Dr Paul Kowal

Introduction: The Better Health Program has been addressing key health system issues in the prevention and control of noncommunicable diseases (NCDs) in Malaysia, Thailand, Vietnam, and the Philippines. As the program comes to an end, the sustainability and scaling-up of issues have assumed importance. Objectives: The objective is to assess how well sustainability and scale-up strategies have been integrated into the design and implementation of a 3-year multicountry technical program; to explore enablers and barriers of sustainability and scaling up; and to identify practical strategies that can improve sustainability and scale-up of Better Health Program interventions. Methods: We applied a staged approach to explore barriers and enablers and to identify practical strategies to improve sustainability and scale-up of four NCD interventions: community-based obesity prevention, front-of-pack labeling, local learning networks (LLNs), and NCD surveillance. We extracted evidence from peer-reviewed literature and local documents. We also conducted in-depth interviews with the implementation teams and key stakeholders. We conducted a thematic synthesis of the resulting information to identify practical strategies that improve sustainability and scale-up of the four interventions. Results: Strong engagement of stakeholders at higher levels of the health system was identified as the main enabler, while limited funding and commitment from local governments were identified as a key barrier to sustainability and scale-up. Strengthening the social and institutional anchors of community health volunteers, enhancing evidence-based advocacy for front-of-pack labeling, trailblazing the LLN innovation, and securing the commitment of local governments in the implementation of NCD surveillance were among the key strategies for improving sustainability and scale-up of Better Health Program interventions in Malaysia, Thailand, Philippines, and Vietnam, respectively. Conclusions: This study identified practical strategies for improving sustainability and scale-up of NCD-related interventions. Implementation of the strategies that had high priority and feasibility will improve the sustainability of critical elements of the program in the respective countries.

Background. The population of people aged =60 years continues to increase globally, and has been projected by the United Nations Population Division to increase to 21% of the total population by 2050. In addition, the number of older people living with HIV has continued to increase owing to the introduction of antiretroviral therapy as a treatment for HIV-infected people. Most of the older people living with HIV are in sub-Saharan Africa, an area that faces the biggest burden of HIV globally. Despite the high burden, there are limited reliable data on how HIV directly and indirectly affects the health and wellbeing of older people within this region. Objective. To showcase the availability of data on how HIV directly and indirectly affects the health and wellbeing of older people in Uganda and South Africa (SA). Methods. The World Health Organization Study on global AGEing and adult health (SAGE), in collaboration with Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI and LSHTM) Uganda Research Unit and the Africa Health Research Institute (AHRI) in SA, started the SAGE Wellbeing of Older People Study (WOPS) in Uganda and SA in 2009. Since initiation, respondents have been surveyed every 2 years, with four waves of surveys conducted in Uganda and three waves in South Africa. Results. The available datasets consist of two cohorts of people, aged >50 years, who were surveyed every 2 years between 2009 and 2018. The prevalence of HIV positivity over this period increased from 39% to 54% in Uganda and 48% to 62% in SA. The datasets provide comparisons of variables at a household level and at an individual level. At the individual level, the following measures can be compared longitudinally for a 10-year period for the following variables: sociodemographic characteristics; work history and benefits; health states and descriptions; anthropometrics performance tests and biomarkers; risk factors and preventive health behaviours; chronic conditions and health services coverage; healthcare utilisation; social cohesion; subjective wellbeing and quality of life; and impact of caregiving. Conclusion. This article describes the WOPS in Uganda and SA, the population coverage of this study, and the survey frequency of WOPS, survey measures, data resources available, the data resource access and the strengths and weaknesses of the study. The article invites interested researchers to further analyse the data and answer research questions of interest to enhance the impact of these data.

Background: Although approximately 79% of the world¿s suicides occur in low- and middle-income countries (LMICs), the limited research in these regions has primarily focused on the rates of suicide attempts (SA) and ideation among men and younger members of the population. Aim: This study investigated the associations between bodily pain, functional limitation, chronic health conditions, and suicidal ideation among older Ghanaian women with a positive screen for depression. Methods: Data was obtained from the World Health Organization¿s Study on global AGEing and adult health (SAGE) Ghana Wave 1, a nationally representative sample. Based on the interpersonal theory of suicide, we used logistic regression analysis to investigate the associations between the variables. Results: Functional limitation, bodily pain, hopelessness, and hypertension were significantly associated with a higher risk of suicidal ideation after accounting for sociodemographic and other confounding factors. Conclusions: Early interventions designed to decrease hopelessness, hypertension, and functional limitations may lead to reduced suicide ideation among older Ghanaian women who screen positive for depression.

Front-of-pack nutrition labelling is an evidence-based nutrition intervention that is recommended by the World Health Organization and other health agencies as an effective non-communicable disease prevention strategy. To date, the types of front-of-pack labels that have been identified as being most effective have yet to be implemented in Southeast Asia. This has been partly attributed to extensive industry interference in nutrition policy development and implementation. This paper outlines the current state of food labelling policy in the region, describes observed industry interference tactics, and provides recommendations for how governments in Southeast Asia can address this interference to deliver best-practice nutrition labelling to improve diets at the population level. The experiences of four focal countries ¿ Malaysia, Thailand, the Philippines, and Viet Nam ¿ are highlighted to provide insights into the range of industry tactics that are serving to prevent optimal food labelling policies from being developed and implemented. Funding: This research was supported by the United Kingdom Global Better Health Programme, which is managed by the United Kingdom Foreign, Commonwealth and Development Office and supported by PricewaterhouseCoopers in Southeast Asia.

Background: The increased prevalence of overweight and obesity are directly related to economic development, eating habits and changes in physical activity levels. Objective: This study aimed to examine population-level body mass index (BMI) and associated factors. Methods: Data from World Health Organization Study on global AGEing and adult health Ghana Wave 2 conducted in 2015 among adults 18 years and older was used for the analysis. Body mass index was used as the main outcome measure. Inferential statistics involving ordered logistic regression models were carried out to assess risk predictors of obesity. Results: The prevalence of overweight and obesity BMI were 24.7% and 12.9% respectively. The prevalence of obesity varied across the regions, with relatively higher rates in southern regions (highest in the Greater Accra region, 28.3%) and was higher in women than men (20.4% versus 3.9%). Significant predictors [adjusted odds ratio (aOR) with 95% confidence interval (CI)] of obesity included female sex (aOR = 2.94, 95% CI = 2.25 ¿ 3.86), adults aged 50 ¿ 59 years (aOR = 3.95, 95% CI = 2.68 ¿ 5.83), dwellers in the capital region, Greater Accra (aOR = 3.58, 95% CI = 2.02 ¿ 6.36) and = 5 fruit intake [3.12 (1.74 ¿ 5.63)]. Conclusion: The prevalence of obesity among adult Ghanaians (= 18 years) has increased over two-fold in a decade based on analysis using similar methods and survey data. Increasing age and place of residence are significantly associated with high BMI. Our findings support the implementation of Ghana's 2012 national policy for the prevention and control of chronic non-communicable diseases (NCDs). The policy aims to change the trajectory of factors that contribute to NCD and fulfil WHO's NCD Target 7 for halting the growth in obesity and diabetes by 2025.

Background: There is a dearth of literature from sub-Saharan Africa on the effects of early (< 15 years) onset of paid work in children on future health status. This analysis was conducted to establish the effect of early onset of paid work in children on the adulthood health status of a cohort of adults in Ghana. Objective: This study aimed to establish the association between early-onset (engaged in work activities before the age of 15 years) paid child labour work activity (CL) and future older adult health status in Ghana. Methods: The World Health Organization study on global AGEing and adult health Ghana Wave 2 dataset was used for this study. A multistage cluster sampling design was used to select a nationally representative of 4735 Ghanaians aged = 18 years. The Modified Poisson and Logistics Regression were employed to assess associations between early onset of child labour and future health status. All analyses were performed with STATA Statistical Software and p < 0.05 was deemed significant. Results: The prevalence of CL was 4.20% [95% confidence interval (CI): 3.30 ¿ 5.20] and poor self-reported health (SRH) was 15.61% (95% CI: 13.92 ¿ 17.60). Overall, SRH was significantly associated with CL. The prevalence of poor SRH among older adults with experience of CL was 41% [from Modified Poisson estimations: adjusted Poisson ratio (aPR) = 1.40; 95% CI = 1.01 ¿ 1.96] and 47% [from Logistic regression: aOR = 1.47; 95% CI = 1.01 ¿ 2.17] compared with those with no experience of CL. Conclusion: A positive relationship existed between child labour and the future health status of individuals in this nationally representative study sample. These results reveal another collateral benefit (healthier adult populations) from the national government¿s quest to provide universal and free education up to the secondary level in Ghana. Equitable distribution of education and social opportunities for the current younger population and children in Ghana will reap several demographic and health dividends.

Recent studies have suggested the common co-occurrence of hypertension and diabetes in South Africa. Given that hypertension and diabetes are known to share common socio-demographic, anthropometric and lifestyle risk factors, the aim of this study was to jointly model the shared and disease-specific geographical variation of hypertension and diabetes. The current analysis used the Study on Global Ageing and Adult Health (SAGE) South Africa Wave 2 (2014/15) data collected from 2761 participants. Of the 2761 adults (median age = 56 years), 641 (23.2%) had high blood pressure on measurement and 338 (12.3%) reported being diagnosed with diabetes. The shared component has distinct spatial patterns with higher values of odds in the eastern districts of Kwa-Zulu Natal and central Gauteng province. The shared component may represent unmeasured health behavior characteristics or the social determinants of health in our population. Our study further showed how a shared component (latent and unmeasured health behavior characteristics or the social determinants of health) is distributed across South Africa among the older adult population. Further research using similar shared joint models may focus on extending these models for multiple diseases with ecological factors and also incorporating sampling weights in the spatial analyses.

