WHO SAGE Research Articles

A comparable yardstick: adjusting for education bias in South African health system responsiveness ratings.

Health-system responsiveness (HSR) measures the experience of health-system users in terms of the non-clinical aspects of the health system. This has been operationalized as a measurable construct in multiple surveys and studies. According to the literature, reporting behaviour may vary systematically across socio-demographic characteristics. In this study we explore the association between education levels and reporting behaviour in terms of HSR in South Africa using data from the World Health Organization Study on Global Ageing and Adult Health for South Africa (WHO SAGE) conducted in 2007 and 2008. We consider the reporting behaviour of 1499 adults aged 50 and older in terms of the reported HSR for their most recent outpatient provider visit during the preceding 12 months. More specifically, we explore whether there are systematic biases in reporting behaviour by education levels and other socio-economic covariates through the use of data from anchoring vignettes. These are questions depicting hypothetical HSR scenarios which provide a fixed benchmark for comparing individuals' own HSR ratings and identifying potential reporting biases. Using a hierarchical-ordered probit model in regression analysis, we found large differences in HSR ratings between the lowest and highest education groups after adjusting for reporting bias using the anchoring vignettes. This finding holds across all seven HSR domains captured in the WHO SAGE dataset. In the most extreme case, individuals with no education are likely to underreport poor HSR by between 2.6 and 9.4% percentage points compared with individuals with secondary schooling or higher. Policy-makers need to take cognizance of potential reporting biases in HSR ratings and make the necessary adjustments to obtain data that are as true and accurate as possible. The need for this is especially acute in a country such as South Africa with large socio-economic inequalities and disparities in access to healthcare.

Including Older Adults in Development Goals: Is Subjective Wellbeing the Answer? A Case Study of Older South Africans

abstractMeasures of subjective wellbeing are gaining importance as indicators of overall societal progress, yet the majority of studies come from higher income countries. This paper explores the relationship between human development indicators and measures of subjective wellbeing among persons aged 50-plus in South Africa. Using the first nationally representative population-based study of older South Africans, WHO Study on global AGEing and adult health (WHO SAGE), this paper adds to a small but growing literature on subjective wellbeing in lower-income countries. Results indicate that education, socio-economic status and health are, in fact, correlated with measures of subjective wellbeing, but the relationships and strength of the relationships differ depending on the measure used to assess wellbeing.

Tetravalent Dengue Vaccine: A Review in the Prevention of Dengue Disease.

Tetravalent, live-attenuated, dengue vaccine (Dengvaxia(®); CYD-TDV) is the first vaccine approved for the prevention of dengue disease caused by dengue virus (DENV) serotypes 1-4 in individuals aged 9-45 or 9-60years living in high dengue endemic areas. This narrative review discusses the immunogenicity, protective efficacy, reactogenicity and safety of CYD-TDV in the prevention of dengue disease. In Latin American and Asian phase 3 trials in children and adolescents (n>30,000), the recommended three-dose CYD-TDV regimen was efficacious in preventing virologically-confirmed dengue (VCD) during the period from 28days after the last dose (month 13) tomonth 25, meeting the primary endpoint criteria. Protective efficacy against VCD in the respective individual trials was 60.8 and 56.5% (primary analysis). During the 25-month active surveillance phase, CYD-TDV also provided protective efficacy against VCD, severe dengue, any grade of dengue haemorrhagic fever and VCD-related hospitalization in children aged 9years and older. CYD-TDV was generally well tolerated, with no safety concerns identified after up to 4 years' follow-up (i.e. from post dose 1) in ongoing long-term studies. Based on evidence from the dengue clinical trial program, the WHO SAGE recommended that countries with high dengue endemicity consider introducing CYD-TDV as part of an integrated disease prevention strategy to lower disease burden. Pharmacoeconomic considerations will be pivotal to implementing dengue vaccination prevention strategies in these countries. The availability of a dengue vaccine is considered essential if the 2012 WHO global strategy targets for reducing the burden of dengue disease by 2020 are to be attained. Hence, CYD-TDV represents a major advance for the prevention of dengue disease in high dengue endemic regions.

