,theseestimatesarelikelytobebiasedupwardasthelaggeddependentvariableiscorrelatedwiththefixedeffectsintheerrorterm.

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[Table4here]

ToaccountforthebiasthatarisesinanOLSframeworkwhenwehavealaggeddependentvariableasaregressor,weusethedifferenceGMMandthesystemGMMapproaches.WeusetwodifferentspecificationsforthedifferenceGMMapproachwhicharepresentedintwoseparatecolumns.ForthesystemGMMapproach,weusethreedifferentspecifications,thefirsttwoofwhicharethesameasthatusedforthedifferenceGMMapproach.Inthefirstspecification(presentedincolumns2and4),allregressorsexceptthelaggeddependentvariablearetreatedasexogenous.Thesecondspecification(columns3and5)treatspercapitaexpenditureandeducationasendogenousandusestheirlagsasinstruments.ThethirdspecificationforthesystemGMM(column6)addsonthesecondspecificationbyusingindividual,household,andcommunitycharacteristicsfrom1997asinstruments.Theseinstrumentsincludeage,mother’seducation,typeoffloorandouterwall,numberofrooms,presenceofwasteandtrasharoundthehouse,andnumberofposyandus(villagehealthposts)inthecommunity,allmeasuredin1997.

[Table5here]

Asexpected,thedifferencebetweentheGMMandthesystemGMMestimatesofthecoefficientonlaggedhemoglobinconcentrationwassmallercomparedwiththedifferencebetweentheGMMandtheOLSestimates.DifferenceGMMestimatesrangefrom0.086to0.113forearlyadolescentsand0.116to0.127forlateadolescents.Similarly,systemGMMestimatesrangefrom0.068to0.083forearlyadolescentsand0.119to0.153forlateadolescents.Thecoefficientsarestatisticallysignificantforallspecifications.Thissuggeststhatsomepersistenceexistsforhemoglobinconcentrationoverthelifecycle.However,thesmallautoregressivecoefficientssuggestthatthelevelofhemoglobinconcentrationconvergesovertimeforthewomeninoursample.

Wefindthatfewotherregressorsarestatisticallysignificant.Thenumberofyearsofeducationhasanegativecoefficient,butitissignificantinonlyonespecification.Therelativewagesoffemalescomparedtomalesinthecommunityhaveasignificantpositiverelationshipforearlyadolescentsbutarenotsignificantforlateadolescents.Theseresultssuggestthatwomen’sincomepotentialandeconomicstatusmayberelatedtotheprevalenceofanemiainthecommunity,especiallyfortheyoungercohort.Furthermore,theresultssuggestsomeregionaldifferencesinanemiaprevalence.ThecoefficientsforSumatraandtheouterislandsaresignificantandpositiveforearlyadolescentsforsomespecifications,suggestingloweranemiaprevalenceintheseregionscomparedwithJavaandBali,theexcludedregion.

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Wealsofindapositiveandstatisticallysignificantrelationshipbetweensocioeconomicstatusandhemoglobinconcentrationfortheoldercohortbutnotfortheyoungercohort.

4

Usingadifferentspecificationthatincludeshousingcharacteristicsbutnotsocioeconomicstatus(tablesnotprovidedhere),wealsofindthatownershipofhouseholdappliancesrelatedtofoodpreparationandnutrition—ownershipofarefrigeratorandagasorelectricstove—hasasignificantnegativerelationshipwithhemoglobinconcentrationamongearlyadolescents.Thisfindingsuggeststhatthereisadditionalscopetoexplorewhethertheprevalenceofanemiaindifferentincomegroupsisdrivenbydifferentfactors.Forexample,itislikelythattheprevalenceofanemiainthelow-incomegroupisdrivenbytheinabilitytoaffordadiversemicronutrient-richdiet.Ontheotherhand,itcouldbethattheprevalenceofanemiainthehigher-incomegroupsisdrivenbydietarychangesassociatedwitheconomicdevelopmentandmodernization.

V.Conclusion

Thispaperexaminedthedeterminantsofwomen’shemoglobinconcentrationthroughouttheirlifecycleusingtheIndonesianFamilyLifeSurvey.Trackingadolescentsfromthesecondsurveywaveinsubsequentwavesrevealedahighprevalenceofanemiawithsomevariationinprevalenceovertime.However,thehighprevalenc