Objectives: Universal salt iodization has been adopted by many countries to address iodine deficiency. More recently, salt-reduction strategies have been widely implemented to meet global salt intake targets of <5 g/d. Compatibility of the two policies has yet to be demonstrated. This study compares urinary iodine excretion (UIE) according to 24-h urinary sodium excretion, between South Africa (SA) and Ghana; both countries have implemented universal salt iodization, but in Ghana no salt-reduction legislation has been implemented. Methods: Participants from the World Health Organization's Study on Global Ageing and Adult Health Wave 3, with survey and valid 24-h urinary data (Ghana, n = 495; SA, n = 707), comprised the sample. Median 24-h UIE was compared across salt intake categories of <5, 5¿9 and >9 g/d. Results: In Ghana, median sodium excretion indicated a salt intake of 10.7 g/d (interquartile range [IQR] = 7.6), and median UIE was 182.4 µg/L (IQR = 162.5). In SA, both values were lower: median salt = 5.6 g/d (IQR = 5.0), median UIE = 100.2 µg/L (IQR = 129.6). UIE differed significantly across salt intake categories (P < 0.001) in both countries, with positive correlations observed in both¿Ghana: r = 0.1501, P < 0.0011; South Africa: r = 0.4050, P < 0.0001. Participants with salt intakes <9 g/d in SA did not meet the World Health Organization's recommended iodine intake of 150 µg/d, but this was not the case in Ghana. Conclusions: Monitoring and surveillance of iodine status is recommended in countries that have introduced salt-reduction strategies, in order to prevent reemergence of iodine deficiency.

Objectives To classify South African adults with chronic health conditions for multimorbidity (MM) risk, and to determine sociodemographic, anthropometric and behavioural factors associated with identified patterns of MM, using data from the WHO's Study on global AGEing and adult health South Africa Wave 2. Design Nationally representative (for =50-year-old adults) cross-sectional study. Setting Adults in South Africa between 2014 and 2015. Participants 1967 individuals (men: 623 and women: 1344) aged =45 years for whom data on all seven health conditions and socioeconomic, demographic, behavioural, and anthropological information were available. Measures MM latent classes. Results The prevalence of MM (coexistence of two or more non-communicable diseases (NCDs)) was 21%. The latent class analysis identified three groups namely: minimal MM risk (83%), concordant (hypertension and diabetes) MM (11%) and discordant (angina, asthma, chronic lung disease, arthritis and depression) MM (6%). Using the minimal MM risk group as the reference, female (relative risk ratio (RRR)=4.57; 95% CI (1.64 to 12.75); p =0.004) and older (RRR=1.08; 95% CI (1.04 to 1.12); p<0.001) participants were more likely to belong to the concordant MM group, while tobacco users (RRR=8.41; 95% CI (1.93 to 36.69); p=0.005) and older (RRR=1.09; 95% CI (1.03 to 1.15); p=0.002) participants had a high likelihood of belonging to the discordant MM group. Conclusion NCDs with similar pathophysiological risk profiles tend to cluster together in older people. Risk factors for MM in South African adults include sex, age and tobacco use.

The prevalence of hypertension is increasing in low- and middle-income countries, however statistics are generally derived from cross sectional surveys that utilize different methodologies and population samples. We investigated blood pressure (BP) changes over 11-12 years in a large cohort of adults aged 50 years and older (n = 820) included in the World Health Organization's Study on global AGEing and adult health (WHO-SAGE Ghana) Wave 1 (2007/8) with follow up in Wave 3 (2019). Participants' BP were measured in triplicate and a survey completed at both time points. Survey instruments collected information on sociodemographic characteristics, lifestyle, health behaviors and chronic conditions. While no significant difference was found in systolic BP between Waves 1 and 3, diastolic BP decreased by 9.7mmHg (mean = 88.6, 15.4 to 78.9, 13.6 respectively) and pulse pressure increased by 9.5mmHg (44.8, 13.7 to 54.3, 14.1). Awareness of hypertension increased by 37%, from (20% to 57%), but no differences were found for the proportion of hypertensives receiving treatment nor those that had controlled BP. Mixed effects modelling showed a decrease in diastolic BP was associated with increasing age, living in rural areas and having health insurance. Factors associated with an increased awareness of hypertension were residing in urban areas, having health insurance and increasing body mass index. While diagnosis of hypertension has improved over time in Ghana, there is an ongoing need to improve its treatment in older adults.

This paper assessed the transition probabilities between the stages of hypertension severity and the length of time an individual might spend at a particular disease state using the new American College of Cardiology/American Heart Association hypertension blood pressure guidelines. Data for this study were drawn from the Ghana WHO SAGE longitudinal study, with an analytical sample of 1884 across two waves. Using a multistate Markov model, we estimated a seven-year transition probability between normal/elevated blood pressure (systolic = 129 mm Hg & diastolic <80 mm Hg), stage 1 (systolic 130-139 mm Hg & diastolic 80-89 mm Hg), and stage 2 (systolic =140mm Hg & diastolic=90 mm Hg) hypertension and adjusted for the individual effects of anthropometric, lifestyle, and socio-demographic factors. At baseline, 22.5% had stage 1 hypertension and 52.2% had stage 2 hypertension. The estimated seven-year transition probability for the general population was 19.0% (95% CI: 16.4, 21.8) from normal/elevated blood pressure to stage 1 hypertension, 31.6% (95% CI: 27.6, 35.4%) from stage 1 hypertension to stage 2 hypertension, and 48.5% (45.6, 52.1%) for remaining at stage 2. Other factors such as being overweight, obese, female, aged 60+ years, urban residence, low education and high income were associated with an increased probability of remaining at stage 2 hypertension. However, consumption of recommended servings of fruits and vegetables per day was associated with a delay in the onset of stage 1 hypertension and a recovery to normal/elevated blood pressure. This is the first study to show estimated transition probabilities between the stages of hypertension severity across the lifespan in sub-Saharan Africa. The results are important for understanding progression through hypertension severity and can be used in simulating cost-effective models to evaluate policies and the burden of future healthcare.

South Africa implemented legislation in June 2016 mandating maximum sodium (Na) levels in processed foods. A pre-post impact evaluation assessed whether the interim legislative approach reduced salt intake and blood pressure. Baseline Na intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) Wave 2 (Aug-Dec 2015). 24-hour urine samples were collected in a random subsample (n = 1,299; of which n = 750 were considered valid (volume = 300 mL and creatinine = 4 mmol/day (women) or = 6 mmol/day (men))). Follow-up urine samples were collected in Wave 3 (Jun 2018-Jun 2019), with replacements included for those lost to follow-up (n = 1,189; n = 548 valid). In those aged 18 - 49y, median salt intake was 7.8 (4.7, 12.0) g/day in W2 (n = 274), remaining similar in the W3 sample (7.7 (4.9, 11.3) g salt/day (n = 92); P = 0.569). In older adults (50 + y), median salt intake was 5.8 (4.0, 8.5) g/day (n = 467) in W2, and 6.0 (4.0, 8.6) g/day (n = 455) in W3 (P = 0.721). Controlling for differences in background characteristics, overall salt intake dropped by 1.15 g/day (P = 0.028). 24hr urinary Na concentrations from a countrywide South African sample suggest that salt intakes have dropped during the interim phase of mandatory sodium legislation. Further measurement of population level salt intake following stricter Na targets, enforced from June 2019, is necessary.

Obesity is a major risk factor for many chronic diseases and disabilities, with severe implications on morbidity and mortality among older adults. With an increasing prevalence of obesity among older adults in Ghana, it has become necessary to develop cost-effective strategies for its management and prevention. However, developing such strategies is challenging as body mass index (BMI)-specific utilization and costs required for cost-effectiveness analysis are not available in this population. Therefore, this study examines the associations between health services utilization as well as direct healthcare costs and overweight (BMI =25.00 and <30.00 kg/m2) and obesity (BMI =30.00 kg/m2) among older adults in Ghana. Data were used from a nationally representative, multistage sample of 3350 people aged 50+ years from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE; 2014/15). Health service utilization was measured by the number of health facility visits over a 12-month period. Direct costs (2017 US dollars) included out-of-pocket payments and the National Health Insurance Scheme (NHIS) claims. Associations between utilization and BMI were examined using multivariable zero-inflated negative binomial regressions; and between costs and BMI using multivariable two-part regressions. Twenty-three percent were overweight and 13% were obese. Compared with normal-weight participants, overweight and obesity were associated with 75% and 159% more inpatient admissions, respectively. Obesity was also associated with 53% additional outpatient visits. One in five of the overweight and obese population had at least one chronic disease, and having chronic disease was associated with increased outpatient utilization. The average per person total costs for overweight was $78 and obesity was $132 compared with $35 for normal weight. The NHIS bore approximately 60% of the average total costs per person expended in 2014/15. Overweight and obese groups had significantly higher total direct healthcare costs burden of $121 million compared with $64 million for normal weight in the entire older adult Ghanaian population. Compared with normal weight, the total costs per person associated with overweight increased by 73% and more than doubled for obesity. Even though the total prevalence of overweight and obesity was about half of that of normal weight, the sum of their cost burden was almost doubled. Implementing weight reduction measures could reduce health service utilization and costs in this population.