Factors associated with cognitive function in older adults in Mexico

BackgroundAs populations age, cognitive decline and dementia pose significant burdens for societies and health care systems, including low- and middle-income countries such as Mexico. Minor age-related declines in cognitive function appear to represent a stable but heterogeneous phase in the continuum between normal cognitive ageing and dementia. Loss of cognitive function has impacts at societal and individual levels and understanding the risk factors can help provide a framework for health policies and interventions to target at-risk groups.DesignA cohort of older Mexican adults (50+) from the World Health Organization's Study on global AGEing and adult health (WHO SAGE) was used to examine cognitive function, including a total of 2315 respondents, with 325 respondents aged 80 years and older. Cognition was objectively evaluated using verbal recall, verbal fluency, forward digit span and backward digit span, with differences in an overall cognitive score assessed against sociodemographic variables, and associated factors using linear regression.ResultsThe most significant predictors of poorer cognitive function were found to be older age (β=−13.88), rural living (β=−2.25), low income (β=−8.28), self-reported severe or extreme memory difficulties (β=−6.62), and difficulty with two or more activities of daily living (β=−2.02).ConclusionsThese findings can inform public health initiatives to address cognitive impairment in ageing populations in Mexico and other middle-income countries.

Association between wealth and health among older adults in rural China and India

Abstract Declining mortality and fertility has resulted in an increase in the size of older adult (60+) populations worldwide, often characterized by limited economic resources, poor health status and challenges with accessing health facilities, thereby increasing their vulnerability to various poor health outcomes. Using data from the World Health Organization’s Study on global AGEing and adult health (WHO SAGE), economic differentials in health-related ailments were examined among rural dwelling older adults in China and India. Employing a disability framework, the associations between wealth status and four health outcomes, active disease, physical impairment, functional limitation and disability, were tested. Older adults from the three wealthiest quintiles (richest, richer and middle) were less likely to report the four health outcomes than the poorest one. Economic inequalities were largest for functional impairment and disability. Age advancement had a significant impact on each of the health outcomes. Equitable old age security schemes providing physical, social and economic support to this population, particularly to the economically disadvantageous groups in rural areas, are needed to ensure healthy aging in rural China and India.

Socio-Economic Differentials in Impoverishment Effects of Out-of-Pocket Health Expenditure in China and India: Evidence from WHO SAGE.

Background and ObjectivesThe provision of affordable health care is generally considered a fundamental goal of a welfare state. In addition to its role in maintaining and improving the health status of individuals and households, it impacts the economic prosperity of a society through its positive effects on labor productivity. Given this context, this paper assesses socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India, two of the fastest growing economies of the world.Data and MethodsThe paper uses data from the World Health Organisation’s Study on Global Ageing and Adult Health (WHO SAGE), and Bivariate as well as Multivariate analyses for investigating the socioeconomic-differentials in the impact of out-of-pocket-health-expenditure (OOPHE) on impoverishment in China and India.Results and ConclusionsAnnually, about 7% and 8% of the population in China and India, respectively, fall in poverty due to OOPHE. Also, the percentage shortfall in income for the population from poverty line due to OOPHE is 2% in China and 1.3% in India. Further, findings from the multivariate analysis indicate that lower wealth status and inpatient as well as outpatient care increase the odds of falling below poverty line significantly (with the extent much higher in the case of in-patient care) due to OOPHE in both China and India. In addition, having at least an under-5 child in the household, living in rural areas and having a household head with no formal education increases the odds of falling below poverty line significantly (compared to a head with college level education) due to OOPHE in China; whereas having at least an under-5 child, not having health insurance and residing in rural areas increases the odds of becoming poor significantly due to OOPHE in India.

Predictors of subjective well-being among older Ghanaians.

