Inequalities in Mortality in the Asia-Pacific: A Cross-National Comparison of Socioeconomic Gradients.

OBJECTIVES: Social inequalities in mortality are poorly studied in much of the Asia-Pacific. Using data from harmonized nationally representative longitudinal health and aging surveys our study systematically assesses mortality disparities across 3 standardized measures of socioeconomic status in 7 Asia-Pacific countries. METHODS: We used data from multiple waves of 7 representative sample surveys: the Health, Income and Labour Dynamics in Australia survey, China Health and Retirement Longitudinal Study, the Indonesian Family Life Survey, the New Zealand Health, Work and Retirement survey, the Korean Longitudinal Study on Ageing and the Health, Aging and Retirement in Thailand survey, and the Japanese Study of Aging and Retirement. We use Cox proportional hazards modeling to examine how the hazard of mortality differs across domains of social stratification including educational attainment, wealth, and occupational status across countries. RESULTS: We found consistent and pervasive gradients in mortality risk in the high-income countries by all available measures of social stratification. In contrast, patterns of inequality in adult mortality in middle-income and recently transitioned high-income countries investigated varied depending on the measure of social stratification, with strong gradients by wealth but mixed gradients by education. DISCUSSION: Analyzing social gradients in mortality in the Asia-Pacific shows that inequalities, especially wealth-based inequalities, in later-life health are present across the region, and that the magnitude of social gradients in mortality is overall larger in high-income countries as compared to middle-income countries.

Disability and morbidity among US birth cohorts, 1998-2018: A multidimensional test of dynamic equilibrium theory.

A substantial body of prior research has explored patterns of disability-free and morbidity-free life expectancy among older populations. However, these distinct facets of later-life health are almost always studied in isolation, even though they are very likely to be related. Using data from the US Health and Retirement Study and a multistate life table approach, this paper explores the interactions between disability, morbidity, and mortality by sex and education among four successive US birth cohorts, born from 1914 to 1923 to 1944-1953 and compared in the periods 1998-2008 and 2008-2018. We find little compression of disability but a marked expansion of morbidity across cohorts. However, disability-free life expectancy (DFLE) among those living with chronic morbidities has increased, even though at the population-level DFLE is largely unchanged. Broadly, these patterns suggest that successive cohorts of older populations in the US are experiencing a dynamic equilibrium, where the link between chronic morbidities and disability has weakened over successive cohorts. Investigating patterns by educational attainment, we find marked disparities where the least educated individuals not only live significantly fewer years free of disabilities or chronic morbidities but also have experienced an expansion in morbidity and disability. Our findings suggest that the future trajectory of disability-free life expectancy in the US is increasingly contingent on efforts to improve disease management and control the severe consequences of chronic morbidities.

A growing divide: Trends in social inequalities in healthy longevity in Australia, 2001-20.

This study examines two decades of change in social inequalities in life and health expectancy among older adults in Australia, one of the few countries that escaped an economic recession during the global financial crisis. We compare adults aged 45+ across three measures of individual socio-economic position-education, occupation, and household wealth-and use multistate life tables to estimate total life expectancy (TLE) and life expectancy free of limiting long-term illness (LLTI-free LE) based on 20 waves of the Household, Income and Labour Dynamics in Australia Survey (2001-20). Our findings highlight substantial social disparities in both TLE and LLTI-free LE in Australia. Grouping individuals by household wealth shows striking differentials in LLTI-free LE. We observe widening social disparities in healthy longevity over time by all three measures of socio-economic position. This diverging trend in healthy longevity is troubling against the backdrop of widening income and wealth inequalities in Australia.

Life Course Socioeconomic Status and Healthy Longevity in China.

In 2020, China's population aged 60 or older exceeded 264 million, representing 25% of the global population in that age-group. Older adults in China experienced periods of dramatic political and social unrest in early life, as well as economic transformations leading to drastic improvements in living standards during adulthood and older age. However, the implications of life course socioeconomic status (SES) trajectories for healthy longevity in later life have not been systematically studied in China. We utilize data from the China Health and Retirement Longitudinal Study (CHARLS) to comprehensively investigate how early-life conditions and adult SES combine to influence healthy longevity in later life. We find that both childhood and adulthood SES are associated with late-life health. The largest disparities in life expectancy (LE) and disability-free LE are found between those with persistently low SES throughout life and those with consistently high SES. At age 45, the gap in total LE between the most advantaged and least advantaged groups is six years for men and five years for women. Despite China's major policy changes prioritizing equity in income and health care in recent decades, our findings suggest that dramatic health inequalities among older adults remain. Our findings extend the literature on the effect of socioeconomic patterns across the life course on gradients in later-life health and highlight continuing disparities in healthy longevity among older adults in China.