Background: Air pollution has been associated with various health outcomes. Its effect on hand-grip strength, a measurement of the construct of muscle strength and health status, remains largely unknown. Methods: We used the survey data from 31,209 adults = 50 years of age within Wave 1 of the Study on Global AGEing and Adult Health in six low- and middle-income countries. The outdoor concentration of fine particulate matter pollution (PM2.5) was estimated using satellite data. Domestic fuel type and ventilation were used as indicators of indoor air pollution. We used multilevel linear regression models to examine the association between indoor and outdoor air pollution and hand-grip strength, as well as the potential effect modifiers. Results: We found inverse associations between both indoor and outdoor air pollution and hand-grip strength. Each 10 µg/m3 increase in 3 years¿ averaged concentrations of outdoor PM2.5 corresponded to 0.70 kg (95% CI: ¿1.26, ¿0.14) lower hand-grip strength; and compared with electricity/liquid/gas fuel users, those using solid fuels had lower hand-grip strength (ß = ¿1.25, 95% CI: ¿1.74, ¿0.75). However, we did not observe a statistically significant association between ventilation and hand-grip strength. We further observed that urban residents and those having a higher education level had a higher association between ambient PM2.5 and hand-grip strength, and men, young participants, smokers, rural participants, and those with lower household income had higher associations between indoor air pollution and hand-grip strength. Conclusion: This study suggests that both indoor and outdoor air pollution might be important risk factors of poorer health and functional status as indicated by hand-grip strength.

Little is known about how retirement and the time use redistribution that comes with it relate to experiential wellbeing, especially in low- and middle-income countries (LAMICs). This study aims to determine whether there are differences in experiential wellbeing between retired and working older adults; whether time use accounts for a portion of these differences; and whether these potential relationships differ across LAMICs and high-income countries. We used data from 2 multicountry studies conducted in countries at different levels of economic development: SAGE (China, Ghana, India, Mexico, and South Africa) and COURAGE in Europe (Finland, Poland, and Spain), focusing on participants aged 50+ (N = 21,000). Retirement was significantly associated with higher experiential wellbeing in both surveys, and time use accounted for more than 40% of the total effect. Retirees were higher in experiential wellbeing than working older adults, and differences in how individuals spend their day accounted for part of this relationship. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Objective: We compared the prevalence of frailty by HIV serostatus and related biomarkers to the modified frailty phenotype among older individuals in a rural population in South Africa. Methods: Questionnaire data were from a cohort of people living with HIV (PWH) on antiretroviral therapy (ART) and HIV-uninfected people aged 50 years and older sampled from the Africa Health Research Institute Demographic Health and Surveillance area in northern KwaZulu-Natal. The prevalence of frailty was compared using five categories: (1) physical activity; (2) mobility; (3) fatigue; (4) gait speed; and (5) grip strength, and assessed for demographic, clinical, and inflammatory correlates of frailty. Results: Among 614 individuals in the study, 384 (62.5%) were women. The median age at study enrolment was 64 years [Interquartile range (IQR) (58.6¿72.0)]. 292 (47.6%) were PWH. 499 (81%) were classified as either pre-frail or frail. 43 (7%) were frail and HIV positive, 185 (30%) were pre-frail and HIV positive, 57 were frail and HIV negative and 214 (35%) were pre-frail and HIV negative. Frailty was similar for HIV negative and PWH (17.7% vs 14.7%, p = 0.72). Women were more likely to be frail (18.3% vs 13.04%, p = 0.16). The prevalence of frailty increased with age for both HIV groups. In the multivariable analysis, the odds of being frail were higher in those aged 70 years and above than those aged between 50 and 59 years (p < 0.001). Females were less likely to be pre-frail than males (p < 0.001). There was no association between any of the inflammatory biomarkers and frailty and pre-frailty. Conclusion: In this population, the prevalence of frailty is similar for PWH and people without HIV, but higher for women than men. These data suggest that the odds of developing frailty is similar for PWH over the age of 50 years, who survive into older age, as for people without HIV.

Given a global focus on salt reduction efforts to reduce cardiovascular risk, it is important to obtain accurate measures of salt intake on a population level. This study determined firstly whether adjustment for intra-individual variation in urinary sodium (Na) excretion using three repeated 24 h collections affects daily estimates and whether the use of repeated spot urine samples results in better prediction of 24 h Na compared to a single collection. Twenty three community-dwelling men and women from South Africa (mean age 59.7 years (SD = 15.6)) participating in the World Health Organization Study on global AGEing and adult health (WHO-SAGE) Wave 3 study collected 24 h and spot early morning urine samples over three consecutive days to assess urinary Na excretion. INTERSALT, Tanaka, and Kawasaki prediction equations, with either average or adjusted spot Na values, were used to estimate 24 h Na and compared these against measured 24 h urinary Na. Adjustment was performed by using the ratio of between-person (sb) and total (sobs) variability obtained from repeated measures analysis of variance. Sensitivity of the equations to predict daily urinary Na values below 5 g salt equivalent was calculated. The sb/sobs for urinary Na using three repeated samples for spot and 24 h samples were 0.706 and 0.798, respectively. Correction using analysis of variance for 3 × 24 h collections resulted in contraction of the upper end of the distribution curve (90th centile: 157 to 136 mmoL/day; 95th centile: 220 to 178 mmoL/day). All three prediction equations grossly over-estimated 24 h urinary Na excretion, regardless of whether a single spot urine or repeated collections corrected for intra-individual variation were used. Sensitivity of equations to detect salt intake equivalent values of =5 g/day was 13% for INTERSALT, while the other two equations had zero sensitivity. Correcting for intra-individual variability in Na excretion using three 24 h urine collections contracted the distribution curve for high intakes. Repeated collection of spot samples for urinary Na analysis does not improve the accuracy of predicting 24 h Na excretion. Spot urine samples are not appropriate to detect participants with salt intakes below the recommended 5 g/day.

Background and Objectives: We reviewed the literature on older adults (OAs) who are caring for persons living with HIV/AIDS in sub-Saharan Africa (SSA), with the goal of adapting models of caregiver stress and coping to include culturally relevant and contextually appropriate factors specific to SSA, drawing on both life course and cultural capital theories. Research Design and Methods: A systematic literature search found 81 articles published between 1975 and 2016 which were reviewed using a narrative approach. Primary sources of articles included electronic databases and relevant WHO websites. Results: The main challenge of caregiving in SSA reflects significant financial constraints, specifically the lack of necessities such as food security, clean water, and access to health care. Caregiving is further complicated in SSA by serial bouts of caring for multiple individuals, including adult children and grandchildren, in the context of high levels of stigma associated with HIV. Factors promoting caregiver resilience included spirituality, bidirectional (reciprocal) caregiving, and collective coping strategies. Discussion and Implications: The creation of a theoretical model of caregiving which focuses more broadly on the sociocultural context of caregiving could lead to new ways of developing interventions in low-resources communities.

Background: Global commitments to reduce cardiovascular disease (CVD) burden by 2025 will require data on CVDs from lower income countries. This study aimed to estimate the prevalence of angina, and its association with hypertension, diabetes, and depression, in six low- and middle-income countries (LMICs). Methods: Data from the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 from China, Ghana, India, Mexico, Russia and South Africa were utilized. Multivariable logistic regression methods were used to examine the factors associated with angina. Results: A total of 31,443 respondents aged 50 years and over were included in these analyses. The prevalence of angina was highest in Russia (39%), lowest in China (8%), and consistently higher in women than men. Angina was comorbid with chronic conditions and depression but patterns varied across countries. Depression was negatively associated with angina among older adults in Ghana but was positively associated with angina in all other countries. Hypertension was associated with increased odds of angina among older adults in China (OR 1.9; 95% CI 1.59¿2.25), India (OR 1.4; 95% CI 1.14¿1.78) and Russia (OR 3.7; 95% CI 2.33¿6.00). Diabetes was associated with higher odds of angina in China (OR 1.6; 95% CI 1.15¿2.15), Russia (OR 2.5; 95% CI 1.57¿3.87), and South Africa (OR 4.1; 95% CI 2.49¿6.88). Conclusions: CVD is a significant contributor to disease burden in LMICs. Angina was often co-morbid with other conditions, therefore compelling health systems to develop longer-term integrated care systems to address co- and multi-morbidity.

The low-and middle-income countries (LMICs) are experiencing rapid population ageing, yet knowledge about disability among older populations in these countries is scarce. This study aims to identify the prevalence and factors associated with disability among people aged 50 years and over in six LMICs. Cross-sectional data from the World Health Organization (WHO) Study on global AGEing and adult health Wave 1 (2007¿2010) in China, Ghana, India, Mexico, the Russian Federation, and South Africa was used. Multivariable logistic regression analyses were undertaken to examine the association between sociodemographic factors, health behaviours, chronic conditions, and activities of daily living (ADL) disability. The prevalence of disability among older adults ranged from 16.2% in China to 55.7% in India. Older age, multimorbidity, and depression were the most common factors related to disability in all six countries. Gender was significant in China (OR = 1.14, 95% CI: 1.01¿1.29), Ghana (OR = 1.22, 95% CI: 1.01¿1.48) and India (OR = 1.65, 95% CI: 1.37¿1.99). Having no access to social capital was significantly associated with ADL disability in China (OR = 2.57, 95% CI: 1.54¿4.31) and South Africa (OR = 4.11, 95% CI: 1.79¿9.43). Prevalence data is valuable in these six ageing countries, with important evidence on mitigating factors for each. Identifying determinants associated with ADL disability among older people in LMICs can inform how to best implement health prevention programmes considering different country-specific factors.