Later years of life are accompanied by many physical, emotional and environmental changes which may impact on the well-being of the individual. Many factors are known to influence the subjective well-being of older adults, but most, if not all of this information was the result of studies in the Western world. This study aimed at obtaining and documenting the predictors of subjective well-being (SWB) among older Ghanaians. Data for the study was obtained from the WHO SAGE study. The single item measure of life satisfaction was used to determine subjective well-being. Descriptive statistics as well as logistic regression analysis were carried out to determine the predictors of SWB. A total of 4724 individuals aged 50 years and above responded to the questionnaires. Of these 50.4% were males. Following multivariate logistic regression analysis, age, sex, educational level, income and ethnic background were found to significantly affect the SWB of older Ghanaians. Being male was associated with higher level of SWB (OR=1.68; CI: 1.39 - 2.03). For those 50 years and above, being younger (50-59 years) was also associated with a high level of SWB (OR=17.72; CI: 10.13-30.98). Earning a low income and having low educational level were both associated with low levels of SWB (OR=0.304; CI: 0.22-0.42; and OR=0.47; CI: 0.37-0.60 respectively). Ewes (p=0.027), Grumas (p=0.002) and Mole-Dagbons (p=0.04) had significantly higher SWB compared to the other ethnic groups. Among older Ghanaians, factors that positively influence SWB are younger age, male sex, high educational level and high income.

Disability and Chronic Disease Among Older Adults in India: Detecting Vulnerable Populations Through the WHO SAGE Study

Chronic noncommunicable diseases (NCDs) are now prevalent in many low- and middle-income countries and confer a heightened risk of disability. It is unclear how public health programs can identify the older adults at highest risk of disability related to NCDs within diverse developing country populations. We studied nationally representative survey data from 7,150 Indian adults older than 50 years of age who participated in the World Health Organization Study on Global Aging and Adult Health (2007-2010) to identify population subgroups who are highly disabled. Using machine-learning algorithms, we identified sociodemographic correlates of disability. Although having 2 or more symptomatic NCDs was a key correlate of disability, the prevalence of symptomatic, undiagnosed NCDs was highest among the lowest 2 wealth quintiles of Indian adults, contrary to prior hypotheses of increased NCDs with wealth. Women and persons from rural populations were also disproportionately affected by nondiagnosed NCDs, with high out-of-pocket health care expenditures increasing the probability of remaining symptomatic from NCDs. These findings also indicate that NCD prevalence surveillance studies in low- and middle-income countries should expand beyond self-reported diagnoses to include more extensive symptom- and examination-based surveys, given the likely high rate of surveillance bias due to barriers to diagnosis among vulnerable populations.

Is Self-Rated Health an Independent Index for Mortality among Older People in Indonesia?

BackgroundEmpirical studies on the association between self-rated health (SRH) and subsequent mortality are generally lacking in low- and middle-income countries. The evidence on whether socio-economic status and education modify this association is inconsistent. This study aims to fill these gaps using longitudinal data from a Health and Demographic Surveillance System (HDSS) site in Indonesia.MethodsIn 2010, we assessed the mortality status of 11,753 men and women aged 50+ who lived in Purworejo HDSS and participated in the INDEPTH WHO SAGE baseline in 2007. Information on self-rated health, socio-demographic indicators, disability and chronic disease were collected through face-to-face interview at baseline. We used Cox-proportional hazards regression for mortality and included all variables measured at baseline, including interaction terms between SRH and both education and socio-economic status (SES).ResultsDuring an average of 36 months follow-up, 11% of men and 9.5% of women died, resulting in death rates of 3.1 and 2.6 per 1,000 person-months, respectively. The age-adjusted Hazard Ratio (HR) for mortality was 17% higher in men than women (HR = 1.17; 95% CI = 1.04–1.31). After adjustment for covariates, the hazard ratios for mortality in men and women reporting bad health were 3.0 (95% CI = 2.0–4.4) and 4.9 (95% CI = 3.2–7.4), respectively. Education and SES did not modify this association for either sex.ConclusionsThis study supports the predictive power of bad self-rated health for subsequent mortality in rural Indonesian men and women 50 years old and over. In these analyses, education and household socio-economic status do not modify the relationship between SRH and mortality. This means that older people who rate their own health poorly should be an important target group for health service interventions.