Impairment in Activities of Daily Living and Unmet Need for Care Among Older Adults: A Population-Based Study From Burkina Faso.

OBJECTIVES: The importance of impairment in performing activities of daily living (ADL) is likely to increase in sub-Saharan Africa because few care options for affected people exist. This study investigated the prevalence of ADL impairment, the extent to which care need was met, and described characteristics of people with ADL impairment and unmet need in Burkina Faso. METHODS: This study used data from the Centre de Recherche en Santé de Nouna Heidelberg Aging Study, a population-based study among 3,026 adults aged older than 40 years conducted in rural Burkina Faso. Information on 6 basic ADL items was sought, with a follow-up question asking whether care need was not met, partially met, or met. Bivariable correlations and multivariable logistic regression were used to determine sociodemographic and health characteristics associated with ADL impairment and unmet need. RESULTS: ADL impairment of any kind was reported by 1,202 (39.7%) respondents and was associated with older age (adjusted odds ratio: 1.05 [95% CI: 1.04-1.06]), being a woman (1.33 [1.06-1.60]), and reporting depressive symptoms (1.90 [1.65-2.18]). Among those with ADL impairment, 67.8% had at least one unmet need. Severe ADL impairment was found in 202 (6.7%) respondents, who reported a lower prevalence of unmet need (43.1%). Severe ADL impairment was associated with depressive symptoms (2.55 [2.11-3.07]) to a stronger degree than any ADL impairment. DISCUSSION: Prevalence of ADL impairment and unmet need was high in this setting. Variation in impairment across the population highlighted key groups for future interventions. Unmet need for care was highest in middle-aged adults, indicating a gap in care provision.

Education and adult mortality in middle-income countries: Surprising gradients in six nationally-representative longitudinal surveys.

BACKGROUND: There are large differences in adult mortality across schooling groups in many high-income countries (HICs). An important open question is whether there are similar gradients in adult mortality in middle-income countries (MICs), where schooling and healthcare quality tends to be lower and health-related behaviors are often not strongly patterned by schooling. METHODS: We present one of the first international-comparative studies on schooling differences in adult mortality across MICs using harmonizedlongitudinal data on adults ages 50+ from China, Costa Rica, Indonesia, Mexico, South Africa, and South Korea. We use Cox proportional hazards models to estimate differences in the hazard of mortality across schooling groups overall and separately by sex and broad age groups. We also estimate schooling gradients in smoking and body mass index to determine whether risk factor gradients potentially explain mortality patterns. RESULTS: Only adults with tertiary schooling have a consistent adult mortality advantage compared to those with no schooling. We do not find evidence that individuals with primary schooling have a lower hazard of mortality compared to individuals with no schooling in five of the six countries. The mortality advantage for individuals with secondary schooling is mixed, with evidence of lower mortality relative to those with no schooling in Mexico, South Africa, and South Korea. Gradients in BMI and smoking are inconsistent across countries and unlikely to explain mortality differences. CONCLUSIONS: We find that adult mortality and risk factor gradients in MICs can be much different than the established patterns seen in modern HICs. Our results highlight that adult mortality gradients are not an inevitability and are not found in all populations. Understanding what factors give rise to inequalities in adult mortality and what can be done to minimize gradients while still ensuring continued mortality improvements in MICs is a crucial focus for research and policy.

Impairment in Activities of Daily Living, Care Receipt, and Unmet Needs in a Middle-Aged and Older Rural South African Population: Findings From the HAALSI Study.

Objectives: The objective of this study is to analyze the degree to which care needs are met in an aging rural African population. Method: Using data from the Health and Aging in Africa: Longitudinal Study of an INDEPTH Community (HAALSI) baseline survey, which interviewed 5,059 adults aged older than 40 years in rural South Africa, we assessed the levels of limitations in activities of daily living (ADLs) and in unmet care for these ADLs, and evaluated their association with sociodemographic and health characteristics. Results: ADL impairment was reported by 12.2% of respondents, with the proportion increasing with age. Among those with ADL impairment, 23.9% reported an unmet need and 51.4% more a partially met need. Relatives provided help most often; formal care provision was rare. Unmet needs were more frequent among younger people and women, and were associated with physical and cognitive deficits, but not income or household size. Discussion: Unmet care needs in rural South Africa are often found among individuals less expected to require care.

