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Disabled persons in Poland
Sot. Sri. Med. Vol. 19. No. II.
0277-9536/X4 S3.00 + 0.00 Pergamon Press Ltd
pp. 1141-1149. 1984
Printed in Great Britain
DISABLED PERSONS IN POLAND JANUS BEJNAROWKZ Central Statistical Office, Warsaw, Poland Abstract-It is generally considered that disability is an important social problem. This was expressed for example by the decision of the United Nations Organisation to nominate 1981 as the International Year of the Disabled. The number of disabled is one of the main problems. For social planning, the proper allocation of goods and resources for changes in the attitudes of society towards disability it is necessary to identify the prevalence, distribution and composition of the disabled. Prior to the 1978 Census, in Poland there was no information available on disability except the number of disabled persons legally classified by the Medical Board for Disability and Employment receiving disability pension, as well as the average amount of such pension, the number of disability certificates issued annually, the number of employed and the number employed in co-operatives for the disabled. The social criterion-major social role associated with psycho-physical state-was the main concept of the investigation on the frequency of disability in 1978 Census. Methodology used in this study of disability was based on the U.S. experience gained from the 1970 NC, as well as on the NCHS Survey of psychophysical causes of permanent limitation of social role performance and locomotion, performed since 1957. It should be explained, however, that the scope of disability investigated in NCHS Survey and in Polish Census is exactly the same and much wider than in U.S. Censuses. The Polish National Census revealed that there are 2,485,OOl disabled persons in Poland, i.e. 7.1% of the total population. The urban population constituted 57.7% and the inhabitants of rural areas 42.5% of the total population. The majority of the disabled came from urban areas-62.2% compared to 37.8%. The rate of disabled persons in the population aged 50 or over was 73x, while in the whole population it was 23.9%. Observations made during preliminary comparisons of work disability in males in U.S.A. and in Poland indicate that differences in prevalance rates were not so significant: U.S.A.-l 1.8% and Poland-8.9”/& And these differences referred mainly to disabled persons in the 25-44 age group whose rate is larger in U.S.A. On the other hand, differences in behavioural response to functional impairment of the disabled in U.S.A. and Poland are quite significant, at least, among the employed. The level of employment in the general population was almost identical whilst among the disabled it was almost twice as low in Poland. It Seems that prevalence of disability, conditioned biomedicaliy and treated as an index of health status, is very similar in U.S.A. and in Poland. But some behavioural responses of the disabled differ considerably and relate to features of the social system.
INTRODUCTION
Permanent incapacity to carry out activities of daily living caused by illness or impairment is experienced by a considerable part of the population. Physical or mental disability refers to partial or complete limitation of functions. indispensable for the performance of major activities diversified by the age of a man. Disabled people unable to meet their responsibilities are often helpless, alienated and isolated. They usually face insensibility or even cruelty, sometimes pity, but relatively rarely understanding and, most important, effective assistance. What is their number? What is their age? What are their needs? What would they like to do? To what extent are we able to help them in recovering their social fitness? These are only a few questions which have so far lacked satisfactory replies because of insufficient knowledge. It could be presumed that in Poland, as in most other developed countries, the percentage of those with partial, serious or complete physical or mental disability due to illness or impairment was about 10. Such a value is based on data obtained from several surveys in different countries. It should be stressed that this 10% means that every SSM 19,1-r+
tenth citizen is completely or partially limited in his functions. On the other hand, if one ‘assumes that every disabled person lives in a three or four member family it can be seen that every third person is involved directly or indirectly. In The Netherlands, according to 1972 surveys, over 8.7% of the population aged five had a physical impairment, while taking families into account, 25% of the population suffered a physical disability or had permanent contact with such persons [l]. These figures are remarkable in spite of disability being defined in biological terms, with physical disability only taken into consideration, excluding the mental dimension altogether. In various countries, different age groups have been the subject of interest. In some, only those disabled who lived with families or alone outside special care institutions, were studied. In others, besides these two groups, the disabled living in special care institutions were also included. These different approaches explain why the percentage of the disabled singled out on the basis of different criteria varies so widely, ranging from 6.5 to 14.1% [Z]. Household surveys, having been carried on in the
1141
1142
JANUSZ BEJNAROWICZ
United States for many years, should also be mentioned. They deserve special attention since the concepts and criteria of disability used in the 1970 U.S. Census has been influential in the study of the disabled during the 1978 Census in Poland. The U.S. survey revealed that the percentage of the physically or mentally disabled, with various levels of disability, activities and social role performance amounted in 1958 to 10.1% while in 1974 it had risen to 14.1%. Between 1970 and 1974 the percentage had risen from 11.8 to 14.1% [3]. Such prevalence of disability creates a wide band of problems across the social spectrum as well as for the disabled themselves. Disabled persons differ greatly in type and level of psychophysical disability, age, education, family status and living conditions. Therefore their needs are also diversified and complex. To satisfy them, well designed activities of specialised institutions in many sectors of governmental administration and, most important, a favourable social climate are required. In Poland, the status of the disabled is the concern of many sectors of administration and governmental agencies. It is obvious that precise knowledge on the number of the disabled, their needs and the conditions for their social and vocational rehabilitation determine the type of solutions provided by the State and by society. The Committee for Rehabilitation and Readaptation of Disabled People of the Polish Academy of Science has prepared a report on the “Social Situation of Disabled People and the State of Rehabilitation in Poland” [4]. The Committee, together with the interdisciplinary board for the unification of reporting systems on health care and social welfare, recommended various investigations on disability and related questions using the general census and in other ways to obtain information necessary for decision-making by responsible central and local administration bodies.
THE ROLE OF THE GENERAL SURVEk’S IN OBTAINING AND CHARACTERISTICS
CENSUS AND SPECIAL
DATA ON THE NUMBER OF DISABLED
PERSONS
As already mentioned, there is a long tradition for using the general census for obtaining data on disability. In 1872 during the International Congress on Statistics, held in Petersburg, it was officially recommended to use the census for this purpose [S]. The recommendation was, however, limited to blindness, deafness, imbecility, cretinism and insanity. The number of such disabled persons was estimated during the general censuses in many countries before World War I and during the interwar period. For example, among studies in 15 European and non-European countries carried out in the 1920s. including Poland, physical, and in some countries, also mental ‘defects’, were analysed [6]. In Poland. studies were held in 1924 to estimate the number of mentally handicapped living in special homes or in medical institutions as well as the number of those who required in-patient care. After World War II, despite a substantial interest in the occurrence and types of disability this question was not included in the national census [7].
Outside Poland. although less frequently than in previous periods-especially during the years preceding World War I-the problem of disability was considered in census surveys [8] and more often in sampling studies. Among the more recent European research worthy of mention were: Denmark (196 1i 1962estimation of the number of physically disabled persons [2]; Federal German Republic (1966 )---physical and mental disability was investigated in the microcensus [9a]; Great Britain [9b] and The Netherlands ( 197 1i 1972)-only physical disability was analysed [lo]. Studies on physical and mental disability were carried out in Bulgaria [ll]. In the United States. physical and mental disability was analysed in a 5”, sample of the general population during the 1970 Census [12] and during houshold interview surveys held for many years [ 13). Prior to the 1978 Census there was no information available on disability except the number of disabled legally classified by the Medical Board for Disability and Employment as entitled to receive disability pension, the average pension amount. the number of disability certificates issued annually. the number employed. and the number employed in co-operatives for the disabled. This information was usually related to such variables as sex, age. type and level of disability and the region in which the disabled person was employed. Only the household survey within the microcensus performed in 1974 by the Chief Census Bureau provided more information and indicated gaps. Previous knowledge was insufficient because only disabled persons issued with MBDE disability certificates, regardless of whether or not they received a disability pension, were considered. The number involved was 1,374,000, or 4.17; of the population, and this was only a part of the total number of disabled. The number of disabled who had not received a disability pension was estimated to be 303.000. Parallel data published by the Social Insurance Institution referred only to those disabled in receipt of disability pensions. This totalled 1,070,6OObut did not include demographic and social characteristics of the population. important for social and employment policy. Accordingly, it was possible to establish the number of disabled persons who do not receive disability of males and females, pension, the proportion age, place of residence (rural/urban), categories of disability, education. occupational activity, and marital status. A series of comparative studies were conducted between the disabled and the total population according to specified social situations [14]. Howcvcr. in spite of so many variables, significant data for a comprehensive analysis were Still lacking for: type of disability. its causes. the age at which a person became disabled. and social status preceding disability [ 151. It should be noted that experience gained during the ‘microcensus’. for example in regard to the reporting of disability among persons without disabilitycertificates who had not applied for social or family reasons, led to the inclusion of this question in the 1978 General Census. and to the development of methodology to defne partial social disability and its degree of intensity.
