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Levels and trends of older adult mortality in Sub-Saharan Africa : comparison of sources and estimates
Abstract
Since independence, efforts to reduce mortality have focused on child and maternal mortality, which is considered too high. Subsequently, analyses of maternal mortality have been extended to adults in general (15 to 50 or even 60 years old). Beyond these ages, mortality studies remain poorly documented due to the lack of adequate civil registration. The numerous errors in age are sources of bias and make it difficult to produce estimates. The aim of this doctoral dissertation is therefore to contribute to improving the state of knowledge on the mortality of adults aged 50-79. The option of restricting the analyses to the under-80s is intended to limit the effect of age errors which can be extreme at very old ages. Starting with a review of existing methods, we examine the extent to which a judicious use of these methods can make it possible to estimate the levels and trends of mortality in older adults by exploiting different sources (censuses, household sample surveys, population surveillance systems) available for several countries in the sub-Saharan region.
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We investigated the temporal trends of short-term mortality (death within 1 year of diagnosis) and cause-specific deaths in human immunodeficiency virus (HIV)-infected persons by stage of HIV infection at diagnosis. We also assessed the impact of late diagnosis (LD) on short-term mortality.
Epidemiological records of HIV-infected Singapore residents from the National HIV Registry were linked to death records from the Registry of Births and Deaths for observational analyses. Newly-diagnosed HIV cases with available cluster of differentiation 4 count at time of diagnosis in a 5-year period from 2012 to 2016 were included in the study. Hazard ratios (HRs) and 95% confidence interval (CI) of LD for all deaths excluding suicides and self-inflicted or accidental injuries, and HIV/ acquired immunodeficiency syndrome (AIDS)-related deaths occurring within 1 year post-diagnosis were calculated using Cox proportional hazards regression models with adjustment for age at HIV/AIDS diagnosis. Population attributable risk proportions (PARPs) were then calculated using the adjusted HRs.
Of the 1990 newly-diagnosed HIV cases included in the study, 7.2% had died by end of 2017, giving an overall mortality rate of 2.16 per 100 person-years (PY) (95% CI 1.82–2.54). The mortality rate was 3.81 per 100 PY (95% CI 3.15–4.56) in HIV cases with LD, compared with 0.71 (95% CI 0.46–1.05) in non-LD (nLD) cases. Short-term mortality was significantly higher in LD (9.1%) than nLD cases (1.1%). Of the 143 deaths reported between 2012 and 2017, 58.0% were HIV/AIDS-related (nLD 28.0% vs LD 64.4%). HIV/AIDS-related causes represented 70.4% of all deaths which occurred during the first year of diagnosis (nLD 36.4% vs LD 74.7%). The PARP of short-term mortality due to LD was 77.8% for all deaths by natural causes, and 87.8% for HIV/AIDS-related deaths.
The mortality rate of HIV-infected persons with LD was higher than nLD, especially within 1 year of diagnosis, and HIV/AIDS-related causes constituted majority of these deaths. To reduce short-term mortality, persons at high risk of late-stage HIV infection should be targeted in outreach efforts to promote health screening and remove barriers to HIV testing and treatment.
Background
In sub-Saharan Africa HIV transmission is a major challenge in adolescents, especially among girls and those living in urban settings. Major international efforts have aimed at reducing sexual transmission of HIV. This analysis aims to assess the trends in HIV prevalence by gender in adolescents, as well as urban–rural disparities.
Methods
HIV prevalence data at ages 15–19 years were obtained for 31 countries with a national survey since 2010 and for 23 countries with one survey circa 2005 and a recent survey circa 2015. Country medians and average annual rates of changes were used to summarize the trends for two subregions in sub-Saharan Africa, Eastern and Southern Africa and West and Central Africa, which largely correspond with higher and lower HIV prevalence countries. Data on HIV incidence at ages 15–24 and prevalence at 5–9 and 10–14 years were reviewed from 11 recent national surveys. Trends in urban–rural disparities in HIV prevalence and selected indicators of sexual and HIV testing behaviours were assessed for females and males 15–24 years, using the same surveys.
Results
HIV prevalence among girls 15–19 years declined in eastern and Southern Africa from 5.7 to 2.6% during 2005–2015 (country median), corresponding with an average annual rate of reduction of 6.5% per year. Among boys, the median HIV prevalence declined from 2.1 to 1.2%. Changes were also observed in West and Central Africa where median HIV prevalence among girls decreased from 0.7 to 0.4% (average annual rate of reduction 5.9%), but not for boys (0.3%). Girl-boy differences at 10–14 years were small with a country median HIV of 1.0% and 1.3%, respectively. Urban females and males 15–24 had at least 1.5 times higher HIV prevalence than their rural counterparts in both subregions, and since the urban–rural declines were similar, the gaps persisted during 2005–2015.
Conclusions
HIV prevalence among adolescents declined in almost all countries during the last decade, in both urban and rural settings. The urban–rural gap persisted and HIV transmission to girls, but not boys, is still a major challenge in Eastern and Southern African countries.