Background: Anemia and frailty contribute to poor health outcomes in older adults; however, most current research in lower income countries has concentrated on anemia or frailty alone rather than in combination. The aim of the present study was to investigate the association between anemia and frailty in community-dwelling adults aged 50 years and older in China. Methods: The study population was sourced from the 2007/10 SAGE China Wave 1. Anemia was defined as hemoglobin less than 13 g/dL for men and less than 12 g/dL for women. A Frailty Index (FI) was compiled to assess frailty. The association between anemia and frailty was evaluated using a 2-level hierarchical logistic model. Results: The prevalence of anemia was 31.0% (95%CI: 28.4, 33.8%) and frailty 14.7% (95%CI: 13.5, 16.0%). In the univariate regression model, presence of anemia was significantly associated with frailty (OR = 1.62, 95% CI: 1.39, 1.90) and the effect remained consistent after adjusting for various potential confounding factors including age, gender, residence, education, household wealth, fruit and vegetable intake, tobacco use, alcohol comsumption and physical activity (adjusted OR = 1.31, 95% CI:1.09, 1.57). Each 1 g/dL increase in hemoglobin concentration was associated with 4% decrease in the odds of frailty after adjusting for several confounding variables (adjusted OR = 0.96, 95% CI: 0.93, 0.99). Conclusion: Anemia and low hemoglobin concentrations were significantly associated with frailty. Therefore, health care professionals caring for older adults should increase screening, assessment of causes and treatment of anemia as one method of avoiding, delaying or even reversing frailty.

Alterations in sleep patterns are common among older adults; further, short and long sleep durations have been linked with impaired cognitive performance in older individuals. Yet most research examining these relationships has been cross-sectional, limited to high-income nations, and has failed to consider how changes in sleep duration may impact cognitive decline. The present longitudinal study uses nationally-representative data to test whether changes in sleep length among ¿healthy¿ baseline sleepers are associated with reduced cognitive function in older Mexican adults (>50 years old) at follow-up. Data were drawn from the first and second waves of the World Health Organization's Study on global AGEing and adult health. Self-report data captured sleep duration over two nights, and five cognitive tests (immediate and delayed verbal recall, forward and backward digit span, and verbal fluency) were used to measure various cognitive domains and create a composite z-score of cognitive performance. Linear regressions were performed to assess associations between sleep length changes and cognitive decline, controlling for relevant lifestyle and health factors. Increased sleep durations at follow-up among individuals who reported intermediate sleep durations (6¿9 h/night) at baseline were significantly associated with greater rates of decline in overall cognitive function. Longer sleepers also trended toward greater rates of decline for attention/working memory and executive function. This study suggests that long sleep durations are a risk factor for certain types of impaired cognition among older adults living in a middle-income country. These findings are clinically important given the growing rates of dementia and aging populations globally.

Objectives Perceived income adequacy is positively associated with self-rated health (SRH) and quality of life (QOL) among adults in higher-income countries. Additionally, older individuals often report higher levels of income adequacy. However, it is unclear if these associations, documented primarily in high-income countries, are also evident across economically and culturally distinctive low- and middle-income countries. Methods Data were drawn from the World Health Organization's Study on global AGEing and adult health (SAGE), a study of adults aged 50 years or older in China, Ghana, India, Mexico, the Russian Federation, and South Africa. Smaller samples of younger adults (18-49 years) were included for comparison purposes. Participants reported income adequacy, SRH, and QOL. Associations between age and income adequacy and between income adequacy and SRH/QOL were examined using country-specific logistic regression analysis. Results Older adults in China and Russia were more likely to report better income adequacy than their 18- to 49-year-old counterparts; however, the opposite was observed in Ghana and India. SRH and QOL improved as income adequacy increased in all countries. Discussion As expected, income adequacy was correlated with SRH and QOL. However, the relationship between age and income adequacy varied cross-culturally, potentially due to differences in familial and governmental financial support.

Identification of sarcopenia in lower- and middle-income countries (LMICs) is limited by access to technologies that assess muscle mass. We investigated associations between two functional measures of sarcopenia, grip strength and gait speed (GS), with functional disability in adults from six LMICs. Data were extracted from the World Health Organization (WHO) Study on global AGEing and adult health Wave 1 (2007¿2010) for adults (= 65¿years) from China, Mexico, Ghana, India, Russia and South Africa (n = 10,892, 52.8% women). We calculated country-specific prevalence of low grip strength, slow GS (= 0.8¿m/s), and both measures combined. Using multivariable negative binomial regression, we separately assessed associations between low grip strength, slow GS, and both measures combined, with the WHO Disability Assessment Schedule 2.0, accounting for selected socioeconomic factors. In women, low grip strength ranged from 7 in South Africa to 51% in India; in men, it ranged from 17 in Russia to 51% in Mexico. Country-specific proportions of slow GS ranged from 77 in Russia, to 33% in China. The concomitant presence of both was the lowest in South Africa and the highest in India (12.3% vs. 33%). Independent of age, those with both low grip strength and slow GS had between 1.2- and 1.5-fold worse functional disability scores, independent of comorbidities, low education, and low wealth (all country-dependent). Low grip strength, slow GS, and the combination of both, were all associated with higher levels of functional disability, thus indicating these objective measures offer a reasonably robust estimate for potential poor health outcomes.

Objective. To examine the longitudinal association between the social determinants of health (SDH) and frailty status with all-cause mortality in older Mexican adults. Materials and methods. Longitudinal study with a sample of adults aged 60 and over of Study on Global AGEing and Adult Health (SAGE) in Mexico. A Cox proportional hazard model was used to estimate the SDH and frailty-related hazard ratios (HR) for mortality over the study period. Results. Overall mortality rate was 16.9%. Higher education, having a higher frequency of inter-personal contacts (HR=0.96; p < 0.01) reduced the risk of dying, after adjusting for potential confounders. While, not counting on someone to trust (HR= 1.59; p < 0.03) and having a sense a lack of control over important decisions in life increased the mortality risk. Conclusions. Given that frailty and the SDH affect health using independent pathways, public health systems in Mexico could benefit from increasing the capacity of identifying frail and isolated older adults and providing a risk-stratified health care accordingly.

Background: Empirical evidence suggests that multimorbidity and disability are each significantly associated with out-of-pocket (OOP) health expenditures; however few efforts have been made to explore their joint association with OOP health expenditures. Objectives: To estimate the association of multimorbidity and disability with OOP health expenditures in households with older adults in Mexico, as well as the potential interaction effects of multimorbidity and disability on OOP health expenditures. Methods: Longitudinal study based on data collected as part of the Study on global AGEing and adult health Wave 1 (2009) and Wave 2 (2014), a nationally representative study in Mexico with a sample of older adults aged 50 and older. The dependent variable was OOP health expenditures, and main exposure variables were multimorbidity and disability. Two-Part regression models were used to analyze the relation between multimorbidity, disability and OOP health expenditures. Results: Multimorbidity was associated with the probability of incurring OOP health expenditures (OR = 1.28, CI95% 1.11¿1.48), and also the tertiles of disability (2nd tertile: OR = 1.45, CI95% 1.23¿1.70; 3rd tertile: OR = 2.19, CI95% 1.81¿2.66). The presence of multimorbidity was associated with an increase of 13% in average OOP health costs (ß = 0.13, CI95% 0.01¿0.25), and 16% for the 3rd tertile of disability (ß = 0.16, CI95% 0.01¿0.31). We did not find significant interaction effects of multimorbidity and disability. Conclusions: Multimorbidity and disability appear to be important determinants of OOP health expenditures. The economic implications for the households and the health system should be highlighted, particularly in low- and middle-income countries because of the rapid growth of their aging populations.

Objectives: We examined the development of disease and disability in a large cohort of older women, the extent to which these conditions exempt them from being classified as successful agers and different trajectories of disease, disability and longevity across women's later life. Methods: We used survey data from 12,432 participants of the 1921-26 birth cohort of the Australian Longitudinal Study of Women's Health from 1996 (age 70-75) to 2016 (age 90-95). Repeated measures latent class analysis (RMLCA) identified trajectories of the development of disease with or without disability and according to longevity. Bivariate analyses and multivariable multinomial logistic regression models were used to examine the association between participants' baseline characteristics and membership of the latent classes. Results: Over one-third of women could be considered to be successful agers when in their early 70s, few women could still be classified in this category throughout their later life or by the end of the study when they were in their 90s (~1%). RMLCA identified six trajectory groups including managed agers long survivors (9.0%) with disease but little disability, usual agers long survivors (14.9%) with disease and disability, usual agers (26.6%) and early mortality (25.7%). A small group of women having no major disease or disability well into their 80s were identified as successful agers (5.5%). A final group, missing surveys (18.3%), had a high rate of non-death attrition. Groups were differentiated by a number of social and health factors including marital status, education, smoking, body mass index, exercise and social support. Conclusions: The study shows different trajectories of disease and disability in a cohort of ageing women, over time and through to very old ages. While some women continue into very old age with no disease or disability, many more women live long with disease but little disability, remaining independent beyond their capacity to be classified as successful agers.

Background: Physical function is positively associated with subjective well-being in older adults from high-income nations. This study tests whether this association is evident in low- and middle-income countries. Methods: Data were drawn from the study on global AGEing and adult health, using nationally representative samples of individuals over 50 years old from China, Ghana, India, Mexico, Russia, and South Africa. Participant interviews measured well-being (quality of life, mood, and happiness) and physical function (grip strength, usual and rapid gait speed). Logistic regressions tested relations between physical function and well-being variables within each country. Results: Higher physical function measures exhibited moderate, yet significant, associations with increased odds of highly rated well-being (p < .05). However, higher gait speeds were unexpectedly associated with decreased odds of highly rated well-being (p < .05) in South Africa and Russia. Conclusion: These results suggest that physical function is generally positively associated with perceived well-being in older individuals from lower income nations.