Disabled THE
INVESTIGATION
RANGE
OF THE
OF DISABILITY
1978 GENERAL
persons
IN THE
CENSUS
The major social role associated with the psychophysical state of a respondent was the main thrust of the investigation on the prevalence of disability, that is to say, an investigation of the social consequences of disorders. The idea of employing sociomedical health measures in the 1978 General Census was based on the assumption that social activity depends on one’s state of health. An inability, or the necessity to limit social role performance as worker, student or housewife, as a consequence of chronic disease is a sociomedical measure of the level of health [ 163. Obviously this refers to permanent or long-term limitation and therefore, uncomplicated pregnancy or early puerperium, for example, were not taken into consideration. One positive aspect of this indicator is that it provided a measure of the physical and mental consequences of disease or handicap [ 173. This was important since in the majority of epidemiological surveys only those diseases are considered which produce a physical inability to perform certain social activities
C181. Attention now turns to both variability in the denotation of health in relation to social situation and to the limited cognitive value of health in purely biomedical terms (i.e. psycho-physical limitations). The relationship between state of health and disease is more complex than it often appears. Many individuals with unsatisfactory health as defined clinically may function remarkably well. On the other hand, life is full of examples of contrasting relations between health and occupation [19]. Another reason for not assessing health in purely biological terms is the possibility of human adjustment; those who do not enjoy the best psycho-physical fitness but who want to work, for example, can have their working conditions changed or be provided with prosthetic help. The disabled population and its characteristics were defined on the basis of a health self-report by all members of the household; in the case of children under age, health state was reported by their mothers. On the basis of responses three categories were used; .the first comprised those unable to perform any kind of activity. The second comprised those with certificated disability but without self-reported confirmation and the third category comprised those with partial disability. DISABILITY CENSUS
IN THE NATIONAL
AND UNITED
SURVEY
IN THE
STATES
The 1970 U.S. Census (5”/, sample) investigated the reduction of work performance of 3 months or more duration through psycho-physical causes. In the 1978 National Polish Census, an attempt was made to apply a method combining the benefits of the study covering the whole population of disabled persons and the use of a limited number of questions. In the Polish Census, as the American, complete disability and those kinds of partial dis-
1143
in Poland
ability which considerably limit the function of a given person were defined. It meant that investigation of less serious forms of partial disability in Poland were abandoned a priori [20]. DISABLED
MALES
STATES
AND
IN THE UNITED IN POLAND
Comparison between the data from the NC and from the 1970 U.S. Census can provide only a general comparison. This is because of considerable differences in the levels of ‘detection’ of disability in the two countries so that similarity though high might be co-incidental. The comparison, to be reliable, should be limited only to males disabled for 6 months and over. In the U.S.A. the percentage of disabled males of the total male population aged 25-64 was 11.8%. This was higher than the Polish figure of 8.9% (Table 1). In the U.S.A. the proportion of disabled males living in urban areas (10.9%) was lower than those in rural areas (14.1%). This difference becomes greater in the case of farmers, (14.7%). In Poland the values for urban and rural areas were almost identical and amounted respectively to 8.9 and 8.8%. In Poland, information on rural areas covers agricultural and non-agricultural populations. This makes the given value only a mean whereas perhaps it should be different for agricultural and non-agricultural populations. In the U.S.A. the rate of disabled males increased with age both in rural and urban areas. Large increases occurred in rural areas in the age groups 45-49 and 60-64, and in the case of farmers in the latter age group. In the American rural population of 60-64 years of age, almost every third person considered himself to be disabled and in urban areas almost every fourth person. In Poland (Table 1) the percentage of disabled males in the age group of 25-44 was 3.5% in urban areas and 3.7% in rural areas. This was twice as low as for the corresponding age group in the United States. Starting with the 45-49 age group, the rates were broadly similar in Poland and in the U.S.A. although in Poland the rural rate was 9.4% lower than in the States, where it was 14.5%. Among older age groups the increase was in general more explicit in Poland than in the U.S.A. In Poland the percentage of disabled males in the age group of 60-64 living in urban areas amounted to 28.3%. It should be noted that among the rural population of 50-64 the percentage of Polish disabled males was similar to that among American farmers. The percentage of young disabled males was much lower in Poland than in the United States, while among older urban inhabitants from the age of 50, the percentage of disabled males was higher in Poland. Moreover, in the U.S.A. among males of 50 years of age the rate of disabled persons increased in the older age groups faster in rural areas whereas in Poland this increase was particularly marked in urban areas. Concluding, one may suppose that young males in both rural and urban areas, confronted with real working conditions, consider themselves disabled or are considered to be so by their employers less frequently in Poland than in the U.S.A. On the other hand, in Poland, there was a marked tendency among
JANUSZBEJNAROWICZ
1144 Table
1. United
States
and Poland work disability rate of males years of age by type of residence
United
States-1970
between
25-64
Poland-1978 Rural
Age
Total
Urban
Total
Farm
Total
Urban
Rural
25-64 25-59 25-44 25-34 35-44 4549 50-54 55-59 6CM4 60-61 62-64
11.8 10.3 6.9 5.8 8.2 12.2 15.2 19.2 25.9 23.7 27.7
10.9 9.7 6.6 5.6 7.8 11.4 14.1 17.8 23.9 21.9 25.4
14.1 12.2 7.8 6.4 9.3 14.5 18.1 22.7 31.0 28.0 33.1
14.7 12.6 8.2 7.5 8.8 13.0 16.5 19.7 27.8 24.9 30.1
8.9 7.8 3.6 2.3 5.4 10.1 16.1 21.9 26. I -
8.9 7.9 3.5 2.1 5.3 10.6 17.6 24.2 28.3
8.8 7.7 3.7 2.5 5.5 9.4 14.1 19.2 23.3 -
older urban males to consider themselves or to be regarded by others disabled. This was probably related to the Polish disability pension system and to the granting of certain privileges to the disabled. The similarity between the Polish village and the American farm in regard to disability occurring among the older age groups results probably from their similar social situation, that is from a relatively limited possibility of receiving a disability pension and constant, almost compulsory contact with the main job, running a farm, and the sense of responsibility for its prosperity which has no general counterpart in urban areas. It can be assumed, therefore, that disability in rural areas has a more biomedical basis than a social one, whereas in towns, especially in Poland, the influence of social factors upon the level of activity among disabled persons is strong. In the United States the rate of completely disabled persons amounted to almost one-third of the total population (Table 2). The value of that rate is considerably diversified-almost 2.4 times depending upon the age of the disabled. Among the youngest
Table 2. United States and Poland work disability United
-
(18-M) it was equal to 21.9% and among the oldest (60-64) was as much as 49.904. In Poland. among the total number of the disabled, including those partially disabled, the rate of the completely disabled is almost twice as low as in the U.S.A., being only 16.0%. This increased to 21.9% in regard to the completely and partially disabled when the only slightly disabled were excluded. In Poland, unlike the United States, the rate of completely disabled, whether with or without the slightly disabled was highest among the youngest age groups. The differences between Poland and the U.S.A. confirmed the assumption that requirements faced by workers in the States are higher than in Poland. This is related to the large number of workers employed in Polish agriculture who have relatively big families and where the requirements faced by the disabled worker may not be high. In Poland the rate of employed males aged 18-64 was almost the same as in the U.S.A. including those employed in the armed forces (Table 3). It is worth noting however, that in the States, despite slightly lower employment than in Poland, the rate of older
of males between
18-64 years of age distributed
Poland-1978
States-1970
Total
Total (includes
Age 18-64 1844 18-19 20-24 25-44 45-54 55-59 6cL64 6G6 I 62-64
Total
Partial disability
by level of limitations
Complete work disability
5.816.218 2.363.37 I -
68.4 78.1
31.6 21.9 -
1SO2.047 91 1.738 I ,039.062 406.248 632.8 14
70.4 60.9 50.1 54.8 47.0
29.5 39. I 49.9 45.2 53.0
only formal status of disability) 758.095 209,908 8603 27.679 173.626 263.6 14 162,568 122,005 -
Partial work disability 84.0 80.8 73.3 76.3 81.9 85.4 85.2 84.7 -
Complete work disability 16.0 19.2 26.7 23.7 18.1 14.6 14.8 15.3
(excludes only formal status of disability) 555,414 165.300 7653 23,259 134,388 189.516 114,726 85,872
Partial work disability 78. I 75.7 70.0 71.8 76.6 79.7 79.0 78.2
Complete work disability 21.9 24.3 30.0 28.2 23.4 20.3 21.0 21.8
1145
Disabled persons in Poland
Table 3. United States and Poland rate of employed among work disabled males in the age group of 25-64 by level of limitations Poland-1978
United States-1970
Disabled population with ‘work disability (includes only formal status of disability)
Disabled population with work disability Age 18-64 18-44 18-19 20-24 25-44 45-54 55-59 60-64 60-61 62-64
General population 85.7 85.7 91.1 85.3 71.8 78.8 66.5
Total
Partial
60.9 68.5 66.0 55.6 40.8 47.8 36.2
85.1 84.4 89.7 86.2 76.7 82.6 72.3
General Complete population 8.5 11.8 9.7 7.7 4.7 5.7 4.2
Disabled population with work disability (excludes only formal status of disability)
87.8 89.5 58.3 82.7 96. I 89.8 81.5 62.4 -
