Economic costs of living with disability and stigma in Vietnam

Le Bach Duong On behalf of the research team

Canberra, August 2014

PROJECT OVERVIEW

Project Rationale• ISDS Disability Survey (2006): high incidence of

S&D against PWDs from society and institutions• Unavailability of quality data on disability,

especially disability-related stigma• Few studies on S&D are qualitative• Low awareness of disability-related stigma and

discrimination among the public, state institutions, and mass media

• Insufficient disability policies and programs regarding stigma and discrimination reduction

• Government’s needs of information/evidence for policies and programs

Project Purpose

1. Provide a profile of disability situation in Vietnam

2. Provide evidences of disability-related stigmas and their impact

3. Provide estimates of disability-related costs at household level

4. Estimate economic costs of disability-related stigmas at household level

5. Policy advocacy and public awareness raising

Project survey• Project time line: From March 2010 through August

2013• Survey sites: 6 provinces (Lang Son, Thai Binh,

Quang Nam, Kontum, Dong Nai, Vinh Long) and two largest cities (Hanoi and Ho Chi Minh City)

• Sample size: 4,224 of both PWDs and PWOD (out of over 20,000 household members screened for disability status) using the the Washington Group short set of six questions on disability, developed based on ICF framework.

RESEARCH APPROACH

Vicious cycle

Evidence from developing world as well as from Vietnam remains very little

Vicious cycle

Stigma

Disability

Costs of living with disability

Cost of disability-related stigma

Definitions

Disability and stigma

Methods• Development of stigma scale:

– Review of other health related stigma scales– Conduct a qualitative study to explore types of stigma

and its impacts on general activities, education, employment and health care among people with disability in Vietnamese context.

– Discussion with experts to revise the first version– Field study to assess validity and reliability of the scale:

200 persons with disability and 200 persons without disability

– A scale of 40 questions after validation study

• Stigma scale

40 questions: five options for choice: - Never (0); - Sometime (1); - Often (2) ; - Very often (3) - and Don’t

know (DK)

Overall stigma score: 120

• 7 sub stigma scale score

• High stigma: Overall stigma score is 49 or greater (stigma score at upper interquartile value or greater)

0 20 40 60 80 100stigmascore

PWD

NDP

Stigma score of people with and without disability

Total stigma score

General stigma score

Work related stigma

Family invest

Perceived stigma

Opportunity

Participation

Health related stigma

Discrimination

0 5 10 15 20 25 30 35 40 45 50

37.9

3.5

9.5

9.7

1.5

9.2

7.3

0.8

1.9

44.8

5

10.5

11.9

2.4

11.2

7.8

1.3

2.6

PWDPeople without disability

Subscale stigma score of people with and without disability

0 20 40 60 80 100stigmascore

above 64

between 45-64

between 25-44

between 15-24

Female

Male

Female

Male

Female

Male

Female

Male

NDP PWD

• Linear regression of stigma score across socioeconomic groups show stigma score was significantly higher among:– PWD vs. PWOD– Female vs. male– Age: younger people vs. older people– People lived in urban areas vs. rural areas– People who are poorer vs. the better off– People who had lower educational levels vs. those

with higher education

Vision

Hearing

Remem-bering

Walk

ing

Commu- nica

tion

Self-c

are0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

33.3 35.9

49.042.5

76.7

62.861.4

51.0

72.9

48.5

84.491.4

A little difficultyLot of difficulty

Percent of high stigma level attributed to disability: overall AR%=43.8%

Key messages

• PWD significantly had higher stigma score and 1.8 time higher risk of high stigma than people without disability did,

• The odds ratio of experiencing high stigma among PWD ranged from 1.5 to 11.7 depending on type of stigma and levels of difficulty

• The stigma score increased by increasing level of difficulty in all types of disabilities.

• The younger people suffered more from high stigma and had higher stigma score as compared to the older people.

Key message• Those with higher education levels

consistently had lower stigma score and lower risk of suffering from high stigma.

• The richest group significantly has lower stigma score than the poorest group did.

• PWD from the urban areas were more likely to have higher stigma score than those PWD from rural areas.

Key message

• Percentage of high stigma level attributed to disability ranged from 33% to 91% and depends on types and levels of difficulty:– People with communication, remembering and

self -care difficulties had higher prevalence of high stigma than the people with other disabilities

Cost of living with disability

Indirect methodsThe standard of living approach

1. Extension of the standard of living

approach

2. Oaxaca decomposition

technique

The standard of living approach

• With the same income, PWD experience a lower standard of living than PWOD, because of diversion of money resources to goods and services required because of their disability.