South Africa has one of the highest levels of hypertension globally, coupled with poor rates of diagnosis, treatment and control. Risk factors that predict hypertension in high income countries may perform differently in the African context, where communicable disease, obesity and malnutrition co-exist. This study investigated traditional risk factors alongside other health and sociodemographic indicators to determine predictors of hypertension prevalence and management. Participants were recruited from households across South Africa as part of WHO¿s Study on global AGEing and adult health (WHO SAGE) Wave 2 (2015). Blood pressure (BP) was measured in triplicate and sociodemographic and health data collected by survey (n = 1847; 30% 18¿39 years, 39% 40¿59 years, 31% 60 years+; median age 51 years; 68% female). Of all adults, 43% were hypertensive (n = 802), of which 58% (n = 398) were unaware, 33% (n = 267) were on medication, with only 18% (n = 141) controlled on medication (BP < 140/90 mmHg). Multivariate logistic regression showed waist-to-height ratio > 0.5 and diabetes comorbidity were the most significant predictors of hypertension presence, awareness and treatment. Individuals with diabetes were twice as likely to have hypertension, 7.0 times more likely to be aware, 3.3 times more likely to be on antihypertensive medication, and 2.4 times more likely to be controlled on medication. Women and individuals reporting lower salt use were more likely to be aware and treated for hypertension. Applying the 2017 AHA/ACC hypertension guidelines showed only 1 in 4 adults had normal BP. As with HIV, similarly intensive efforts are now needed in the region to improve non-communicable disease diagnosis and management.

Background: Obesity is a major public health challenge and its prevalence has increased across the age spectrum from 1980 to date in most parts of the world including sub-Saharan Africa. Studies that derive health state utilities (HSUs) stratified by weight status to support the conduct of economic evaluations and prioritization of cost-effective weight management interventions are lacking in sub-Saharan Africa. Objectives: To estimate age- and sex-specific HSUs for Ghana, along with HSUs by weight status. Associations between HSUs and overweight and obesity will be examined. Study Design: Cross-sectional survey of the Ghanaian population. Methods: Data were sourced from the World Health Organization Study of Global AGEing and Adult Health (WHO SAGE), 2014 to 2015. Using a ¿judgment-based mapping¿ method, responses to items from the World Health Organization Quality-of-Life (WHOQOL-100) used in the WHO SAGE were mapped to EQ-5D-5L profiles, and the Zimbabwe value set was applied to calculate HSUs. Poststratified sampling weights were applied to estimate mean HSUs, and a multivariable linear regression model was used to examine associations between HSUs and overweight or obesity. Results: Responses from 3966 adults aged 18 to 110 years were analyzed. The mean (95% confidence interval) HSU was 0.856 (95% CI: 0.850, 0.863) for the population, 0.866 (95% CI: 0.857, 0.875) for men, and 0.849 (95% CI: 0.841, 0.856) for women. Lower mean HSUs were observed for obese individuals and with older ages. Multivariable regression analysis showed that HSUs were negatively associated with obesity (-0.024; 95% CI: -0.037, -0.011), female sex (-0.011; 95% CI: -0.020, -0.003), and older age groups in the population. Conclusions: The study provides HSUs by sex, age, and body mass index (BMI) categories for the Ghanaian population and examines associations between HSU and high BMI. Obesity was negatively associated with health state utility in the population. These data can be used in future economic evaluations for Ghana and sub-Saharan African populations.

Background: Cotinine, a nicotine metabolite, is used to measure tobacco use and exposure, but recommended cut-offs to differentiate tobacco users from those exposed through the environment range from 3 to 58 ng/ml in serum, and 2.5 to 550 ng/ml in urine. Cut-offs may differ by ethnicity, sex and age. As data from adults in Africa are scarce, our aim was to evaluate cut-offs for serum and urine cotinine that best predict self-reported tobacco use in South African adults. Methods: Two datasets were explored: African-PREDICT (n = 941 black and white healthy young adults, 20¿30 years, serum cotinine); and WHO SAGE Wave 2 (n = 604 adults, 18¿102 years, urine cotinine). Population specific cut-offs (ROC analyses) were compared with published cut-offs and self-reported tobacco use. Results: Overall, 19% (293 of 1545) reported current tobacco use. The following cotinine cut-offs showed the highest sensitivity and specificity: serum =15 ng/ml in black and white men, and white women; serum =10 ng/ml in black women; urine =300 ng/ml for black, mixed ancestry, and older adults (50-plus years); urine =500 ng/ml for younger adults (18¿49 years). Specificity was lower for urine than for serum cotinine. Conclusion: Our study suggests that a serum cotinine level of =15 ng/ml and a urine cotinine level of =300 ng/ml best distinguish current tobacco users from non-users generally in the South African adult population.

Objectives: The study compared the proportion of older adults identified as drinking hazardously based on the Alcohol Use Disorders Identification Test¿Consumption (AUDIT-C) with the older adult-specific Comorbidity Alcohol Risk Evaluation Tool (CARET) and investigated whether sociodemographics, comorbidities, health, medication use, and alcohol-related risk behaviors explained discrepancies between the screens in classification of hazardousness. Method: The AUDIT-C and the CARET were administered to 3,673 adults aged 55 to 89 years. Classification agreement between the screens was evaluated using Cohen¿s kappa. Hazardous drinking groups were compared using logistic regression. Results: Analysis indicated moderate agreement between the screens. Drinkers classified as ¿hazardous on the CARET only¿ consumed less alcohol, but were more likely to drink-drive. Introducing a drink-driving criterion into the calculation of hazardousness on the AUDIT-C substantially decreased the classification discrepancy between the measures. Discussion: Standard screening can be improved by investigating comorbidities, medication use, and alcohol-related risk behaviors in those initially identified as nonhazardous drinkers.

Background: : Data from the World Health Organization Study on global AGEing and adult health (SAGE) were used to estimate the prevalence of depression in older adults in six low- and middle-income countries (LMICs), namely China, Ghana, India, Mexico, the Russian Federation, and South Africa, and to examine the relationship between demographic and lifestyle characteristics and depression. Method: : A total of 33,421 participants aged = 50 years were included. A set of diagnostic questions from the World Mental Health Survey was used within SAGE to define depression. Results: : The crude population prevalence of depression was 7.4% [95%CI: 6.5%¿8.3%] ranging from 1.5% in China to 15.2% in India. It was higher in females 8.6% [7.6%¿9.6%] compared to males 6.1% [5.0%¿7.2%]. The age-standardized prevalence of depression was 7.8% [6.3%¿9.6%] in pooled data, 8.9% [6.9%¿11.1%] in females and 6.6% [4.6%¿9.0%] in males. Greater fruit (0.89[0.84¿0.93]) and vegetable intake (0.94 [0.89¿1.00]) was associated with a lower prevalence of depression. Furthermore, those who were older, female, underweight, and with lower education and lower wealth, had higher prevalence of depression. Limitations: : The cross-sectional design of this study precluded conclusions on causality. Conclusion: : In nationally-representative samples of older adults in six LMICs, an average of one in every 13 participants suffered from depression. The prevalence of depression varied considerably between countries, sexes, and with wealth and educational disadvantage. Increased fruit and vegetable intake appeared to co-occur with significantly lower rates of depression, suggesting diet as a modifiable factor for addressing depression burden.

Background: The aim of current study is to assess the cross-sectional association of chronic non-communicable diseases (diabetes mellitus, arthritis, asthma, chronic lung disease, angina, and stroke) with both diagnosed and undiagnosed depression in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1, a study of adults in six low- and middle-income countries. Methods: A total of 41,810 participants, aged = 18 years, were included. Depression status was assessed by standard methods derived from the World Mental Health Survey (WHH-CIDI). Undiagnosed depression was defined as a depressed person who did not report history of diagnosis/treatment for depression. Associations between depression/undiagnosed depression and chronic diseases, adjusting for country of residence, demographics and chronic diseases risk factors were assessed. Results: Depression was detected in 2508 (6.0%) cases, from whom 2098 (87%) were undiagnosed. Diabetes (Odds ratio:1.47[95%CI:1.24,1.75]), arthritis (2.14[1.82,2.52]), asthma (3.36[2.73,4.14]), chronic lung disease (3.74[3.10,4.51]), angina (3.20[2.66,3.85]), and stroke (3.14[2.55,3.86]) were associated with depression (p-values < 0.001). Being older, female, underweight, and having lower education, and lower income were positively associated with depression. The estimated odds ratios were similar for undiagnosed depression. Limitations: Cross-sectional design of study prevent us to determine whether depression followed exposures in time. About 12% of the participant did not have data for depression status and were excluded from the study. Conclusions: Most depression cases were undiagnosed. Depression/undiagnosed depression were strongly associated with chronic diseases; stronger than what has been reported in developed countries.

Objectives: The aim of this study was to investigate socioeconomic inequalities in frailty among older adults in six low- and middle-income countries (LMICs), and to examine to what extent chronic diseases account for these inequalities. Study design: Data were used from the Study on global AGEing and adult health (SAGE) wave 1 (2007¿2010). Nationally representative samples of adults aged 50+ years from China, Ghana, India, Mexico, the Russian Federation and South Africa were analyzed (n = 31,174). Main outcome measures: Educational level and wealth were used as socioeconomic indicators. Frailty was assessed with modified criteria for the frailty phenotype. Self-reported disease diagnoses were used. A relative index of inequality (RII) was calculated to compare socioeconomic inequalities in frailty between countries. Results: People in lower socioeconomic positions had higher prevalence rates of frailty. The largest inequalities in frailty were found in Mexico (RII 3.7, 95% CI 2.1¿6.4), and the smallest inequalities in Ghana (RII 1.1, 95% CI 0.7¿1.8). Mediation analyses revealed that the chronic diseases considered in this study do not explain the higher prevalence of frailty seen in lower socioeconomic groups. Conclusions: Substantial socioeconomic inequalities in frailty were observed in LMICs, but additional research is needed to find explanations for these. Given that the population of older adults in many LMICs is expanding at a greater rate than in many high-income countries, our results indicate an urgent public health need to address frailty in these countries.