persons amounted to 71.8% while in Poland it was 62.4%. Occupational activity among the disabled in Poland was’ much lower than in the U.S., its rate amounted to only 35.4% of the total employed population, while among the disabled population (including those with slight disability) the rate of employed was 32.0% and in the States it was 60.9% [21]. In Poland the employment level of the disabled was almost identical for each of the investigated age groups. In the United States the employment level decreased significantly with increase of age, reaching 40.8% in the 60-64 age group, close to the corresponding Polish figure (3 1.8%). In the United States, the rate of employment among the completely or partially disabled was very diversified as much as 85.1% among the partially disabled and S.S”,d,ten times lower, for the totally disabled. In regard to age, the rates were 11.8% (18-44) and 4.7”/, (6G64). Among the partially disabled the level of employment was similar in each age group, for the 60-64 it amounted to 76.70/, exceeding the employment rate of the total male population of this age (71.87;). In Poland the employment rate of the completely disabled amounted to 10.3”,a slightly higher than the 8.5’; in the U.S.A.. but unlike the States, it was almost constant for all the compared age groups. The employment rate among both the seriously and mildly handicapped amounted to 40.2% and among only more seriously handicapped it was even lower. 38.10,. Comparative analysis showed the following major differences and similarities: employed
(I) In the United States, occupational activity among the disabled was almost twice as high as in Poland, but in the sub-population of the completely disabled the employment level was almost identical in both countries, though it increased with age in the States and remained at the same level in Poland. (2) In the United States occupational activity
Total
Partial
Complete
Total
Partial
35.4 36.9 23.5 39.6 37.2 35.5 36.0 31.8 -. -
40.2 43.3 30.2 49.3 43.0 39.8 40.4 35.8 -
10.3 9.8 5.1 8.4 10.5 10.9 10.5 10.0 _ -
32.0 33.4 20.4 34.9 33.9 32.4 32. I 28.5 -
38.1 41.0 26.9 45.3 41.0 37.9 37.9 33.6 -
among partially disabled males was almost the same as for the male population as a whole and in the 55-59 and 60-64 age groups it was even higher. In Poland the employment of partially disabled persons was more than twice as low as among the total male population. In both countries, employment levels of the partially disabled were constant for all age groups. This suggests that the differences depended mainly on social factors such as disability pension system and employment requirements. Biomedical factors caused similar limitations in both countries. LEVEL OF DISABILITY ACCORDING TO SOCIOMEDICAL CRITERIA AND LEVEL
OF DISABILITY
THE MEDICAL DISABILITY
DEFINED
BOARD
BY
FOR
AND EMPLOYMENT
The national census asked two questions in order to define the level of psycho-physical disability. The first related to health based on subjective sociomedical criteria, the second to level of disability as defined by the Medical Board for Disability and Employment (MBDE). The first question was addressed t.o all those who considered themselves unable to perform a basic social role. Many disabled persons especially in rural areas do not apply to MBDE for obtaining the disability certificate; moreover, since MBDE defined disability after medical examinations, it can be assumed that all persons recognized by MBDE as disabled, identified themselves as disabled when answering the first question. In view of this, responses to the first question will be discussed first. The results are presented in Table 4. Among all those investigated, 18.6% considered themselves having only limited ability to perform activities. related to a given age, such as occupation, education, running a household. activities of daily living, for pre-school children an inability to play;
JANUSZBEINAROWICZ
1146
Table 4. The disabled according to categories of disability and self-report Persons with certificated disability without self-report confirmation
The disabled with limitations of performance of activities major for a given age according to self-report Total The disabled according to categories of disability Total I II III Self-reported disabled persons without disability certificate
Complete
Number
%
Number
%’
Number
%
Number
O0
2,485,001 305,423 868,609 754,609 556,360
100.0 100.0 100.0 100.0 100.0
463,037 150.263 139,682 52,265 120,827
18.6 49.2 16.1 6.9 21.7
1,437,526 113,642 484,897 403,454 435,533
57.9 37.2 55.8 53.5 78.3
584,438 41.518 244,030 298.890 -
23.5 13.6 28.1 39.6 -
57.9% perceived themselves as being considerably handicapped in the performance of major activities for a given age; while 23.5% did not report complete or partial limitations in performing major activities despite being recognized as disabled by the MBDE.
This shows clearly that the relationship between physical or mental impairment and social performance is not always explicit. This is supported by the fact that among persons recognized as disabled by the MBDE, but who did not report complete or partial handicap related to the performance of age-specific roles, there were 41,518 respondents (7.1%) having category one disability (Table 5). This represented 13.6% of the total number in category one recognized by MBDE, (Table 4). 70.4% of those aged 70 and over with a category one handicap failed to report complete or partial disability. This suggests that of those in this category occupational activity is very often limited not so much by the level of psycho-physical ability as by the absence of an appropriate job. Among persons who reported complete fitness for social role performance the rate of category one and two disabled was almost the same (Table 5). Furthermore, among the total disabled, the 305,423 with category one disability was so proportionately high that their rate in the sub-population of the completely disabled could be theoretically doubled (Table 4). We turn to the fact that among
Table
Partial
persons
with com-
5. The disabled
plete disability, 11.3% were in category three. This probably refers to people whose physical state is good but whose mental state required constant care. It should be noted that among the completely disabled 26.1% were not classified in any category of disability. This group probably comprised those for whom a certificate from the MBDE had no special meaning. In the sub-population with partial disability, those with category two disability, form the largest group (33,7x); the corresponding figure for category three was 28.1% and for category one it was 7.9%. It should be noted that the rates for the first category of disability, and to some extent, the second category, were similar to the rates of these groups in the sub-population with partial disability. Concluding the above observations, it was observed that in each of the groups, distinguished by level of disability, the rate of persons with category two disability was similar, contrary to other categories of disability. Also, the rate of disabled not classified according to disability was approximately the same among persons with complete or partial disability. There was, then, a slight relationship between subjective level of disability as stated in the self-report, and the level of disability determined by the MBDE i.e. the category of disability. This conclusion is confirmed by the fact that
according to self-report disability
categories
The disabled The disabled according to categories of disability Total I II III Self-reported disabled persons without disability certificate
with limitations of performance of activities major for a given age according to self-report
and
Total
Complete
Partial
Persons with certificated disability without self-report confirmation
100.0 12.3 34.9 30.4 22.4
100.0 32.4 30.2 Il.3 26.1
100.0 7.9 33.7 28. I 30.3
100.0 7. I 41.8 51.1 -
of
Disabled persons in Poland among those in the first category the rate of those with partial disability amounted to 37.2’:{,and among persons who do not consider themselves disabled it was as much as 13.6”,, (Table 4). In the sub-population of category three the rate of persons completely disabled was 6.9”,, and for those who did not consider themselves disabled it was as high as 39.6”,,. In the sub-population of category two the rate of those who did not consider themselves disabled amounted to 28.19,,. It should also be noted that the rate of people with partial disability was almost the same for both sub-populations categories two and three, that is about 50” The cri&ia used for defining category of disability differed from those used in the self-report. The criteria used by MBDE were limited to a narrow spectrum of medical questions and were therefore insufficient for the assessment of social role performance. Furthermore. among persons without any certified category of disability. the percentage who were completely disabled was 21.7”,, and partially disabled 78.3%. These figures correspond with the rates for those groups in the total population of disabled persons who did consider themselves disabled. (24.4 and 15.6”,) These rates and those presented previously indicate that the self-report criterion used in two different sub-populations produces almost the same result. Indirectly. this finding seems to show that the applied criteria are universally useful in index calculation. and their properties. as one may judge. justify even to a greater extent the performance of comparative studies between Poland and U.S.A.
1147
To gain more precise knowledge of the criteria under discussion, the relationship between the criteria and the age of persons defined in the NC as disabled. was analysed. Three age groups were considered: 60-64; 65-69; 70 and over. Investigating this relationship in sub-populations divided according to MBDE, age structures in individual sub-populations of the disabled distinguished, according to level of disability, differed considerably. Among all the disabled, the percentage of those aged 60 and over was 47.0(x, while in the age of 70 and over it was 24.8x,, but in the sub-population with category one disability the percentage increased respectively to 71.4 and 56.00/,. Thus the percentage of older persons is twice as high as among the total number of disabled. The percentages were especially high in category one who did not consider themselves disabled, amounting respectively to 84.3 and 70.4%. As to the sub-population in category two, the percentage of persons in the above age groups, and particularly in the oldest, was over twice as low as among persons in category one. The rate of older persons in this subpopulation was almost the same as for the total number of disabled, for persons aged 60 and over amounting to 5 1.7% and for persons aged 70 and over 20.6%. In category three, the percentage of older persons is lowest (24.6%) and for persons aged 70 and over it was 7.6%. Among those without any defined level of disability, the’rate of older persons is slightly higher than in the total population of disabled (56.9%).