• For a given standard of living it is possible to compare what incomes PWD and PWOD have=the extra costs incurred by disability

Extra cost = Y1-Y0= -b/a

S = aY + bD + gX + k

The standard of living

Annual cost of living with disability, by type (VND 000)

Overall Vision Hearing Moving Remembering Self-care Communication

4,343,468 5,777,743

9,148,149

4,112,796

9,620,848

4,785,109

14,996,645

3,990,565 4,648,145

9,044,692

5,597,888

8,697,379

3,032,961

11,018,077

OLS model Ordered logit model

Annual cost of living with disability, by age (VND 000)

Elderly Non-elderly Elderly Non-elderlyOLS model Ordered logit model

13,345,277

3,731,021

12,636,462

3,256,848

Annual cost of living with disability, by gender (VND 000)

Men Women Men WomenOLS model Ordered logit model

3,882,576

4,568,803

2,104,986

5,824,080

Annual cost of living with disability, by location (VND 000)

Urban Rural Urban RuralOLS model Ordered logit model

6,496,479

2,483,784

5,000,932

3,194,453

Cost of living with disability, by severity (VND 000)

Some difficulty A lot of difficulty Can’t not do at all

1,853,006

8,644,090

15,470,795

1,872,476

7,849,516

12,863,675

OLS model Ordered logit model

Cost of living with disability + stigma

1. Extension of the standard of living approach

• Create a new variable1. Non-disabled & Low-stigma2. Non-disabled & High-Stigma3. Disabled & Low-stigma4. Disabled & High-Stigma

Annual cost of living with both disability and stigmaUsing median value of stigma score as cut-off point

Cos

t of

livi

ng w

ith d

isab

ility

and

an

y le

vel o

f st

igm

a

Cos

t of

livi

ng w

ith d

isab

ility

and

hi

gh le

vel o

f st

igm

a

Cos

t of

livi

ng w

ith d

isab

ility

and

an

y le

vel o

f st

igm

a

Cos

t of

livi

ng w

ith d

isab

ility

and

hi

gh le

vel o

f st

igm

a

OLS model Ordered logit model

4,343,468

17,903,837

3,990,565

15,906,502

Annual cost of living with both disability and stigmausing upper bound of interquatile as cut-off point

4,343,468

19,858,344

3,990,565

18,262,581

Annual household income by disability and stigma status (median of stigma score as the cut-off point)

(VND 000)

Low stigma High stigma Overall

109,036

62,406

89,062

106,432

52,803

75,801

Non-disabled Disabled

19.5% explained by stigma status

Annual household income by disability and stigma status (upper bound of inter-quartile of stigma score as the cut-off point)

(VND 000)

31.6% explained by stigma status

Low stigma High stigma Overall

97,577

48,966

89,062 91,643

46,324

75,801

Non-disabled Disabled

Key messages

1. The cost of living with disability in Vietnam is substantial – Per household with PWD: 8.8%-9.5% of annual household income =

VND 3.9-4.3 million or US$ 200-218 per year– For whole Vietnam: @ 6 million with disabled person= 1.2-1.3

billion USD per year

2. Communication difficulty was shown to result in highest additional costs.

3. The costs of living with disability in Vietnam were higher among households with disabled person aged 60 years old and over, among households with female disabled person and disable household located in urban area

4. The costs of living with disability increased as people had more severe impairment

Key message5. Stigma aggravated the cost of living with

disability– The cost of living with both disability and stigma

was about 4 to 5-times higher than that of living with disability with any level of stigma; and

– Stigma status explains 19.5%-31.6% of the income gaps between PWD and PWOD households

Cost of living with disability

Cost of living with disability

Stigma

PROJECT PRODUCTS

• Report dissemination organized jointly by ISDS, HMU, PHAD and the Communist Party’s Central Committee for Culture and Communication.

• A peer-review publication (Global Public Health journal); another on stigma to come

• A guide for reduction of disability-related stigma for Party organs and the mass media

• Thousands of a disability bulletin disseminated to all provinces

• Training courses on disability organized at the University of Labour and Social Affairs (under the Ministry of Labour, Invalids and Social Affairs)

• A tools for addressing disability-related stigma

Thank you a million