Objectives: Telomere length (TL) is a biomarker of aging and age-related decline. Although venous blood is considered the ¿gold standard¿ for TL measurement, its collection is often not feasible or desired in nonclinical settings. Saliva and dried blood spots (DBS) have been used as alternatives when venipuncture cannot be performed. However, it is not known whether these sample types yield TL measurements comparable to those obtained from venous blood. We sought to determine whether different samples from the same individual yield comparable TL measurements. Methods: We extracted DNA from matched buffy coat, saliva (Oragene and Oasis), and DBS (venous and capillary) samples from 40 women aged 18-77 years. We used the monochrome multiplex qPCR (MMQPCR) assay to measure TL in all sample types for each participant and applied quality control measures to retain only high-quality samples for analysis. We then compared TL from buffy coat and saliva to examine how these measurements differ and to test if TL is correlated across sample types. Results: TL differed significantly across buffy coat, Oragene saliva, and Oasis saliva samples. TL from buffy coat and Oragene saliva was moderately correlated (¿ = 0.48, P =.002) and the most similar in size. Oasis saliva TL was not correlated with buffy coat or Oragene saliva TL, and was the shortest. DBS DNA yields were inadequate for TL measurement using the MMQPCR assay. Conclusions: Using a matched dataset we demonstrate that sample type significantly influences the TL measurement obtained using the MMQPCR assay.

This study examined the association between social engagement and survival in people with or without HIV aged 50 years and over in Uganda. We analysed two waves of a survey from two sites in Uganda to assess predictors of mortality between waves. The first wave was conducted between 2009 and 2010 while the second wave was conducted between 2012 and 2013. A standardised questionnaire adapted from the World Health Organization study on global AGEing and adult health (SAGE) was administered through face-to-face interviews at both survey waves. Cox proportional hazards models and Nelson¿Aalen cumulative hazards functions were used to investigate associations between the strength of participants¿ social ties, using distance and intimacy metrics, and their social engagement with mortality between waves. Of the original 510 participants, 63 (12.3%) died between waves. Being more socially engaged and able to provide in-kind or financial contributions to family or friends were protective. After adjusting for covariates neither social tie measure was predictive of mortality. There were no significant differences in social engagement and survival by HIV status. Further research is needed in African settings on the relationship between social relationships and subsequent mortality in older adults to assess if improved social relationships could moderate mortality.

Background: Populations globally are ageing, resulting in increased need for long-term care. Where social welfare systems are insufficient, these costs may fall to other family members. We set out to estimate the association between long-term care needs and family transfers in selected low- and middle- income countries. Methods: We used data from the World Health Organization's Study on global AGEing and adult health (SAGE). Using regression, we analysed the relationship between long-term care needs in older households and i) odds of receiving net positive transfers from family outside the household and ii) the amount of transfer received, controlling for relevant socio-demographic characteristics. Results: The proportion of household members requiring long-term care was significantly associated with receiving net positive transfers in China (OR: 1.76; p = 0.023), Ghana (OR: 2.79; p = 0.073), Russia (OR: 3.50; p < 0.001). There was a statistically significant association with amount of transfer received only in Mexico (B: 541.62; p = 0.010). Conclusion: In selected LMICs, receiving family transfers is common among older households, and associated with requiring long-term care. Further research is needed to better understand drivers of observed associations and identify ways in which financial protection of older adults¿ long-term care needs can be improved.

The objective of this article is to document factors associated with the recency of health-care service utilization by people aged 50 years and over living with and without HIV in Uganda. A survey was conducted with 510 Ugandans aged 50 and older, living with and without HIV. The survey included information on sociodemographic characteristics, health state, self-reported chronic conditions, and timing of most recent visit to a health-care facility (time since last visit [TSLV]). We use ordinal logistic regression to identify independent factors associated TSLV. Independent factors associated with TSLV (>6 months) include age, OR = 2.40 [95% CI 1.08-5.37] for those aged 80 years and above, urban respondents, OR = 0.6 [95%CI 0.38-0.94], HIV-positive respondents, OR = 0.33 [95%CI 0.18-0.59], and better health. To understand the meaning of these finding, further investigation should examine (a) how best to define and measure older persons' health-care service needs and (b) older persons' decision-making processes around the timing of their access to health-care facilities.

Apolipoprotein B (ApoB) is a strong predictor of cardiovascular disease, which remains the leading cause of mortality in both higher and lower income countries. Here, we adapted an enzyme-linked immunosorbent assay (ELISA) development kit for quantitative determination of ApoB levels in serum and plasma for use with dried blood spots (DBS). After confirming the dilution linearity of the assay for DBS, we measured ApoB in 208 venous DBS samples. Then, using Passing-Bablok regression analysis and Spearman rank correlation analysis, we evaluated the correspondence in ApoB values between matched plasma and finger-prick DBS samples from 40 individuals who had ApoB values spanning the range of ApoB values observed in the 208 vDBS samples. We also evaluated assay precision and recovery, the effects of hematocrit, number of freeze-thaw cycles, and different storage temperatures on ApoB levels in DBS. There was a strong, significant correlation between plasma and DBS ApoB levels with little bias. Assay precision and recovery were within the range recommended by the U.S. government¿s industry guidelines for bioanalytical assay validation. The assay was not affected by the DBS matrix or physiological hematocrit levels. This DBS-based ELISA assay will facilitate population-scale assessment of cardiovascular risk in previously unexplored populations.

Background: Little is known about the joint mental health effects of air pollution and tobacco smoking in low- and middle-income countries. Aims: To investigate the effects of exposure to ambient fine particulate matter pollution (PM2.5) and smoking and their combined (interactive) effects on depression. Method: Multilevel logistic regression analysis of baseline data of a prospective cohort study (n=41 785). The 3-year average concentrations of PM2.5 were estimated using US National Aeronautics and Space Administration satellite data, and depression was diagnosed using a standardised questionnaire. Three-level logistic regression models were applied to examine the associations with depression. Results: The odds ratio (OR) for depression was 1.09 (95% Cl 1.01-1.17) per 10µg/m3 increase in ambient PM2.5, and the association remained after adjusting for potential confounding factors (adjusted OR=1.10, 95% CI 1.02-1.19). Tobacco smoking (smoking status, frequency, duration and amount) was also significantly associated with depression. There appeared to be a synergistic interaction between ambient PM2.5 and smoking on depression in the additive model, but the interaction was not statistically significant in the multiplicative model. Conclusions: Our study suggests that exposure to ambient PM2.5 may increase the risk of depression, and smoking may enhance this effect.

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of cormorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50. Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents. Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p =.03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p <.001) and respondents from rural settings (OR 2.9; p <.01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care. Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services¿which can inform South Africa¿s development of a national health insurance scheme.

In this paper, we examine patterns of self-reported diagnosis of noncommunicable diseases (NCDs) and prevalences of algorithm/measured test-based, undiagnosed, and untreated NCDs in China, Ghana, India, Mexico, Russia, and South Africa. Nationally representative samples of older adults aged =50 years were analyzed from wave 1 of the World Health Organization's Study on Global Ageing and Adult Health (2007-2010; n = 34,149). Analyses focused on 6 conditions: Angina, arthritis, asthma, chronic lung disease, depression, and hypertension. Outcomes for these NCDs were: 1) self-reported disease, 2) algorithm/measured test-based disease, 3) undiagnosed disease, and 4) untreated disease. Algorithm/measured test-based prevalence of NCDs was much higher than self-reported prevalence in all 6 countries, indicating underestimation of NCD prevalence in low- and middle-income countries. Undiagnosed prevalence of NCDs was highest for hypertension, ranging from 19.7% (95% confidence interval (CI): 18.1, 21.3) in India to 49.6% (95% CI: 46.2, 53.0) in South Africa. The proportion untreated among all diseases was highest for depression, ranging from 69.5% (95% CI: 57.1, 81.9) in South Africa to 93.2% (95% CI: 90.1, 95.7) in India. Higher levels of education and wealth significantly reduced the odds of an undiagnosed condition and untreated morbidity. A high prevalence of undiagnosed NCDs and an even higher proportion of untreated NCDs highlights the inadequacies in diagnosis and management of NCDs in local health-care systems.

Background: Physical activity impacts the ageing process; yet, few studies have examined relationships among physical activity, functional abilities and health among older adults in non-Western settings. Aim: This study tests for associations among measures of physical activity, function and self-report health conditions among 200 older adults (49--50 years old) in Jodhpur, Rajasthan, India. Methods: Seven consecutive days of accelerometry data were used in measures of physical activity (Total Daily Energy Expenditure [TDEE], Physical Activity Level [PAL], Daily Average Activity Count [AC] and Activity Energy Expenditure [AEE]). Measures of physical function included grip strength, timed walk and daily average sit time. Participants reported if they had been diagnosed with diabetes, hypertension, arthritis and/or depression. Results: All four measures of physical activity were positively associated with grip strength (p = 0.05). AC was negatively associated with timed walk (p = 0.05), and both AC and AEE were negatively associated with daily average sit time (p = 0.05). Women who reported diagnosis of hypertension had lower PAL and AC (p = 0.05). Conclusion: This study provides further evidence for a positive relationship between physical activity and functional ability among older adults and between physical activity and cardiovascular health among women in India.