Tables. 6. Unemployed disabled persons living in urban and rural areas according to self-report, MBDE criteria, age, sex Persons according to self-report and MBDE criteria Urban
Age Sex T-total M-male F-female Total (20-64 years1 20-24 25-39
40-49
5s59
60-64
Complete Total T 752.641 M 328.537 F 424.104 15.787 T 9058 M 6729 F T 78.808 M 39.048 F 39.760 T 177.802 M 79.703 F 98.099 T 347.754 M 145.331 F 202.423 T 132.490 M 55.397 F 77.093
Partial
Rural Persons with certificated disability without self-rep. confirmation
“/, Distribution 19.1 21.8 17.1 36.4 35.9 37.1 25.0 21.4 22.7 18.2 20.7 16.2 17.9 20.4 16.0 18.2 20.7 16.4
56.9 55.4 58.1 53.4 54.3 52.3 57.2 56.0 58.4 58.5 57.0 59.6 56.6 55.0 57.8 55.8 54.0 57.1
Complete Total
24.0 22.8 24.8 10.2 9.8 10.6 17.8 16.6 18.9 23.3 22.3 24.2 25.5 24.6 26.2 26.0 25.3 26.5
297,433 154,414 143,019 13,229 7664 5565 44,686 26,268 18,418 64,747 35,649 29,098 117,504 57,076 60,428 57,267 27.757 29,510
Partial
Persons with certificated disability without self-rep. confirmation
% Distribution 21.7 22.9 20.5 38.6 36.0 42.1 30.3 29.2 31.8 21.6 22.3 20.8 18.4 20.4 16.6 18.1 19.3 16.9
54.4 53.5 55.3 53.1 55.1 50.5 53.6 54.1 53.0 54.6 53.9 55.5 54.2 53.0 55.3 55.1 52.8 57.4
23.9 23.6 24.2 8.3 8.9 7.4 16.1 16.7 15.2 23.8 23.8 23.7 27.4 26.6 2811 26.8 27.9 25.7
JANUSZBEJNAROWICZ
1148
This indicated that the sub-population of the disabled analysed according to an objective level of disability comprised three different populations from the point of view of age, those of 70 and over, the 55-59 and the 50-54 year olds. Thus it seemed that the category of disability decided by MBDE was often closely related to the age that reflected the level of biological depreciation, and this is frequently considered when viewing occupational activity. It may be concluded that level of disability is more related to level of biological impairment, especially in case of category one disability, associated with age, probably viewed as work ability, than to psycho-physical disability viewed as social role performance relative to age and quality of life. COMPARISON
BETWEEN THE TOTAL
POPULATION
AND THE DISABLED
IN RELATION DEMOGRAPHIC
TO MAJOR FEATURES AND
OCCUPATIONAL
ACTIVITY
The Polish National Census revealed that there were 2,485,OOl disabled people in Poland, i.e. 7.1% of the total population, of whom 48% were male and 52% female. This relation was almost identical with regard to the total population. The urban population constituted 57.5% and the rural 42.576 of the total population. The majority of disabled persons came from urban areas-62.2 against 37.8%. The age of disabled persons was usually advanced. The percentage of persons aged 50 and over in the disabled population was 73.0% while in the whole population it amounted to 23.9%. It is worth noting that the percentage of disabled aged 60 and over was very high-equal to 25% of the total number within the same age range. Since the majority of disabled people less than 16
Table
SELECTED DEMOGRAPHIC CHARACTERISTICS DISABLED
Total
Under
20 years
2CL59 years
years
4G-59 years
60 years
and over
AND CONDITIONS
OF
ACTIVITY
The total number of unemployed disabled amounted to 1,940,060, including 1,324,523 living in urban areas (68.3%) and 615,537 in rural areas (31.7%). We are here mainly concerned with the unemployed disabled of productive age. In the unemployed sub-population of the disabled living in urban areas the 50-64 age group was the largest, amounting to 480,244 persons (63.87; of those between 20 and 64). In all these classes there were more females than males.
in the age group 2G59 pension, sex and age
Urban
T M F T M F T M F T M F T M F T M F
AND SOCIAL
OF UNEMPLOYED
THEIR OCCUPATIONAL
7. The rate of employed among work disabled according to the type of residence, disability
Age Sex T-total M-male F-female
20-39
years old attended schools and did not apply for a job the total number in this age group seems artificially low. The rate calculated in relation to the total population excluding the O-16 age group amounted to 9.5%. It is obvious that for employment policy data on disabled persons of between 17 and 64 years old, that is in the productive years, are of great importance, and the rate amounted to 6.8%. The number of disabled in the productive years was I497.430. It is worthwhile to add that the number of disabled in the 17-19 age group was only 21,122. In the total population, 51.2:s were employed including 57.4% of males and 45.4% of females, while in the population of disabled the rates were 29.3% of males and 15.2% of females (21.9% overall). The employment rate was variable among age groups. Overall, the highest values, especially in regard to males, were observed in the 20-59 age group. Among males the highest value of occupational activity was in the 25-39 age group (96.5%) while among females the highest rate (80.6%) occurred among the 40-49 age group.
years
Rural
Disability pension
Without disability pension
Disability pension
Without disability pension
8.1 12.2 4.8 7.5 8.1 6.5 10.6 14.7 6.9 14.4 17.9 10.0 10.1 14.1 6.5 4.4 7.8 2.2
24.4 33.0 18.1 4.1 4.2 3.9 51.7 62.3 42.5 57.7 62.1 53.0 48.9 62.4 38.7 7.0 12.3 3.9
31.2 37.6 18.2 9.1 10.8 6.3 34. I 40.0 21.8 23.3 26.8 14.7 36.2 42.7 23.0 27.7 34.7 13.8
36.9 46.0 29.5 4.5 5.3 3.4 55.2 63.0 48.4 42.4 47.3 36.4 59.6 69.6 51.7 28. I 39.6 19.5
Disabled persons in Poland Special attention was given to disability categories defined in self-reports. Among the total number of 20-64 urban disabled 19.1T(,reported themselves completely disabled. Among males, the rate for partially distibled was 56.9”j, and for those who did not report themselves disabled despite certified disability it was 24.09; (Tables 6 and 7).
REFERENCES
Survey: United States
Socjologia a zdrowie (Edited by Sokolowska M., Holowka J. and Ostrowska A.) pp. 39-103. PWN, Warsaw, 1976. 12. See: One in eleven. Handicapped adults in America. A survey based on 1970 U.S. Census data. By the President Committee on Employment of the Handicapped. Hershkowitz, Washington, DC. 13. See: National Center for Health Statistics. Heulth Servey Procedure, Contents, Questionnaire Developmenr and Definitions in the Health Interview Survey. Vital and Health Statistics Series 1, No. 2, Washington, DC.
1. See: The PhJxically Handicapped in The Netherlands 1971/1972, p.12. Staatsuitgeverig, The Hague, 1976. 2. See: Fysisk Handicappedr I Danmark. p. 109. Social forskningsinstituttets Publikationer No. 16, Copenhagen. 1964 (English summary). National Center for Health Statistics. Currenr Estimates from the Health Interview
1149
1978.
Vital Health and
Statistics Series 10. No. 130. Hyattsville, MD, 1979. 3. See: National Center for Health Statistics. Limifation
of Acfivity and Mobility Due to Chronic Conditions: United Stares 1974, p. 3. Vital and Health Statistics
Series 10, No. 111. Rockville, MD, 1977. 4. This committee has been set up as an interdisciplinary body. Data on the disabled population, its demographic and social characteristics was provided by the Central Statistical Office. Data were collected by means of a microcensus in 1974. 5. 411 information about the studies of disability during the period prior to World War II comes from the paper: Bulawski R. The scheme of the second National Census in Poland based on the experience gained during 1921 Census and abroad. Statist. Q. VII, 17-151, 1930. 6. The questionnaire used during 1921 Polish Census included questions on: deafness, complete blindness and lack of upper and lower extremities. See Bulawski R. Organisation and technique of the first Polish National Census on September 30, 1921. Statist. Q. VII, 851, 1930. 7 Information about the intention of carrying on studies of disability was taken from the paper’of the Department of Statistics, Ministry of Health and Social Welfare. Justification for incorporation into the 1970 Census the question of disability, prepared for the need of the Census Sub-Committee operating within the framework of the Census Committee activities. 8. See: Population Census Programme 1945-1954. Experience. Physical and Mental Disabilities, Vol. 12. Statistical Office of the United Nations, New York, 1955. 9a. See: Korperbehindterte Bevolkerung und Kultur. Fuchserie A. und Reihe F. Gesundheitswesen, Sanderbeitrag, Ergebenisse der Mikrozensus 1966. Statistisches Bundesant, Wiesbaden, 1969. 9b. See: Harris A. J. er al. Handicapped and Impaired in Great Britain, Part I. HMSO, London, 1971. 10. op. cit. [l]. 11. Jablenski A. Epidemiologia inwalidztwa w Bulgarii in
1964. 14. Basic data on disability obtained from microcensus, except those provided for the Committee, were published in: Census of population and households by means of sampling meihdd as on March 30 1974. Part 1. Sratistics in Poland. pp. 41-51. Chief Census Bureau. Warsaw, 1977. Part of the information on disabled persons was presented in the report prepared for the Parliamentary Commission. 15. It read as follows: “Are you at the moment recognised by the Medical Board for Disability and Employment as a disabled person (regardless whether you receive a disability pension or not)? In the case of a positive reply, the respondent was obliged to report his category of disability as defined by the MBDE. 16. Methodology of the earliest investigation. See: Limitation qf Activity and Mobility Due to Chronic Conditions: United States 1972. Vitality and Health Statistics Series 10, No. 96, Rockville, MD. 1974. 17. Compare: Sokolowska M. and Bejnarowitz J. Social policy and the concept of health status. In Sociorechnits (Edited by Cherns H.), pp. 137-148. Malaby Press, London, 1976. Elinson J. Towards sociomedical health indicators. In Health, Medicine und Socier) (Edited by Sokolowska M., Holowka J. and Ostrowska A.). PWN, Warsaw, 1976. 18. Screening of the health state of the population in Poland. Zdrow. publ. 83, 519-531. 1972. 19. The World Health Organisation uses the following definition of health; Health is a state of complete physical, mental and social well-being and not merely the absence of disease of infirmity. That means evaluation of health based on the criterion of socia! function namely social role performance. 20. It should be explained here that in Poland it was found that, due to the Polish National Census, 5.845.000 people, including 2,027,OOOof the 18-64 age group, replied positively to the second of the quoted questions stating thereby that they possess a status of a disabled person. These persons, however, in their answer to the first question, did not report complete or partial disability. It was agreed, therefore, that they were partly disabled and they were not eliminated from the comparative study. 21 In Poland a considerable number of disabled persons, particularly middle-aged urban inhabitants who receive disability pension take occasionally odd jobs which do not fall under the term of “employment activity”.