Notre objectif est de présenter et synthétiser les grands changements démographiques intervenus dans la région, les sous-régions et les pays qui la composent pendant près de 20 ans, de la fin des années 1990 à la fin des années 2010. Cet article est le prolongement de la synthèse publiée en 2004 sur la période 1950-2000 (Tabutin et Schoumaker, 2004). Afin d’assurer une comparabilité, nous en conservons les grandes lignes, mais en supprimant néanmoins quelques points (l'histoire lointaine, les systèmes d'informations, les inégalités en matière d'éducation), en en allégeant d'autres, en nous arrêtant davantage sur l’évolution des disparités sociales dans les pays et sur les perspectives et défis à venir.
Après quelques mots sur le contexte socioéconomique africain par rapport à d'autres régions en ce début du xxie siècle, seront abordés successivement :
les effectifs et croissances des populations
les grands modèles de transition
la nuptialité (âge au mariage, célibat, rupture, polygamie)
la fécondité et ses variables intermédiaires, dont la contraception
la mortalité (générale, infanto-juvénile, maternelle, les causes de décès et notamment le sida)
les migrations internes et l'urbanisation
les migrations internationales.
Nous terminerons par un aperçu des perspectives les plus récentes et des défis à relever d'ici 2050 en termes d’éducation, de santé et d’emploi, avant une synthèse générale intégrant les questions de recherche qui nous semblent prioritaires.
Background: Since the 1950s, many indirect or semi-indirect methods have been developed to either adjust mortality estimates or generate complete life tables from mortality indices in countries lacking high quality vital registration data. These methods are underused for estimating older adult mortality.Objective: I seek to answer the following questions: How to better estimate older adult mortality from imperfect data? Can consistent estimates be derived from indirect-based methods? If not, what could explain the possible differences?Methods: After adjusting population and intercensal death counts for incompleteness using death distribution methods, data from the last three censuses in Burkina Faso (1985, 1996, 2006) were fitted using Singular Value Decomposition (SVD) and Brass models, and specifically the Makeham model (MKH) for extrapolation to advanced ages where large age errors were suspected. The resulting estimates were then compared in terms of age patterns and risk of death between the ages of 50 and 80.Results: Estimates from the SVD model are higher than those from both the adjusted data and the Brass model, which are consistent, but only before age 70. Extrapolation by the MKH model reveals obvious underestimations in the adjusted data beyond age 70, but of smaller magnitude than those suggested by the SVD model. When compared with the empirical data from the Human Mortality Database (HMD), all estimates agree with the empirical data before age 70, but only the estimates from the SVD and MKH models remain consistent beyond age 70.Conclusions: When used to infer mortality in older adults, the estimates from empirical models such as the SVD model should be taken with caution. Further refinements of the model are required to better reflect the observed mortality level at older ages.Contribution: This study highlights issues with using empirical models indexed by child and adult mortality to infer mortality at older ages from imperfect data.
“A multimorbidity lens creates exciting opportunities to reconceptualise health and wellbeing in all its complexity. We need to improve health metrics to capture this complexity and strengthen health services to respond to it.”
Background:
The majority of low- and middle-income countries (LMICs) do not have adequate civil registration and vital statistics (CRVS) systems to properly support health policy formulation. Verbal autopsy (VA), long used in research, can provide useful information on the cause of death (COD) in populations where physicians are not available to complete medical certificates of COD. Here, we report on the application of the SmartVA tool for the collection and analysis of data in several countries as part of routine CRVS activities.
Methods:
Data from VA interviews conducted in 4 of 12 countries supported by the Bloomberg Philanthropies Data for Health (D4H) Initiative, and at different stages of health statistical development, were analysed and assessed for plausibility: Myanmar, Papua New Guinea (PNG), Bangladesh and the Philippines. Analyses by age- and cause-specific mortality fractions were compared to the Global Burden of Disease (GBD) study data by country. VA interviews were analysed using SmartVA-Analyze-automated software that was designed for use in CRVS systems. The method in the Philippines differed from the other sites in that the VA output was used as a decision support tool for health officers.
Results:
Country strategies for VA implementation are described in detail. Comparisons between VA data and country GBD estimates by age and cause revealed generally similar patterns and distributions. The main discrepancy was higher infectious disease mortality and lower non-communicable disease mortality at the PNG VA sites, compared to the GBD country models, which critical appraisal suggests may highlight real differences rather than implausible VA results.
Conclusion:
Automated VA is the only feasible method for generating COD data for many populations. The results of implementation in four countries, reported here under the D4H Initiative, confirm that these methods are acceptable for wide-scale implementation and can produce reliable COD information on community deaths for which little was previously known.