This paper describes overall socioeconomic gradients and the age patterns of socioeconomic gradients of health of Indian adults for multiple health indicators encompassing the multiple aspects of health. Cross-sectional data on 11,230 Indians aged 18¿years and older from the WHO-SAGE India Wave 1, 2007 were analyzed. Multivariate logit models were estimated to examine effects of socioeconomic status (education and household wealth) and age on four health domains: self-rated health, self-reported functioning, chronic diseases, and biological health measures. Results show that socioeconomic status (SES) was negatively associated with prevalence of each health measure but with considerable heterogeneity across age groups. Results for hypertension and COPD were inconclusive. SES effects are significant while adjusting for background characteristics and health risk factors. The age patterns of SES gradient of health depict divergence with age, however, no conclusive age pattern emerged for biological markers. Overall, results in this paper dispelled the conclusion of negative SES-health association found in some previous Indian studies and reinforced the hypothesis of positive association of SES with health for Indian adults. Higher prevalence of negative health outcomes and SES disparities of health outcomes among older age-groups highlight need for inclusive and focused health care interventions for older adults across socioeconomic spectrum.

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.

One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individual's cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Fried's frailty phenotype; Rockwood and Mitnitski's Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Clegg's guidelines for frailty classification - that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.

Background The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. Methods Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. Results This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. Conclusions Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Objective: Our objective was to quantify disability prevalence among older adults of low- and middle-income countries, and measure socio-demographic distribution of disability. Methods: World Health Survey data included 53,447 adults aged 50 or older from 43 low- and middle-income countries. Disability was a binary classification, based on a composite score derived from self-reported functional difficulties. Socio-demographic variables included sex, age, marital status, area of residence, education level, and household economic status. A multivariate Poisson regression model with robust variance was used to assess associations between disability and socio-demographic variables. Results: Overall, 33.3¿% (95¿% CI 32.2¿34.4¿%) of older adults reported disability. Disability was 1.5 times more common in females, and was positively associated with increasing age. Divorced/separated/widowed respondents reported higher disability rates in all but one study country, and education and wealth levels were inversely associated with disability rates. Urban residence tended to be advantageous over rural. Country-level datasets showed disparate patterns. Conclusions: Effective approaches aimed at disability prevention and improved disability management are warranted, including the inclusion of equity considerations in monitoring and evaluation activities.

Objectives: Accelerometry provides researchers with a powerful tool to measure physical activity in population-based studies, yet this technology has been underutilized in cross-cultural studies of older adults. The present study was conducted among older adults in an urban setting in India with the following three objectives: (1) to compare average activity levels obtained through different durations of monitoring (1, 3, and 7 days); (2) to document differences in physical activity patterns by sex and age and (3) to evaluate links between measures of physical activity and anthropometrics, as well as between activity parameters and measures of household size, work status, and social cohesion. Methods: The present study uses data from a physical activity substudy of the World Health Organization's Study on global AGEing and adult health (SAGE-PA). This study of 200 older adults (49-90 years old; 72 males, 128 females) in urban India combines 7 continuous days of ActiGraph GT3X accelerometry with anthropometric and sociodemographic data. Results: Results reveal overall low activity levels, with significantly lower activity energy expenditure (AEE) among females (P<0.05). No significant differences were documented in activity level by monitoring duration. Age was negatively correlated with AEE in men (P<0.01) and women (P<0.001). AEE was positively correlated with BMI in men (P<0.01) and women (P<0.05). Finally, women who were more socially integrated had greater AEE (P<0.01). Conclusions: This study illustrates the utility of accelerometry for quantifying activity levels in aging populations in non-Western nations.

Background: As 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. Design: A 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. Results: The most significant predictors of poorer cognitive function were found to be older age (ß=-13.88), rural living (ß=-2.25), low income (ß=-8.28), self-reported severe or extreme memory difficulties (ß=-6.62), and difficulty with two or more activities of daily living (ß=-2.02). Conclusions: These findings can inform public health initiatives to address cognitive impairment in ageing populations in Mexico and other middle-income countries.

Our objective was to validate a commercially available ELISA to measure antibody titers against Epstein-Barr virus (EBV) in dried blood spots (DBS) to replace a previously validated assay for DBS that is no longer available. We evaluated the precision, reliability, and stability of the assay for the measurement of EBV antibodies in matched plasma, fingerprick DBS, and venous blood DBS samples from 208 individuals. Effects of hematocrit and DBS sample matrix on EBV antibody determination were also investigated, and the cutoff for seropositivity in DBS was determined. A conversion equation was derived to enable comparison of results generated using this method with the former DBS method. There was a high correlation between plasma and DBS EBV antibody titers (R2¿=¿0.93) with very little bias (-0.07 based on Bland-Altman analysis). The assay showed good linearity and did not appear to be affected by the DBS matrix, and physiological hematocrit levels had no effect on assay performance. There was reasonable agreement between DBS EBV titer estimates obtained using this assay and the previously validated assay (R2¿=¿0.72). The commercially available ELISA assay for EBV antibody titers that we validated for use with DBS will facilitate continued investigation of EBV antibody titers in DBS.

Objectives Edentulism has important health implications for aging individuals and is used as an indicator of the oral health of a population. Its distribution is unequal within populations, with the greatest burden on disadvantaged and socially marginalized populations. With an increasing older adult population in Ghana, its burden may increase; however, there is no nationwide information on edentulism in Ghana. Focusing on adults 50 years and older, this study assessed the prevalence of edentulism among older Ghanaians and its distribution across the country. Methods Secondary analysis of WHO's Study on global AGEing and adult health (SAGE) Wave 1 in Ghana was conducted using self-reported edentulism as the dependent variable. Results The overall prevalence was 2.8%, varying by sex (men had lower rates; OR = 0.67, 95% CI = 0.47-0.97); by location, being more prevalent in urban areas (3.6%) and the Western Region (4.7%); by education levels (rates were higher among those with no formal education; OR = 1.626, 95% CI = 1.111-2.380); and by marital status (those living without a partner had higher rates; OR = 1.980, 95% CI =1.366-2.870). On multivariate logistic regression, the variables positively associated with edentulism were older age (OR = 0.945) and urban residence (OR = 0.582). Living in the Brong Ahafo (OR = 3.138), Central (OR = 2.172), Eastern (OR = 2.257), or Volta regions (OR = 3.333) was negatively associated with edentulism. Conclusion Edentulism is unequally distributed across Ghana. Future aged cohorts are likely to follow the same patterns of geographic and social disadvantage if needed interventions are not carried out. This study provides nationwide data to assist service planning.

Background: Chronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as 'multimorbidity'. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs. Methods: Data was obtained from the WHO's Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries. Results: The prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases. Conclusions: Findings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes.

Background: Healthcare financing through out-ofpocket payments and inequities in healthcare utilisation are common in low and middle income countries (LMICs). Given the dearth of pertinent studies on these issues among older people in LMICs, we investigated the determinants of health service use, out-of-pocket and catastrophic health expenditures among older people in one LMIC, India. Methods: We accessed data from a nationally representative, multistage sample of 2414 people aged 65 years and older from the WHO's Study on global Ageing and adult health in India. Sociodemographic characteristics, health profiles, health service utilisation and out-of-pocket health expenditure were assessed using standard instruments. Multivariate zero-inflated negative binomial regression models were used to evaluate the determinants of health service visits. Multivariate Heckman sample selection regression models were used to assess the determinants of out-of-pocket and catastrophic health expenditures. Results: Out-of-pocket health expenditures were higher among participants with disability and lower income. Diabetes, hypertension, chronic pulmonary disease, heart disease and tuberculosis increased the number of health visits and out-of-pocket health expenditures. The prevalence of catastrophic health expenditure among older people in India was 7% (95% CI 6% to 8%). Older men and individuals with chronic diseases were at higher risk of catastrophic health expenditure, while access to health insurance lowered the risk. Conclusions: Reducing out-of-pocket health expenditure among older people is an important public health issue, in which social as well as medical determinants should be prioritised. Enhanced public health sector performance and provision of publicly funded insurance may protect against catastrophic health expenses and healthcare inequities in India.

Objectives: The obesity epidemic in Mexico is increasing and represents a considerable public health challenge. The population aged 50 years and older is also increasing and is not exempt from the obesity rise. We aimed to determine the current prevalence of Body Mass Index (BMI) categories in a sample of Mexicans aged 50 years and older and to test the associations of BMI with physical activity categories and related factors. Methods: Data from 2,032 individuals aged 50 years and older who participated in SAGE Wave 1 (2009-2010) were analyzed. Representativeness of the sample was obtained by using weighted data. Descriptive statistics, chi square tests, simple regression analysis, and multiple regression analysis were performed in relation to BMI, self-reported physical activity categories, and several variables, including demographic characteristics and selected risk factors for non-communicable diseases. Results: Among older adults, 0.6% was found to be underweight, 21.4% normal weight, 49.4% overweight, and 28.7% obese. It was also found that practicing vigorous intensity physical activity (-1.32) and being 80 years or older (-2.73) were significantly associated (P<0.05) with a lower mean BMI (28.3). In contrast, being in the lowest income quintile (1.35), and living in urban areas (0.86) were significantly associated with a higher mean BMI. Conclusions: The study results contribute to the current understanding of obesity etiology in Mexico, and moreover confirm that overweight and obesity are current public health problems that must be addressed in specific subgroups of older adults. Am. J. Hum. Biol. 27:326-333, 2015.

The objective of this study was to examine gender roles in the provision and receipt of care among older Ugandans. Survey data on care work were collected in 2009-2010 from 510 older people infected or affected by HIV/AIDS, at one rural and one semi-urban site. The questionnaire was adapted from the WHO Study on global AGEing and adult health survey. The type of care work done by older men and women for children in their households differs, yet, both men and women are taking on various types of care work. Women were more likely to report taking part in health/personal and physical care, whereas men were more likely to report providing financial assistance. Some older people, particularly women, were providing care at the same time as needing care. The finding on reciprocity of care suggests the need for further studies focused on how the reciprocity of care may affect health and well-being in older age.