0277-9536/X4 S3.00 + 0.00 Pergamon Press Ltd
pp. 1141-1149. 1984
Printed in Great Britain
DISABLED PERSONS IN POLAND JANUS BEJNAROWKZ Central Statistical Office, Warsaw, Poland Abstract-It is generally considered that disability is an important social problem. This was expressed for example by the decision of the United Nations Organisation to nominate 1981 as the International Year of the Disabled. The number of disabled is one of the main problems. For social planning, the proper allocation of goods and resources for changes in the attitudes of society towards disability it is necessary to identify the prevalence, distribution and composition of the disabled. Prior to the 1978 Census, in Poland there was no information available on disability except the number of disabled persons legally classified by the Medical Board for Disability and Employment receiving disability pension, as well as the average amount of such pension, the number of disability certificates issued annually, the number of employed and the number employed in co-operatives for the disabled. The social criterion-major social role associated with psycho-physical state-was the main concept of the investigation on the frequency of disability in 1978 Census. Methodology used in this study of disability was based on the U.S. experience gained from the 1970 NC, as well as on the NCHS Survey of psychophysical causes of permanent limitation of social role performance and locomotion, performed since 1957. It should be explained, however, that the scope of disability investigated in NCHS Survey and in Polish Census is exactly the same and much wider than in U.S. Censuses. The Polish National Census revealed that there are 2,485,OOl disabled persons in Poland, i.e. 7.1% of the total population. The urban population constituted 57.7% and the inhabitants of rural areas 42.5% of the total population. The majority of the disabled came from urban areas-62.2% compared to 37.8%. The rate of disabled persons in the population aged 50 or over was 73x, while in the whole population it was 23.9%. Observations made during preliminary comparisons of work disability in males in U.S.A. and in Poland indicate that differences in prevalance rates were not so significant: U.S.A.-l 1.8% and Poland-8.9”/& And these differences referred mainly to disabled persons in the 25-44 age group whose rate is larger in U.S.A. On the other hand, differences in behavioural response to functional impairment of the disabled in U.S.A. and Poland are quite significant, at least, among the employed. The level of employment in the general population was almost identical whilst among the disabled it was almost twice as low in Poland. It Seems that prevalence of disability, conditioned biomedicaliy and treated as an index of health status, is very similar in U.S.A. and in Poland. But some behavioural responses of the disabled differ considerably and relate to features of the social system.
INTRODUCTION
Permanent incapacity to carry out activities of daily living caused by illness or impairment is experienced by a considerable part of the population. Physical or mental disability refers to partial or complete limitation of functions. indispensable for the performance of major activities diversified by the age of a man. Disabled people unable to meet their responsibilities are often helpless, alienated and isolated. They usually face insensibility or even cruelty, sometimes pity, but relatively rarely understanding and, most important, effective assistance. What is their number? What is their age? What are their needs? What would they like to do? To what extent are we able to help them in recovering their social fitness? These are only a few questions which have so far lacked satisfactory replies because of insufficient knowledge. It could be presumed that in Poland, as in most other developed countries, the percentage of those with partial, serious or complete physical or mental disability due to illness or impairment was about 10. Such a value is based on data obtained from several surveys in different countries. It should be stressed that this 10% means that every SSM 19,1-r+
tenth citizen is completely or partially limited in his functions. On the other hand, if one ‘assumes that every disabled person lives in a three or four member family it can be seen that every third person is involved directly or indirectly. In The Netherlands, according to 1972 surveys, over 8.7% of the population aged five had a physical impairment, while taking families into account, 25% of the population suffered a physical disability or had permanent contact with such persons [l]. These figures are remarkable in spite of disability being defined in biological terms, with physical disability only taken into consideration, excluding the mental dimension altogether. In various countries, different age groups have been the subject of interest. In some, only those disabled who lived with families or alone outside special care institutions, were studied. In others, besides these two groups, the disabled living in special care institutions were also included. These different approaches explain why the percentage of the disabled singled out on the basis of different criteria varies so widely, ranging from 6.5 to 14.1% [Z]. Household surveys, having been carried on in the
1141
1142
JANUSZ BEJNAROWICZ
United States for many years, should also be mentioned. They deserve special attention since the concepts and criteria of disability used in the 1970 U.S. Census has been influential in the study of the disabled during the 1978 Census in Poland. The U.S. survey revealed that the percentage of the physically or mentally disabled, with various levels of disability, activities and social role performance amounted in 1958 to 10.1% while in 1974 it had risen to 14.1%. Between 1970 and 1974 the percentage had risen from 11.8 to 14.1% [3]. Such prevalence of disability creates a wide band of problems across the social spectrum as well as for the disabled themselves. Disabled persons differ greatly in type and level of psychophysical disability, age, education, family status and living conditions. Therefore their needs are also diversified and complex. To satisfy them, well designed activities of specialised institutions in many sectors of governmental administration and, most important, a favourable social climate are required. In Poland, the status of the disabled is the concern of many sectors of administration and governmental agencies. It is obvious that precise knowledge on the number of the disabled, their needs and the conditions for their social and vocational rehabilitation determine the type of solutions provided by the State and by society. The Committee for Rehabilitation and Readaptation of Disabled People of the Polish Academy of Science has prepared a report on the “Social Situation of Disabled People and the State of Rehabilitation in Poland” [4]. The Committee, together with the interdisciplinary board for the unification of reporting systems on health care and social welfare, recommended various investigations on disability and related questions using the general census and in other ways to obtain information necessary for decision-making by responsible central and local administration bodies.
THE ROLE OF THE GENERAL SURVEk’S IN OBTAINING AND CHARACTERISTICS
CENSUS AND SPECIAL
DATA ON THE NUMBER OF DISABLED
PERSONS
As already mentioned, there is a long tradition for using the general census for obtaining data on disability. In 1872 during the International Congress on Statistics, held in Petersburg, it was officially recommended to use the census for this purpose [S]. The recommendation was, however, limited to blindness, deafness, imbecility, cretinism and insanity. The number of such disabled persons was estimated during the general censuses in many countries before World War I and during the interwar period. For example, among studies in 15 European and non-European countries carried out in the 1920s. including Poland, physical, and in some countries, also mental ‘defects’, were analysed [6]. In Poland. studies were held in 1924 to estimate the number of mentally handicapped living in special homes or in medical institutions as well as the number of those who required in-patient care. After World War II, despite a substantial interest in the occurrence and types of disability this question was not included in the national census [7].
Outside Poland. although less frequently than in previous periods-especially during the years preceding World War I-the problem of disability was considered in census surveys [8] and more often in sampling studies. Among the more recent European research worthy of mention were: Denmark (196 1i 1962estimation of the number of physically disabled persons [2]; Federal German Republic (1966 )---physical and mental disability was investigated in the microcensus [9a]; Great Britain [9b] and The Netherlands ( 197 1i 1972)-only physical disability was analysed [lo]. Studies on physical and mental disability were carried out in Bulgaria [ll]. In the United States. physical and mental disability was analysed in a 5”, sample of the general population during the 1970 Census [12] and during houshold interview surveys held for many years [ 13). Prior to the 1978 Census there was no information available on disability except the number of disabled legally classified by the Medical Board for Disability and Employment as entitled to receive disability pension, the average pension amount. the number of disability certificates issued annually. the number employed. and the number employed in co-operatives for the disabled. This information was usually related to such variables as sex, age. type and level of disability and the region in which the disabled person was employed. Only the household survey within the microcensus performed in 1974 by the Chief Census Bureau provided more information and indicated gaps. Previous knowledge was insufficient because only disabled persons issued with MBDE disability certificates, regardless of whether or not they received a disability pension, were considered. The number involved was 1,374,000, or 4.17; of the population, and this was only a part of the total number of disabled. The number of disabled who had not received a disability pension was estimated to be 303.000. Parallel data published by the Social Insurance Institution referred only to those disabled in receipt of disability pensions. This totalled 1,070,6OObut did not include demographic and social characteristics of the population. important for social and employment policy. Accordingly, it was possible to establish the number of disabled persons who do not receive disability of males and females, pension, the proportion age, place of residence (rural/urban), categories of disability, education. occupational activity, and marital status. A series of comparative studies were conducted between the disabled and the total population according to specified social situations [14]. Howcvcr. in spite of so many variables, significant data for a comprehensive analysis were Still lacking for: type of disability. its causes. the age at which a person became disabled. and social status preceding disability [ 151. It should be noted that experience gained during the ‘microcensus’. for example in regard to the reporting of disability among persons without disabilitycertificates who had not applied for social or family reasons, led to the inclusion of this question in the 1978 General Census. and to the development of methodology to defne partial social disability and its degree of intensity.