Are China's oldest-old living longer with less disability? A longitudinal modeling analysis of birth cohorts born 10 years apart.

BACKGROUND: China has transitioned from being one of the fastest-growing populations to among the most rapidly aging countries worldwide. In particular, the population of oldest-old individuals, those aged 80+, is projected to quadruple by 2050. The oldest-old represent a uniquely important group-they have high demand for personal assistance and the highest healthcare costs of any age group. Understanding trends in disability and longevity among the oldest-old-that is, whether successive generations are living longer and with less disability-is of great importance for policy and planning purposes. METHODS: We utilized data from successive birth cohorts (n = 20,520) of the Chinese oldest-old born 10 years apart (the earlier cohort was interviewed in 1998 and the later cohort in 2008). Disability was defined as needing personal assistance in performing one or more of five essential activities (bathing, transferring, dressing, eating, and toileting) or being incontinent. Participants were followed for age-specific disability transitions and mortality (in 2000 and 2002 for the earlier cohort and 2011 and 2014 for the later cohort), which were then used to generate microsimulation-based multistate life tables to estimate partial life expectancy (LE) and disability-free LE (DFLE), stratified by sex and age groups (octogenarians, nonagenarians, and centenarians). We additionally explored sociodemographic heterogeneity in LE and DFLE by urban/rural residence and educational attainment. RESULTS: More recently born Chinese octogenarians (born 1919-1928) had a longer partial LE between ages 80 and 89 than octogenarians born 1909-1918, and octogenarian women experienced an increase in partial DFLE of 0.32 years (P = 0.004) across the two birth cohorts. Although no increases in partial LE were observed among nonagenarians or centenarians, partial DFLE increased across birth cohorts, with a gain of 0.41 years (P < 0.001) among nonagenarians and 0.07 years (P = 0.050) among centenarians. Subgroup analyses revealed that gains in partial LE and DFLE primarily occurred among the urban resident population. CONCLUSIONS: Successive generations of China's oldest-old are living with less disability as a whole, and LE is expanding among octogenarians. However, we found a widening urban-rural disparity in longevity and disability, highlighting the need to improve policies to alleviate health inequality throughout the population.

Aging in the Americas: Disability-free Life Expectancy Among Adults Aged 65 and Older in the United States, Costa Rica, Mexico, and Puerto Rico.

Objectives: To estimate and compare disability-free life expectancy (DFLE) and current age patterns of disability onset and recovery from disability between the United States and countries in Latin America and the Caribbean. Method: Disability is measured using the activities of daily living scale. Data come from longitudinal surveys of older adult populations in Costa Rica, Mexico, Puerto Rico, and the United States. Age patterns of transitions in and out of disability are modeled with a discrete-time logistic hazard model, and a microsimulation approach is used to estimate DFLE. Results: Overall life expectancy for women aged 65 is 20.11 years in Costa Rica, 19.2 years in Mexico, 20.4 years in Puerto Rico, and 20.5 years in the United States. For men, these figures are 19.0 years in Costa Rica, 18.4 years in Mexico, 18.1 years in Puerto Rico, and 18.1 years in the United States. Proportion of remaining life spent free of disability for women at age 65 is comparable between Mexico, Puerto Rico, and the United States, with Costa Rica trailing slightly. Male estimates of DFLE are similar across the four populations. Discussion: Though the older adult population of Latin America and the Caribbean lived many years exposed to poor epidemiological and public health conditions, their functional health in later life is comparable with the older adult population of the United States.

Childhood deprivation and later-life cognitive function in a population-based study of older rural South Africans.