Background: Edentulism affects the quality of life and general health of an individual. But in ageing individuals, it has been observed to have greater impact, manifesting in functional, psychological and social limitations. With an increasing older adult population in Ghana, its burden is likely to increase. This study was thus carried out to explore the association between edentulism and quality of life among older Ghanaian adults. Methods: Secondary analysis of WHO's Study on global AGEing and adult health (SAGE) Wave 1 in Ghana was conducted using self-reported edentulism as the dependent variable. Participants included a nationally representative sample of adult's aged 50 years and older living in Ghana. Quality of life was measured using the 8 item WHOQOL measure and a single item measure which was a question "How would you rate your overall quality of life?". To assess the association between edentulism and the independent variables, a bivariate analysis was carried out. A Poisson regression model was then performed, adjusting for age, sex, income, education and the diagnosis of a chronic disease condition. A Spearman's correlation analysis was also carried out between the single and multi item measure of quality of life to assess how well they correlate. Results: Edentulism was observed to be associated with significantly lower levels of SWB among older adults using both the single-item and multiple-item measure (WHOQOL). It, however, showed no association with happiness. Among edentulous respondents, females and those with no formal education reported significantly lower quality of life. The WHOQOL correlated positively and strongly with the single-item measure. Conclusion: Edentulism may not be life threatening and yet it has been shown to have a negative effect on the quality of life of older adult Ghanaians. More emphasis may thus need to be placed on the oral health of the aging population in Ghana to avoid it.

Background: Multimorbidity defined as the "the coexistence of two or more chronic diseases" in one individual, is increasing in prevalence globally. The aim of this study is to compare the prevalence of multimorbidity across low and middle-income countries (LMICs), and to investigate patterns by age and education, as a proxy for socio-economic status (SES). Methods: Chronic disease data from 28 countries of the World Health Survey (2003) were extracted and inter-country socio-economic differences were examined by gross domestic product (GDP). Regression analyses were applied to examine associations of education with multimorbidity by region adjusted for age and sex distributions. Results: The mean world standardized multimorbidity prevalence for LMICs was 7.8 % (95 % CI, 7.79 % - 7.83 %). In all countries, multimorbidity increased significantly with age. A positive but non-linear relationship was found between country GDP and multimorbidity prevalence. Trend analyses of multimorbidity by education suggest that there are intergenerational differences, with a more inverse education gradient for younger adults compared to older adults. Higher education was significantly associated with a decreased risk of multimorbidity in the all-region analyses. Conclusions: Multimorbidity is a global phenomenon, not just affecting older adults in HICs. Policy makers worldwide need to address these health inequalities, and support the complex service needs of a growing multimorbid population.

In 2010 falls were responsible for approximately 80 % of disability stemming from unintentional injuries excluding traffic accidents in adults 50 years and over. Falls are becoming a major public health problem in low- and middle-income countries (LMICs) where populations are ageing rapidly. Methods: Nationally representative standardized data collected from adults aged 50 years and over participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, the Russian Federation and South Africa are analysed. The aims are to identify the prevalence of, and risk factors for, past-year fall-related injury and to assess associations between fall-related injury and disability. Regression methods are used to identify risk factors and association between fall-related injury and disability. Disability was measured using the WHO Disability Assessment Schedule Version 2.0 (WHODAS 2.0). Results: The prevalence of past-year fall-related injuries ranged from 6.6 % in India to 1.0 % in South Africa and was 4.0 % across the pooled countries. The proportion of all past-year injuries that were fall-related ranged from 73.3 % in the Russian Federation to 44.4 % in Ghana. Across the six countries this was 65.7 %. In the multivariable logistic regression, the odds of past-year fall-related injury were significantly higher for: women (OR: 1.27; 95 % CI: 0.99,1.62); respondents who lived in rural areas (OR: 1.36; 95 % CI: 1.06,1.75); those with depression (OR: 1.43; 95 % CI: 1.01,2.02); respondents who reported severe or extreme problems sleeping (OR: 1.54; 95 % CI: 1.15,2.08); and those who reported two or more (compared with no) chronic conditions (OR: 2.15; 95 % CI: 1.45,3.19). Poor cognition was also a significant risk factor for fall-related injury. The association between fall-related injury and the WHODAS measure of disability was highly significant (P<0.0001) with some attenuation after adjusting for confounders. Reporting two or more chronic conditions (compared with none) was significantly associated with disability (P<0.0001). Conclusions: The findings provide a platform for improving understanding of risk factors for falls in older adults in this group of LMICs. Clinicians and public health professionals in these countries must be made aware of the extent of this problem and the need to implement policies to reduce the risk of falls in older adults.

Background: Behavioral risk factors such as tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol are known and modifiable contributors to a number of NCDs and health mediators. The purpose of this paper is to describe the distribution of main risk factors for NCDs by socioeconomic status (SES) among adults aged 50 years and older within a country and compare these risk factors across six lower- And upper-middle income countries. Methods: The study population in this paper draw from SAGE Wave 1 and consisted of adults aged 50-plus from China (N=13,157), Ghana (N=4,305), India (N=6,560), Mexico (N=2,318), the Russian Federation (N=3,938) and South Africa (N=3,836). Seven main common risk factors for NCDs were identified: daily tobacco use, frequent heavy drinking, low level physical activity, insufficient vegetable and fruit intake, high risk waist-hip ratio, obesity and hypertension. Multiple risk factors were also calculated by summing all these risk factors. Results: The prevalence of daily tobacco use ranged from 7.7% (Ghana) to 46.9% (India), frequent heavy drinker was the highest in China (6.3%) and lowest in India (0.2%), and the highest prevalence of low physical activity was in South Africa (59.7%). The highest prevalence of respondents with high waist-to-hip ratio risk was 84.5% in Mexico, and the prevalence of self-reported hypertension ranging from 33% (India) to 78% (South Africa). Obesity was more common in South Africa, the Russia Federation and Mexico (45.2%, 36% and 28.6%, respectively) compared with China, India and Ghana (15.3%, 9.7% and 6.4%, respectively). China, Ghana and India had a higher prevalence of respondents with multiple risk factors than Mexico, the Russia Federation and South Africa. The occurrence of three and four risk factors was more prevalent in Mexico, the Russia Federation and South Africa. Conclusion: There were substantial variations across countries and settings, even between upper-middle income countries and lower-middle income countries. The baseline information on the magnitude of the problem of risk factors provided by this study can help countries and health policymakers to set up interventions addressing the global non-communicable disease epidemic.

Background: Back pain is a common disabling chronic condition that burdens individuals, families and societies. Epidemiological evidence, mainly from high-income countries, shows positive association between back pain prevalence and older age. There is an urgent need for accurate epidemiological data on back pain in adult populations in low- and middle-income countries (LMICs) where populations are ageing rapidly. The objectives of this study are to: measure the prevalence of back pain; identify risk factors and determinants associated with back pain, and describe association between back pain and disability in adults aged 50 years and older, in six LMICs from different regions of the world. The findings provide insights into country-level differences in self-reported back pain and disability in a group of socially, culturally, economically and geographically diverse LMICs. Methods: Standardized national survey data collected from adults (50 years and older) participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) were analysed. The weighted sample (n = 30, 146) comprised respondents in China, Ghana, India, Mexico, South Africa and the Russian Federation. Multivariable regressions describe factors associated with back pain prevalence and intensity, and back pain as a determinant of disability. Results: Prevalence was highest in the Russian Federation (56%) and lowest in China (22%). In the pooled multi-country analyses, female sex, lower education, lower wealth and multiple chronic morbidities were significant in association with past-month back pain (p<0.01). About 8% of respondents reported that they experienced intense back pain in the previous month. Conclusions: Evidence on back pain and its impact on disability is needed in developing countries so that governments can invest in cost-effective education and rehabilitation to reduce the growing social and economic burden imposed by this disabling condition.

Dietary guidelines around the world recommend increased intakes of fruits and non-starchy vegetables for the prevention of chronic diseases and possibly obesity. This study aimed to describe the association between body mass index (BMI) and habitual fruit and vegetable consumption in a large sample of 246,995 Australian adults aged 45 + year who had been recruited for the "45 and Up" cohort study. Fruit and vegetable intake was assessed using validated short questions, while weight and height were self-reported. Multinomial logistic regression was used, by sex, to assess the association between fruit and vegetable intake and BMI. Compared to the referent normal weight category (BMI 18.5 to 24.9), the odds ratio (OR) of being in the highest vegetable intake quartile was 1.09 (95% confidence interval (CI) 1.04-1.14) for overweight women (BMI 25.0-29.9) and 1.18 (95% CI 1.12-1.24) for obese women. The association was in the opposite direction for fruit for overweight (OR 0.85; 95% CI 0.80-0.90) and obese women (OR 0.75; 95% CI 0.69-0.80). Obese and overweight women had higher odds of being in the highest intake quartile for combined fruit and vegetable intake, and were more likely to meet the "2 and 5" target or to have five or more serves of fruit and vegetables per day. In contrast, overweight men were less likely to be in high intake quartiles and less likely to meet recommended target of 5 per day, but there was no consistent relationship between obesity and fruit and vegetable intake. Underweight women and underweight men were less likely to be in the highest intake quartiles or to meet the recommended targets. These data suggest that improving adherence to dietary targets for fruit and vegetables may be a dietary strategy to overcome overweight among men, but that overweight and obese women are already adhering to these targets. The association between fruit and vegetable intake and underweight in adults suggests that improving fruit and vegetables intakes are important for the overall dietary patterns of people in this group. © 2014 by the authors; licensee MDPI, Basel, Switzerland.