Disabled THE
INVESTIGATION
RANGE
OF THE
OF DISABILITY
1978 GENERAL
persons
IN THE
CENSUS
The major social role associated with the psychophysical state of a respondent was the main thrust of the investigation on the prevalence of disability, that is to say, an investigation of the social consequences of disorders. The idea of employing sociomedical health measures in the 1978 General Census was based on the assumption that social activity depends on one’s state of health. An inability, or the necessity to limit social role performance as worker, student or housewife, as a consequence of chronic disease is a sociomedical measure of the level of health [ 163. Obviously this refers to permanent or long-term limitation and therefore, uncomplicated pregnancy or early puerperium, for example, were not taken into consideration. One positive aspect of this indicator is that it provided a measure of the physical and mental consequences of disease or handicap [ 173. This was important since in the majority of epidemiological surveys only those diseases are considered which produce a physical inability to perform certain social activities
C181. Attention now turns to both variability in the denotation of health in relation to social situation and to the limited cognitive value of health in purely biomedical terms (i.e. psycho-physical limitations). The relationship between state of health and disease is more complex than it often appears. Many individuals with unsatisfactory health as defined clinically may function remarkably well. On the other hand, life is full of examples of contrasting relations between health and occupation [19]. Another reason for not assessing health in purely biological terms is the possibility of human adjustment; those who do not enjoy the best psycho-physical fitness but who want to work, for example, can have their working conditions changed or be provided with prosthetic help. The disabled population and its characteristics were defined on the basis of a health self-report by all members of the household; in the case of children under age, health state was reported by their mothers. On the basis of responses three categories were used; .the first comprised those unable to perform any kind of activity. The second comprised those with certificated disability but without self-reported confirmation and the third category comprised those with partial disability. DISABILITY CENSUS
IN THE NATIONAL
AND UNITED
SURVEY
IN THE
STATES
The 1970 U.S. Census (5”/, sample) investigated the reduction of work performance of 3 months or more duration through psycho-physical causes. In the 1978 National Polish Census, an attempt was made to apply a method combining the benefits of the study covering the whole population of disabled persons and the use of a limited number of questions. In the Polish Census, as the American, complete disability and those kinds of partial dis-
1143
in Poland
ability which considerably limit the function of a given person were defined. It meant that investigation of less serious forms of partial disability in Poland were abandoned a priori [20]. DISABLED
MALES
STATES
AND
IN THE UNITED IN POLAND
Comparison between the data from the NC and from the 1970 U.S. Census can provide only a general comparison. This is because of considerable differences in the levels of ‘detection’ of disability in the two countries so that similarity though high might be co-incidental. The comparison, to be reliable, should be limited only to males disabled for 6 months and over. In the U.S.A. the percentage of disabled males of the total male population aged 25-64 was 11.8%. This was higher than the Polish figure of 8.9% (Table 1). In the U.S.A. the proportion of disabled males living in urban areas (10.9%) was lower than those in rural areas (14.1%). This difference becomes greater in the case of farmers, (14.7%). In Poland the values for urban and rural areas were almost identical and amounted respectively to 8.9 and 8.8%. In Poland, information on rural areas covers agricultural and non-agricultural populations. This makes the given value only a mean whereas perhaps it should be different for agricultural and non-agricultural populations. In the U.S.A. the rate of disabled males increased with age both in rural and urban areas. Large increases occurred in rural areas in the age groups 45-49 and 60-64, and in the case of farmers in the latter age group. In the American rural population of 60-64 years of age, almost every third person considered himself to be disabled and in urban areas almost every fourth person. In Poland (Table 1) the percentage of disabled males in the age group of 25-44 was 3.5% in urban areas and 3.7% in rural areas. This was twice as low as for the corresponding age group in the United States. Starting with the 45-49 age group, the rates were broadly similar in Poland and in the U.S.A. although in Poland the rural rate was 9.4% lower than in the States, where it was 14.5%. Among older age groups the increase was in general more explicit in Poland than in the U.S.A. In Poland the percentage of disabled males in the age group of 60-64 living in urban areas amounted to 28.3%. It should be noted that among the rural population of 50-64 the percentage of Polish disabled males was similar to that among American farmers. The percentage of young disabled males was much lower in Poland than in the United States, while among older urban inhabitants from the age of 50, the percentage of disabled males was higher in Poland. Moreover, in the U.S.A. among males of 50 years of age the rate of disabled persons increased in the older age groups faster in rural areas whereas in Poland this increase was particularly marked in urban areas. Concluding, one may suppose that young males in both rural and urban areas, confronted with real working conditions, consider themselves disabled or are considered to be so by their employers less frequently in Poland than in the U.S.A. On the other hand, in Poland, there was a marked tendency among
JANUSZBEJNAROWICZ
1144 Table
1. United
States
and Poland work disability rate of males years of age by type of residence
United
States-1970
between
25-64
Poland-1978 Rural
Age
Total
Urban
Total
Farm
Total
Urban
Rural
25-64 25-59 25-44 25-34 35-44 4549 50-54 55-59 6CM4 60-61 62-64
11.8 10.3 6.9 5.8 8.2 12.2 15.2 19.2 25.9 23.7 27.7
10.9 9.7 6.6 5.6 7.8 11.4 14.1 17.8 23.9 21.9 25.4
14.1 12.2 7.8 6.4 9.3 14.5 18.1 22.7 31.0 28.0 33.1
14.7 12.6 8.2 7.5 8.8 13.0 16.5 19.7 27.8 24.9 30.1
8.9 7.8 3.6 2.3 5.4 10.1 16.1 21.9 26. I -
8.9 7.9 3.5 2.1 5.3 10.6 17.6 24.2 28.3
8.8 7.7 3.7 2.5 5.5 9.4 14.1 19.2 23.3 -
older urban males to consider themselves or to be regarded by others disabled. This was probably related to the Polish disability pension system and to the granting of certain privileges to the disabled. The similarity between the Polish village and the American farm in regard to disability occurring among the older age groups results probably from their similar social situation, that is from a relatively limited possibility of receiving a disability pension and constant, almost compulsory contact with the main job, running a farm, and the sense of responsibility for its prosperity which has no general counterpart in urban areas. It can be assumed, therefore, that disability in rural areas has a more biomedical basis than a social one, whereas in towns, especially in Poland, the influence of social factors upon the level of activity among disabled persons is strong. In the United States the rate of completely disabled persons amounted to almost one-third of the total population (Table 2). The value of that rate is considerably diversified-almost 2.4 times depending upon the age of the disabled. Among the youngest
Table 2. United States and Poland work disability United
-
(18-M) it was equal to 21.9% and among the oldest (60-64) was as much as 49.904. In Poland. among the total number of the disabled, including those partially disabled, the rate of the completely disabled is almost twice as low as in the U.S.A., being only 16.0%. This increased to 21.9% in regard to the completely and partially disabled when the only slightly disabled were excluded. In Poland, unlike the United States, the rate of completely disabled, whether with or without the slightly disabled was highest among the youngest age groups. The differences between Poland and the U.S.A. confirmed the assumption that requirements faced by workers in the States are higher than in Poland. This is related to the large number of workers employed in Polish agriculture who have relatively big families and where the requirements faced by the disabled worker may not be high. In Poland the rate of employed males aged 18-64 was almost the same as in the U.S.A. including those employed in the armed forces (Table 3). It is worth noting however, that in the States, despite slightly lower employment than in Poland, the rate of older
of males between
18-64 years of age distributed
Poland-1978
States-1970
Total
Total (includes
Age 18-64 1844 18-19 20-24 25-44 45-54 55-59 6cL64 6G6 I 62-64
Total
Partial disability
by level of limitations
Complete work disability
5.816.218 2.363.37 I -
68.4 78.1
31.6 21.9 -
1SO2.047 91 1.738 I ,039.062 406.248 632.8 14
70.4 60.9 50.1 54.8 47.0
29.5 39. I 49.9 45.2 53.0
only formal status of disability) 758.095 209,908 8603 27.679 173.626 263.6 14 162,568 122,005 -
Partial work disability 84.0 80.8 73.3 76.3 81.9 85.4 85.2 84.7 -
Complete work disability 16.0 19.2 26.7 23.7 18.1 14.6 14.8 15.3
(excludes only formal status of disability) 555,414 165.300 7653 23,259 134,388 189.516 114,726 85,872
Partial work disability 78. I 75.7 70.0 71.8 76.6 79.7 79.0 78.2
Complete work disability 21.9 24.3 30.0 28.2 23.4 20.3 21.0 21.8
1145
Disabled persons in Poland
Table 3. United States and Poland rate of employed among work disabled males in the age group of 25-64 by level of limitations Poland-1978
United States-1970
Disabled population with ‘work disability (includes only formal status of disability)
Disabled population with work disability Age 18-64 18-44 18-19 20-24 25-44 45-54 55-59 60-64 60-61 62-64
General population 85.7 85.7 91.1 85.3 71.8 78.8 66.5
Total
Partial
60.9 68.5 66.0 55.6 40.8 47.8 36.2
85.1 84.4 89.7 86.2 76.7 82.6 72.3
General Complete population 8.5 11.8 9.7 7.7 4.7 5.7 4.2
Disabled population with work disability (excludes only formal status of disability)
87.8 89.5 58.3 82.7 96. I 89.8 81.5 62.4 -
