Paul Kowal

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• BS, MS, PharmD
• Deputy Director at Australian National University

Background. The population of people aged ≥60 years continues to increase globally, and has been projected by the United NationsPopulation Division to increase to 21% of the total population by 2050. In addition, the number of older people living with HIV hascontinued to increase owing to the introduction of antiretroviral therapy as a treatment fo...

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutiliz...

Introduction Metabolic Syndrome (MetS), diabetes, and other noncommunicable diseases (NCDs) have been a major focus of research in recent decades as the prevalence of these conditions continues to rapidly increase globally. However, the timing and patterns of development from metabolic risk factors to disease states are less well understood and are...

This background paper was prepared for the report Aging Well In Asia: Asian Development Policy Report.

Megumi Rosenberg and colleagues argue for standardised survey questions and improved data collection on unmet need, particularly in lower income countries

Background: This study aimed to determine the prevalence and factors associated with pre-type 2 diabetes (pre-T2D) and undiagnosed T2D in Cambodia. Method: This cross-sectional study included 5,271 individuals aged 18+ years from all provinces in Cambodia. Pre-T2D and undiagnosed T2D were defined using the World Health Organization (WHO)'s haemoglo...

The objectives were to describe the health of older Mongolians and compare those living in rural areas and apartment and ger districts in the capital, Ulaanbaatar. A population-based random sample survey of 975 people aged 60 years and older was conducted in 2017 to 2018. Data were collected using methods of the World Health Organization’s Study on...

Background The Cambodian government aims to boost healthcare utilisation in public facilities and reduce the spending burden for disadvantaged households. This study aims to describe patterns of public and private outpatient and inpatient healthcare use and investigate the factors associated with public healthcare usage in Cambodia. Method A cross...

Non-communicable diseases (NCDs) are now the leading causes of death globally. Their increasing rates have been associated with market integration and they tend to cluster in certain neighborhoods and communities, yet research has mostly focused on individual level causes. The aim of this research was to identify neighborhood/community level associ...

Better alignment of National Adaptation Plan (NAP) strategic goals with implementation strategies is needed to protect communities from the health impacts of climate change. Using the World Health Organization (WHO) Operational Framework for Building Climate Resilient Health Systems, we undertook content analysis to review 37 NAPs published in Engl...

Though the Ghanaian social structure is largely communal in several of its social life and social spaces, the extent to which cohesive neighbourhood affects functional ability of older persons and the moderating factors of the relationship, are unknown in Ghana. This study examines the moderating roles of sex, multimorbidity, and physical activity...

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...

Knowledge about how physical activity levels relate to functional disability is essential for health promotion and planning older adults’ care or rehabilitation. The risk of living with one or more chronic health conditions increases with increasing age in lower and higher income countries–many of which are associated with physical inactivity. We c...

Introduction: Despite the public health system's critical role in non-communicable disease (NCD) surveillance in Vietnam, limited evidence exists on the implementation of NCD surveillance activities within these systems and the need for capacity building across different system levels to meet expected NCD surveillance goals. This study aimed to ev...

We aimed to explore the distribution of positive and negative emotions across nine low-, middle- and high-income countries; and the association between social factors and these emotions. Data were drawn from the SAGE and the COURAGE studies, with 52,553 participants. Emotions were assessed through the day reconstruction method.Sociodemographic char...

The present study examined the association between housing conditions and long-term care needs of older adults in Ghana. We used data from 4,920 adults aged ≥50 years that participated in the World Health Organisation’s (WHO) Study on adult health and AGEing Ghana Wave 1. Housing conditions were assessed with drinking water, sanitation, cooking con...

Current measures for monitoring progress towards universal health coverage (UHC) do not adequately account for populations that do not have the same level of access to quality care services and/or financial protection to cover health expenses for when care is accessed. This gap in accounting for unmet health care needs may contribute to underutiliz...

Objective: To examine how older adults perceive their own risk of acquiring HIV; and how this perception correlates with their sexual behaviour and HIV status. Methods: We used cross-sectional survey data for 435 adults aged 50 years and older from South Africa. All participants completed a questionnaire on their basic socio-demographic and economi...

Thailand has used front‐of‐pack labelling (FoPL) policies to support its public health objectives of improving consumer nutrition to reduce the risk of noncommunicable disease. A rapid literature review explored the current types of FoPL systems in Thailand and how they are understood by consumers. Twelve studies were included, most of which examin...

Objectives: Low education and unhealthy lifestyle factors such as obesity, smoking, and no exercise are modifiable risk factors for disability and premature mortality. We aimed to estimate the individual and joint impact of these factors on disability-free life expectancy (DFLE) and total life expectancy (TLE). Methods: Data ( n = 22,304) were from...