RATIONALE: Little research has evaluated the life course drivers of cognitive aging in South Africa. OBJECTIVES: We investigated the relationships of self-rated childhood health and father's occupation during childhood with later-life cognitive function score and whether educational attainment mediated these relationships among older South Africans living in a former region of Apartheid-era racial segregation. METHODS: Data were from baseline assessments of "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community" (HAALSI), a population-based study of 5059 men and women aged ≥40 years in 2015 in rural Agincourt sub-district, South Africa. Childhood health, father's occupation during childhood, and years of education were self-reported in study interviews. Cognitive measures assessed time orientation, numeracy, and word recall, which were included in a z-standardized latent cognitive function score variable. Linear regression models adjusted for age, sex, and country of birth were used to estimate the total and direct effects of each childhood risk factor, and the indirect effects mediated by years of education. RESULTS: Poor childhood health predicted lower cognitive scores (total effect = -0.28; 95% CI = -0.35, -0.21, versus good); this effect was not mediated by educational attainment. Having a father in a professional job during childhood, while rare (3% of sample), predicted better cognitive scores (total effect = 0.25; 95% CI = 0.10, 0.40, versus unskilled manual labor, 29% of sample). Half of this effect was mediated by educational attainment. Education was linearly associated with later-life cognitive function score (0.09; 95% CI = 0.09, 0.10 per year achieved). CONCLUSION: In this post-Apartheid, rural South African context, older adults with poor self-reported childhood health or whose father worked in unskilled manual labor had relatively poor cognitive outcomes. Educational attainment strongly predicted cognitive outcomes, and appeared to be, in part, a mechanism of social stratification in later-life cognitive health in this context.

Physical Function in an Aging Population in Rural South Africa: Findings From HAALSI and Cross-National Comparisons With HRS Sister Studies.

OBJECTIVES: We use recently-collected data from the Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort from Agincourt, South Africa, to describe physical functioning in this aging population, and place the overall level and age-trajectories of physical health in the context of other Health and Retirement Study (HRS) sister studies in low- and middle-income countries (LMICs). METHOD: We conduct multiple regression to estimate associations of physical functioning assessed from both self-report (activities of daily living [ADL] limitation, self-reported health) and performance (grip strength, gait speed) with socio-demographic and health characteristics in HAALSI, and use fully-interacted regression models to compare age-patterns of physical functioning outcomes cross-nationally. RESULTS: Gender differences in self-reported health are minimal, and men had 30% higher odds of being ADL limited controlling for socio-demographic and health characteristics. Measured physical performance is closely tied with socioeconomic conditions, but self-reported measures have a much smaller or weaker socioeconomic gradient. In international age-adjusted comparisons, the HAALSI sample had lower physical performance outcomes than most comparison populations. DISCUSSION: As the first HRS sister study undertaken in Africa, HAALSI adds vital information on population aging and health in the region. Continuing waves of HAALSI data will be a key resource for understanding differences in the complex processes of disability across LMIC contexts.

Disability transitions and health expectancies among adults 45 years and older in Malawi: a cohort-based model.

BACKGROUND: Falling fertility and increasing life expectancy contribute to a growing elderly population in sub-Saharan Africa (SSA); by 2060, persons aged 45 y and older are projected to be 25% of SSA's population, up from 10% in 2010. Aging in SSA is associated with unique challenges because of poverty and inadequate social supports. However, despite its importance for understanding the consequences of population aging, the evidence about the prevalence of disabilities and functional limitations due to poor physical health among older adults in SSA continues to be very limited. METHODS AND FINDINGS: Participants came from 2006, 2008, and 2010 waves of the Malawi Longitudinal Survey of Families and Health, a study of the rural population in Malawi. We investigate how poor physical health results in functional limitations that limit the day-to-day activities of individuals in domains relevant to this subsistence-agriculture context. These disabilities were parameterized based on questions from the SF-12 questionnaire about limitations in daily living activities. We estimated age-specific patterns of functional limitations and the transitions over time between different disability states using a discrete-time hazard model. The estimated transition rates were then used to calculate the first (to our knowledge) microdata-based health expectancies calculated for SSA. The risks of experiencing functional limitations due to poor physical health are high in this population, and the onset of disabilities happens early in life. Our analyses show that 45-y-old women can expect to spend 58% (95% CI, 55%-64%) of their remaining 28 y of life (95% CI, 25.7-33.5) with functional limitations; 45-y-old men can expect to live 41% (95% CI, 35%-46%) of their remaining 25.4 y (95% CI, 23.3-28.8) with such limitations. Disabilities related to functional limitations are shown to have a substantial negative effect on individuals' labor activities, and are negatively related to subjective well-being. CONCLUSIONS: Individuals in this population experience a lengthy struggle with disabling conditions in adulthood, with high probabilities of remitting and relapsing between states of functional limitation. Given the strong association of disabilities with work efforts and subjective well-being, this research suggests that current national health policies and international donor-funded health programs in SSA inadequately target the physical health of mature and older adults.