persons amounted to 71.8% while in Poland it was 62.4%. Occupational activity among the disabled in Poland was’ much lower than in the U.S., its rate amounted to only 35.4% of the total employed population, while among the disabled population (including those with slight disability) the rate of employed was 32.0% and in the States it was 60.9% [21]. In Poland the employment level of the disabled was almost identical for each of the investigated age groups. In the United States the employment level decreased significantly with increase of age, reaching 40.8% in the 60-64 age group, close to the corresponding Polish figure (3 1.8%). In the United States, the rate of employment among the completely or partially disabled was very diversified as much as 85.1% among the partially disabled and S.S”,d,ten times lower, for the totally disabled. In regard to age, the rates were 11.8% (18-44) and 4.7”/, (6G64). Among the partially disabled the level of employment was similar in each age group, for the 60-64 it amounted to 76.70/, exceeding the employment rate of the total male population of this age (71.87;). In Poland the employment rate of the completely disabled amounted to 10.3”,a slightly higher than the 8.5’; in the U.S.A.. but unlike the States, it was almost constant for all the compared age groups. The employment rate among both the seriously and mildly handicapped amounted to 40.2% and among only more seriously handicapped it was even lower. 38.10,. Comparative analysis showed the following major differences and similarities: employed
(I) In the United States, occupational activity among the disabled was almost twice as high as in Poland, but in the sub-population of the completely disabled the employment level was almost identical in both countries, though it increased with age in the States and remained at the same level in Poland. (2) In the United States occupational activity
Total
Partial
Complete
Total
Partial
35.4 36.9 23.5 39.6 37.2 35.5 36.0 31.8 -. -
40.2 43.3 30.2 49.3 43.0 39.8 40.4 35.8 -
10.3 9.8 5.1 8.4 10.5 10.9 10.5 10.0 _ -
32.0 33.4 20.4 34.9 33.9 32.4 32. I 28.5 -
38.1 41.0 26.9 45.3 41.0 37.9 37.9 33.6 -
among partially disabled males was almost the same as for the male population as a whole and in the 55-59 and 60-64 age groups it was even higher. In Poland the employment of partially disabled persons was more than twice as low as among the total male population. In both countries, employment levels of the partially disabled were constant for all age groups. This suggests that the differences depended mainly on social factors such as disability pension system and employment requirements. Biomedical factors caused similar limitations in both countries. LEVEL OF DISABILITY ACCORDING TO SOCIOMEDICAL CRITERIA AND LEVEL
OF DISABILITY
THE MEDICAL DISABILITY
DEFINED
BOARD
BY
FOR
AND EMPLOYMENT
The national census asked two questions in order to define the level of psycho-physical disability. The first related to health based on subjective sociomedical criteria, the second to level of disability as defined by the Medical Board for Disability and Employment (MBDE). The first question was addressed t.o all those who considered themselves unable to perform a basic social role. Many disabled persons especially in rural areas do not apply to MBDE for obtaining the disability certificate; moreover, since MBDE defined disability after medical examinations, it can be assumed that all persons recognized by MBDE as disabled, identified themselves as disabled when answering the first question. In view of this, responses to the first question will be discussed first. The results are presented in Table 4. Among all those investigated, 18.6% considered themselves having only limited ability to perform activities. related to a given age, such as occupation, education, running a household. activities of daily living, for pre-school children an inability to play;
JANUSZBEINAROWICZ
1146
Table 4. The disabled according to categories of disability and self-report Persons with certificated disability without self-report confirmation
The disabled with limitations of performance of activities major for a given age according to self-report Total The disabled according to categories of disability Total I II III Self-reported disabled persons without disability certificate
Complete
Number
%
Number
%’
Number
%
Number
O0
2,485,001 305,423 868,609 754,609 556,360
100.0 100.0 100.0 100.0 100.0
463,037 150.263 139,682 52,265 120,827
18.6 49.2 16.1 6.9 21.7
1,437,526 113,642 484,897 403,454 435,533
57.9 37.2 55.8 53.5 78.3
584,438 41.518 244,030 298.890 -
23.5 13.6 28.1 39.6 -
57.9% perceived themselves as being considerably handicapped in the performance of major activities for a given age; while 23.5% did not report complete or partial limitations in performing major activities despite being recognized as disabled by the MBDE.
This shows clearly that the relationship between physical or mental impairment and social performance is not always explicit. This is supported by the fact that among persons recognized as disabled by the MBDE, but who did not report complete or partial handicap related to the performance of age-specific roles, there were 41,518 respondents (7.1%) having category one disability (Table 5). This represented 13.6% of the total number in category one recognized by MBDE, (Table 4). 70.4% of those aged 70 and over with a category one handicap failed to report complete or partial disability. This suggests that of those in this category occupational activity is very often limited not so much by the level of psycho-physical ability as by the absence of an appropriate job. Among persons who reported complete fitness for social role performance the rate of category one and two disabled was almost the same (Table 5). Furthermore, among the total disabled, the 305,423 with category one disability was so proportionately high that their rate in the sub-population of the completely disabled could be theoretically doubled (Table 4). We turn to the fact that among
Table
Partial
persons
with com-
5. The disabled
plete disability, 11.3% were in category three. This probably refers to people whose physical state is good but whose mental state required constant care. It should be noted that among the completely disabled 26.1% were not classified in any category of disability. This group probably comprised those for whom a certificate from the MBDE had no special meaning. In the sub-population with partial disability, those with category two disability, form the largest group (33,7x); the corresponding figure for category three was 28.1% and for category one it was 7.9%. It should be noted that the rates for the first category of disability, and to some extent, the second category, were similar to the rates of these groups in the sub-population with partial disability. Concluding the above observations, it was observed that in each of the groups, distinguished by level of disability, the rate of persons with category two disability was similar, contrary to other categories of disability. Also, the rate of disabled not classified according to disability was approximately the same among persons with complete or partial disability. There was, then, a slight relationship between subjective level of disability as stated in the self-report, and the level of disability determined by the MBDE i.e. the category of disability. This conclusion is confirmed by the fact that
according to self-report disability
categories
The disabled The disabled according to categories of disability Total I II III Self-reported disabled persons without disability certificate
with limitations of performance of activities major for a given age according to self-report
and
Total
Complete
Partial
Persons with certificated disability without self-report confirmation
100.0 12.3 34.9 30.4 22.4
100.0 32.4 30.2 Il.3 26.1
100.0 7.9 33.7 28. I 30.3
100.0 7. I 41.8 51.1 -
of
Disabled persons in Poland among those in the first category the rate of those with partial disability amounted to 37.2’:{,and among persons who do not consider themselves disabled it was as much as 13.6”,, (Table 4). In the sub-population of category three the rate of persons completely disabled was 6.9”,, and for those who did not consider themselves disabled it was as high as 39.6”,,. In the sub-population of category two the rate of those who did not consider themselves disabled amounted to 28.19,,. It should also be noted that the rate of people with partial disability was almost the same for both sub-populations categories two and three, that is about 50” The cri&ia used for defining category of disability differed from those used in the self-report. The criteria used by MBDE were limited to a narrow spectrum of medical questions and were therefore insufficient for the assessment of social role performance. Furthermore. among persons without any certified category of disability. the percentage who were completely disabled was 21.7”,, and partially disabled 78.3%. These figures correspond with the rates for those groups in the total population of disabled persons who did consider themselves disabled. (24.4 and 15.6”,) These rates and those presented previously indicate that the self-report criterion used in two different sub-populations produces almost the same result. Indirectly. this finding seems to show that the applied criteria are universally useful in index calculation. and their properties. as one may judge. justify even to a greater extent the performance of comparative studies between Poland and U.S.A.
1147
To gain more precise knowledge of the criteria under discussion, the relationship between the criteria and the age of persons defined in the NC as disabled. was analysed. Three age groups were considered: 60-64; 65-69; 70 and over. Investigating this relationship in sub-populations divided according to MBDE, age structures in individual sub-populations of the disabled distinguished, according to level of disability, differed considerably. Among all the disabled, the percentage of those aged 60 and over was 47.0(x, while in the age of 70 and over it was 24.8x,, but in the sub-population with category one disability the percentage increased respectively to 71.4 and 56.00/,. Thus the percentage of older persons is twice as high as among the total number of disabled. The percentages were especially high in category one who did not consider themselves disabled, amounting respectively to 84.3 and 70.4%. As to the sub-population in category two, the percentage of persons in the above age groups, and particularly in the oldest, was over twice as low as among persons in category one. The rate of older persons in this subpopulation was almost the same as for the total number of disabled, for persons aged 60 and over amounting to 5 1.7% and for persons aged 70 and over 20.6%. In category three, the percentage of older persons is lowest (24.6%) and for persons aged 70 and over it was 7.6%. Among those without any defined level of disability, the’rate of older persons is slightly higher than in the total population of disabled (56.9%).