This report was prepared by Wan He and Daniel Goodkind of the U.S. Census Bureau and Paul Kowal of International Health Transition, Australia, under the direction of Oliver Fischer, chief of International Programs Center, Population Division, Census Bureau. Karen Battle, chief of Population Division, and Victoria A. Velkoff, associate director for...

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 Southeas...

Introduction Despite the public health system’s critical role in non-communicable disease (NCD) surveillance in Vietnam, limited evidence exists on the implementation of NCD surveillance activities within these systems and the need for capacity building across different system levels to meet expected NCD surveillance goals. This study aimed to eval...

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...

Background and objectives Human susceptibility to chronic non-communicable disease may be explained, in part, by mismatches between our evolved biology and contemporary environmental conditions. Disease-induced fatigue may function to reduce physical activity during acute infection, thereby making more energy available to mount an effective immune...

Objectives We examined the associations between food insecurity and functional disability among older adults in Ghana and, the roles of sex and physical activity on the relationship. Design A cross-sectional study design was employed. Setting and participants A total of 4446 older adults (50+ years of age) from the Study on Global Aging and Adult...

BACKGROUND A series of studies have explored the health effects of long-term exposure to ambient PM2.5 among older adults. However, few studies have investigated the adverse effect of long-term exposure to ambient PM2.5 on frailty, and the results are inconclusive. This study sought to investigate the associations between long-term exposure to ambi...

Objective To estimate the probability of onset and progression of disease and disability, length of life with or without disease and/or disability, and incidence of mortality, and to identify factors associated with transitioning to disease and/or disability over time. Study design A prospective cohort study. Data were provided by 12,432 participa...

Background Mongolia has made significant progress towards achieving Universal Health Coverage (UHC), but there are still challenges ahead with population ageing and non-communicable diseases (NCDs). The purpose of this study was to investigate patterns and determinants of outpatient and inpatient health service use amongst older people in Mongolia....

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...

Ghana's older population is projected to increase in coming decades and as a result will see increasing care needs. Understanding the functional difficulties older adults experience , and the associated factors, will help identify relevant intervention to assist older adults in meeting their care needs. This study aimed to analyse the prevalence of...

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 longitudina...

Objective South Africa implemented legislation in June 2016 mandating maximum sodium (Na) levels in a range of processed foods. A pre-post impact evaluation was undertaken to assess whether the legislative approach reduced salt intake and blood pressure in South Africans. Design and method Baseline sodium intake was assessed in a nested cohort of...

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 ≥5...

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 th...

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 diabet...

Background A previous multi-site study involving lower- and middle-income countries demonstrated that asthma in older adults is associated with long-term exposure to particulate matter, male gender and smoking. However, variations may occur within individual countries, which are relevant to inform health promoting policies as populations live longe...

Background: The prevalence of allergic and autoimmune conditions has been steadily increasing in wealthy nations over the past century. One hypothesis put forward to explain this is the Old Friends Hypothesis, which posits that increased hygiene, urbanization, and lifestyle changes have reduced our exposure to parasites and microbes that we co-evo...

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...

Background: Noncommunicable disease burden is rising in Malaysia, accounting for 72% of all deaths. Urbanization and globalization have contributed to changing patterns of diet and physical activity, creating an obesogenic environment that increases noncommunicable disease risk, especially in low-income populations. Community-based and technologic...

Introduction Prior studies have revealed the increasing prevalence of obesity and its associated health effects among ageing adults in resource poor countries. However, no study has examined the long-term and economic impact of overweight and obesity in sub-Saharan Africa. Therefore, we quantified the long-term impact of overweight and obesity on l...

Though Ghana has high hypertension prevalence, the country lacks current national salt consumption data required to build and enhance advocacy for salt reduction. We explored the characteristics of a randomly selected sub sample that had valid urine collection, along with matched survey, anthropometric and BP data (n = 839, mean age = 60y), from th...

This is a text box within the excellent Africa Aging:2020 International Population Report.

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 sa...

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...

Background: Data on the survival status of older adults on antiretroviral treatment (ART) are scarce in sub-Saharan Africa. The objective of this study was to determine the survival status of people aged 50 years and older who were HIV-negative, HIV-positive not on ART, and HIV-positive on ART. Methods: We used three waves of data from the World...

Background: Health effects of air pollution on anaemia have been scarcely studied worldwide. We aimed to explore the associations of long-term exposure to ambient air pollutants with anaemia prevalence and haemoglobin levels in Chinese older adults. Methods: We used two-level linear regression models and modified Poisson regression with robust e...