Tables. 6. Unemployed disabled persons living in urban and rural areas according to self-report, MBDE criteria, age, sex Persons according to self-report and MBDE criteria Urban
Age Sex T-total M-male F-female Total (20-64 years1 20-24 25-39
40-49
5s59
60-64
Complete Total T 752.641 M 328.537 F 424.104 15.787 T 9058 M 6729 F T 78.808 M 39.048 F 39.760 T 177.802 M 79.703 F 98.099 T 347.754 M 145.331 F 202.423 T 132.490 M 55.397 F 77.093
Partial
Rural Persons with certificated disability without self-rep. confirmation
“/, Distribution 19.1 21.8 17.1 36.4 35.9 37.1 25.0 21.4 22.7 18.2 20.7 16.2 17.9 20.4 16.0 18.2 20.7 16.4
56.9 55.4 58.1 53.4 54.3 52.3 57.2 56.0 58.4 58.5 57.0 59.6 56.6 55.0 57.8 55.8 54.0 57.1
Complete Total
24.0 22.8 24.8 10.2 9.8 10.6 17.8 16.6 18.9 23.3 22.3 24.2 25.5 24.6 26.2 26.0 25.3 26.5
297,433 154,414 143,019 13,229 7664 5565 44,686 26,268 18,418 64,747 35,649 29,098 117,504 57,076 60,428 57,267 27.757 29,510
Partial
Persons with certificated disability without self-rep. confirmation
% Distribution 21.7 22.9 20.5 38.6 36.0 42.1 30.3 29.2 31.8 21.6 22.3 20.8 18.4 20.4 16.6 18.1 19.3 16.9
54.4 53.5 55.3 53.1 55.1 50.5 53.6 54.1 53.0 54.6 53.9 55.5 54.2 53.0 55.3 55.1 52.8 57.4
23.9 23.6 24.2 8.3 8.9 7.4 16.1 16.7 15.2 23.8 23.8 23.7 27.4 26.6 2811 26.8 27.9 25.7
JANUSZBEJNAROWICZ
1148
This indicated that the sub-population of the disabled analysed according to an objective level of disability comprised three different populations from the point of view of age, those of 70 and over, the 55-59 and the 50-54 year olds. Thus it seemed that the category of disability decided by MBDE was often closely related to the age that reflected the level of biological depreciation, and this is frequently considered when viewing occupational activity. It may be concluded that level of disability is more related to level of biological impairment, especially in case of category one disability, associated with age, probably viewed as work ability, than to psycho-physical disability viewed as social role performance relative to age and quality of life. COMPARISON
BETWEEN THE TOTAL
POPULATION
AND THE DISABLED
IN RELATION DEMOGRAPHIC
TO MAJOR FEATURES AND
OCCUPATIONAL
ACTIVITY
The Polish National Census revealed that there were 2,485,OOl disabled people in Poland, i.e. 7.1% of the total population, of whom 48% were male and 52% female. This relation was almost identical with regard to the total population. The urban population constituted 57.5% and the rural 42.576 of the total population. The majority of disabled persons came from urban areas-62.2 against 37.8%. The age of disabled persons was usually advanced. The percentage of persons aged 50 and over in the disabled population was 73.0% while in the whole population it amounted to 23.9%. It is worth noting that the percentage of disabled aged 60 and over was very high-equal to 25% of the total number within the same age range. Since the majority of disabled people less than 16
Table
SELECTED DEMOGRAPHIC CHARACTERISTICS DISABLED
Total
Under
20 years
2CL59 years
years
4G-59 years
60 years
and over
AND CONDITIONS
OF
ACTIVITY
The total number of unemployed disabled amounted to 1,940,060, including 1,324,523 living in urban areas (68.3%) and 615,537 in rural areas (31.7%). We are here mainly concerned with the unemployed disabled of productive age. In the unemployed sub-population of the disabled living in urban areas the 50-64 age group was the largest, amounting to 480,244 persons (63.87; of those between 20 and 64). In all these classes there were more females than males.
in the age group 2G59 pension, sex and age
Urban
T M F T M F T M F T M F T M F T M F
AND SOCIAL
OF UNEMPLOYED
THEIR OCCUPATIONAL
7. The rate of employed among work disabled according to the type of residence, disability
Age Sex T-total M-male F-female
20-39
years old attended schools and did not apply for a job the total number in this age group seems artificially low. The rate calculated in relation to the total population excluding the O-16 age group amounted to 9.5%. It is obvious that for employment policy data on disabled persons of between 17 and 64 years old, that is in the productive years, are of great importance, and the rate amounted to 6.8%. The number of disabled in the productive years was I497.430. It is worthwhile to add that the number of disabled in the 17-19 age group was only 21,122. In the total population, 51.2:s were employed including 57.4% of males and 45.4% of females, while in the population of disabled the rates were 29.3% of males and 15.2% of females (21.9% overall). The employment rate was variable among age groups. Overall, the highest values, especially in regard to males, were observed in the 20-59 age group. Among males the highest value of occupational activity was in the 25-39 age group (96.5%) while among females the highest rate (80.6%) occurred among the 40-49 age group.
years
Rural
Disability pension
Without disability pension
Disability pension
Without disability pension
8.1 12.2 4.8 7.5 8.1 6.5 10.6 14.7 6.9 14.4 17.9 10.0 10.1 14.1 6.5 4.4 7.8 2.2
24.4 33.0 18.1 4.1 4.2 3.9 51.7 62.3 42.5 57.7 62.1 53.0 48.9 62.4 38.7 7.0 12.3 3.9
31.2 37.6 18.2 9.1 10.8 6.3 34. I 40.0 21.8 23.3 26.8 14.7 36.2 42.7 23.0 27.7 34.7 13.8
36.9 46.0 29.5 4.5 5.3 3.4 55.2 63.0 48.4 42.4 47.3 36.4 59.6 69.6 51.7 28. I 39.6 19.5
Disabled persons in Poland Special attention was given to disability categories defined in self-reports. Among the total number of 20-64 urban disabled 19.1T(,reported themselves completely disabled. Among males, the rate for partially distibled was 56.9”j, and for those who did not report themselves disabled despite certified disability it was 24.09; (Tables 6 and 7).
REFERENCES
Survey: United States
Socjologia a zdrowie (Edited by Sokolowska M., Holowka J. and Ostrowska A.) pp. 39-103. PWN, Warsaw, 1976. 12. See: One in eleven. Handicapped adults in America. A survey based on 1970 U.S. Census data. By the President Committee on Employment of the Handicapped. Hershkowitz, Washington, DC. 13. See: National Center for Health Statistics. Heulth Servey Procedure, Contents, Questionnaire Developmenr and Definitions in the Health Interview Survey. Vital and Health Statistics Series 1, No. 2, Washington, DC.
1. See: The PhJxically Handicapped in The Netherlands 1971/1972, p.12. Staatsuitgeverig, The Hague, 1976. 2. See: Fysisk Handicappedr I Danmark. p. 109. Social forskningsinstituttets Publikationer No. 16, Copenhagen. 1964 (English summary). National Center for Health Statistics. Currenr Estimates from the Health Interview
1149
1978.
Vital Health and
Statistics Series 10. No. 130. Hyattsville, MD, 1979. 3. See: National Center for Health Statistics. Limifation
of Acfivity and Mobility Due to Chronic Conditions: United Stares 1974, p. 3. Vital and Health Statistics
Series 10, No. 111. Rockville, MD, 1977. 4. This committee has been set up as an interdisciplinary body. Data on the disabled population, its demographic and social characteristics was provided by the Central Statistical Office. Data were collected by means of a microcensus in 1974. 5. 411 information about the studies of disability during the period prior to World War II comes from the paper: Bulawski R. The scheme of the second National Census in Poland based on the experience gained during 1921 Census and abroad. Statist. Q. VII, 17-151, 1930. 6. The questionnaire used during 1921 Polish Census included questions on: deafness, complete blindness and lack of upper and lower extremities. See Bulawski R. Organisation and technique of the first Polish National Census on September 30, 1921. Statist. Q. VII, 851, 1930. 7 Information about the intention of carrying on studies of disability was taken from the paper’of the Department of Statistics, Ministry of Health and Social Welfare. Justification for incorporation into the 1970 Census the question of disability, prepared for the need of the Census Sub-Committee operating within the framework of the Census Committee activities. 8. See: Population Census Programme 1945-1954. Experience. Physical and Mental Disabilities, Vol. 12. Statistical Office of the United Nations, New York, 1955. 9a. See: Korperbehindterte Bevolkerung und Kultur. Fuchserie A. und Reihe F. Gesundheitswesen, Sanderbeitrag, Ergebenisse der Mikrozensus 1966. Statistisches Bundesant, Wiesbaden, 1969. 9b. See: Harris A. J. er al. Handicapped and Impaired in Great Britain, Part I. HMSO, London, 1971. 10. op. cit. [l]. 11. Jablenski A. Epidemiologia inwalidztwa w Bulgarii in
1964. 14. Basic data on disability obtained from microcensus, except those provided for the Committee, were published in: Census of population and households by means of sampling meihdd as on March 30 1974. Part 1. Sratistics in Poland. pp. 41-51. Chief Census Bureau. Warsaw, 1977. Part of the information on disabled persons was presented in the report prepared for the Parliamentary Commission. 15. It read as follows: “Are you at the moment recognised by the Medical Board for Disability and Employment as a disabled person (regardless whether you receive a disability pension or not)? In the case of a positive reply, the respondent was obliged to report his category of disability as defined by the MBDE. 16. Methodology of the earliest investigation. See: Limitation qf Activity and Mobility Due to Chronic Conditions: United States 1972. Vitality and Health Statistics Series 10, No. 96, Rockville, MD. 1974. 17. Compare: Sokolowska M. and Bejnarowitz J. Social policy and the concept of health status. In Sociorechnits (Edited by Cherns H.), pp. 137-148. Malaby Press, London, 1976. Elinson J. Towards sociomedical health indicators. In Health, Medicine und Socier) (Edited by Sokolowska M., Holowka J. and Ostrowska A.). PWN, Warsaw, 1976. 18. Screening of the health state of the population in Poland. Zdrow. publ. 83, 519-531. 1972. 19. The World Health Organisation uses the following definition of health; Health is a state of complete physical, mental and social well-being and not merely the absence of disease of infirmity. That means evaluation of health based on the criterion of socia! function namely social role performance. 20. It should be explained here that in Poland it was found that, due to the Polish National Census, 5.845.000 people, including 2,027,OOOof the 18-64 age group, replied positively to the second of the quoted questions stating thereby that they possess a status of a disabled person. These persons, however, in their answer to the first question, did not report complete or partial disability. It was agreed, therefore, that they were partly disabled and they were not eliminated from the comparative study. 21 In Poland a considerable number of disabled persons, particularly middle-aged urban inhabitants who receive disability pension take occasionally odd jobs which do not fall under the term of “employment activity”.