Background: The Ghanaian population aged 60 years and older will almost double to reach 10% of the total population by 2050. Ascertaining the pattern of health expenditures among this growing population group is important to inform policy makers about the targets for financial risk protection as part of achieving Universal Health Coverage (UHC) by...

Background: The Ghanaian population aged 60 years and older will almost double to reach 14% of the total population by 2050. Ascertaining the pattern of health expenditures among this growing population group is important to inform policy makers about the targets for financial risk protection as part of achieving Universal Health Coverage (UHC) by...

Objectives Diabetes and depression are commonly present in the same individuals, suggesting the possibility of underlying shared physiological processes. Inflammation, as assessed with the biomarker C‐reactive protein (CRP), has not consistently explained the observed relationship between diabetes and depression, although both are associated with i...

Overweight/obesity is becoming increasingly prevalent in sub-Saharan Africa including Ghana. However, transition probabilities, an essential component to develop cost-effective measures for weight management is lacking in this population. We estimated annual transition probabilities between three body mass index (BMI) categories: normal weight (BMI...

Objectives: Investigating factors that contribute to bone loss and accretion across populations in remote settings is challenging, particularly where diagnostic tools are scarce. To mitigate this challenge, we describe validation of a commercial ELISA assay to measure osteocalcin, a biomarker of bone formation, from dried blood spots (DBS). Metho...

Repeated 24-hour urine collection is considered to be the gold standard for assessing salt intake. This is often impractical in large-population studies, especially in low–middle-income countries. Equations to estimate 24-hour urinary salt excretion from a spot urine sample have been developed, but have not been widely validated in African populati...

The current longitudinal study consisted of baseline and follow-up surveys among older adults living with HIV (OALHIV) in Thailand. The health-related quality of life (HRQoL) was assessed using the Medical Outcomes Study HIV (MOS-HIV) questionnaire. We performed multiple linear regression analysis to document correlates of HRQoL at baseline and the...

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...

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 i...

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-re...

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 Organiz...

The World Health Organization’s Study on global AGEing and adult health (SAGE) is a longitudinal study in China, Ghana, India, Mexico, Russia, and South Africa, with nationally representative samples of persons aged 50 years and older and a smaller sample of adults aged 18–49 years in each country for comparison purposes (Kowal et al. 2012). It bui...

The aim of the study was to analyze the prevalence of activities of daily living (ADL) difficulties among older Ghanaians and specifically how one ADL, toileting difficulty, predicts care and supports needs using the World Health Organization International Classification of Disability and Health framework (WHO-ICF). Toileting difficulty requiring u...

The World Health Organization (WHO) estimates that 79% suicides occur in low- and middle-income countries (LMICs) in 2016 (WHO, 2018) putting a spotlight on the topic of suicide in these countries. While the rates are highest among individuals ages 15 to 29 years, suicide affects individuals, families, and communities throughout the lifespan. The t...

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...

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...

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...

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerabili...

Background: The recent surge in economic development in Myanmar will also contribute to accelerating the health burden shift from acute infectious to chronic non-communicable diseases (NCDs) across the country. With just 11 years to achieve its goal of universal health coverage by the year 2030, significant efforts will be needed to quantify the sc...

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...

Background Studies on changes in the prevalence and determinants of obesity in older adults living in sub-Saharan Africa are scarce. We examined recent changes in obesity prevalence and associated factors for older adults in Ghana between 2007/08 and 2014/15. Methods Data on adults aged 50 years and older in Ghana were drawn from the WHO SAGE 2007...

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 o...

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...

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 t...

Objectives: Determinants of hypertension prevalence, diagnosis and control are poorly understood in sub-Saharan Africa, including whether these determinants vary between and among countries. Methods: A cross-sectional analysis of Study on global AGEing and adult health (SAGE) data, nationally representative samples of adults aged 50+ (n=3 458 Sout...

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 w...

Background: Few studies have examined the associations between mental and physical health conditions in low- and middle-income countries (LMICs). The aim of this study was to evaluate comorbidity of depression and other chronic diseases in community-dwelling older adults. Methods: Data were obtained from the World Health Organization Study on gl...

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 Org...

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...

Background: Studies on changes in the prevalence and determinants of obesity in older adults living in sub-Saharan Africa are limited. We examined recent changes in obesity prevalence and associated factors for older adults in Ghana between 2007/08 and 2014/15. Methods: Data on adults aged 50 years and older in Ghana were collected in the WHO SAGE...

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 Or...

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...

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 data from 31,209 adults ≥ 50 years of age within the Study on global AGEing and adult health (SAGE) Wave 1 in six low- and middle-income coun...