BACKGROUND Age misreporting is pervasive in most low-and middle-income countries (LMIC). It may bias estimates of key demographic indicators, such as those required to track progress towards sustainable development goals. Existing methods to improve age data are often ineffective, cannot be adopted on a large scale, and/or do not permit estimating age over the entire life course. OBJECTIVE We tested a computer vision approach, which produces an age estimate by analyzing a photograph of an individual's face. METHODS We constituted a small training dataset in a population of Senegal covered by a health and demographic surveillance system (HDSS) since 1962. We collected facial images of 353 women aged 18 and above, whose age could be ascertained precisely using HDSS data. We developed automatic age estimation (AAE) systems through machine learning and cross-validation. RESULTS AAE was highly accurate in distinguishing women of reproductive age from women aged 50 and older (area under the curve > 0.95). It allowed estimating age in completed years, with a level of precision comparable to those obtained in European or East Asian populations with training datasets of similar sizes (mean absolute error = 4.62 years). CONCLUSION Computer vision might help improve age ascertainment in demographic datasets collected in LMICs. Further improving the accuracy of this approach will require constituting larger and more complete training datasets in additional LMIC populations. CONTRIBUTION Our work highlights the potential benefits of widely used computer science tools for improving demographic measurement in LMIC settings with deficient data.
Central and Eastern Europe (CEE) have experienced considerable instability in mortality since the 1960s. Long periods of stagnating life expectancy were followed by rapid increases in life expectancy and, in some cases, even more rapid declines, before more recent periods of improvement. These trends have been well documented, but to date, no study has comprehensively explored trends in lifespan variation. We improved such analyses by incorporating life disparity as a health indicator alongside life expectancy, examining trends since the 1960s for 12 countries from the region. Generally, life disparity was high and fluctuated strongly over the period. For nearly 30 of these years, life expectancy and life disparity varied independently of each other, largely because mortality trends ran in opposite directions over different ages. Furthermore, we quantified the impact of large classes of diseases on life disparity trends since 1994 using a newly harmonized cause-of-death time series for eight countries in the region. Mortality patterns in CEE countries were heterogeneous and ran counter to the common patterns observed in most developed countries. They contribute to the discussion about life expectancy disparity by showing that expansion/compression levels do not necessarily mean lower/higher life expectancy or mortality deterioration/improvements.
Electronic supplementary material
The online version of this article (10.1007/s13524-018-0729-9) contains supplementary material, which is available to authorized users.
Adult mortality is an important development and public health issue that continues to attract the attention of demographers and public health researchers. Controversies exist about the accurate level of adult mortality in sub-Saharan Africa (SSA), due to different data sources and errors in data collection. To address this shortcoming, methods have been developed to accurately estimate levels of adult mortality. Using three different methods (orphanhood, widowhood, and siblinghood) of indirect estimation and the direct siblinghood method of adult mortality, we examined the levels of adult mortality in 10 countries in SSA using 2001–2009 census and survey data. Results from the different methods vary. Estimates from the orphanhood data show that adult mortality rates for males are in decline in South Africa and West African countries, whilst there is an increase in adult mortality in the East African countries, for the period examined. The widowhood estimates were the lowest and reveal a marked increase in female adult mortality rates compared to male. A notable difference was observed in adult mortality estimates derived from the direct and indirect siblinghood methods. The method of estimation, therefore, matters in establishing the level of adult mortality in SSA.
Introduction
Many national and subnational governments need to routinely measure the completeness of death registration for monitoring and statistical purposes. Existing methods, such as death distribution and capture-recapture methods, have a number of limitations such as inaccuracy and complexity that prevent widespread application. This paper presents a novel empirical method to estimate completeness of death registration at the national and subnational level.
Methods
Random-effects models to predict the logit of death registration completeness were developed from 2,451 country-years in 110 countries from 1970–2015 using the Global Burden of Disease 2015 database. Predictors include the registered crude death rate, under-five mortality rate, population age structure and under-five death registration completeness. Models were developed separately for males, females and both sexes.
Findings
All variables are highly significant and reliably predict completeness of registration across a wide range of registered crude death rates (R-squared 0.85). Mean error is highest at medium levels of observed completeness. The models show quite close agreement between predicted and observed completeness for populations outside the dataset. There is high concordance with the Hybrid death distribution method in Brazilian states. Uncertainty in the under-five mortality rate, assessed using the dataset and in Colombian departmentos, has minimal impact on national level predicted completeness, but a larger effect at the subnational level.
Conclusions
The method demonstrates sufficient flexibility to predict a wide range of completeness levels at a given registered crude death rate. The method can be applied utilising data readily available at the subnational level, and can be used to assess completeness of deaths reported from health facilities, censuses and surveys. Its utility is diminished where the adult mortality rate is unusually high for a given under-five mortality rate. The method overcomes the considerable limitations of existing methods and has considerable potential for widespread application by national and subnational governments.
The burden of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) on the elderly population in three divisions within the Northwest Region of Cameroon was examined. Data for this paper were extracted from a larger study which had been conducted concerning the burden of HIV infection and AIDS on the older adults in the Northwest Region of Cameroon. Using in-depth interviews (IDIs) and focus group discussions (FGDs), data were collected from 36 participants who were purposively selected from the three divisions which had been chosen randomly. 6 FGD sessions were held with 30 women aged 60 years and above and who were affected by HIV infection and AIDS, while IDIs sessions were held with 6 male community leaders. The results revealed that HIV infection and AIDS has added another dimension to the role of older persons. HIV infection and AIDS affects older people in diverse ways, as they have to look after themselves, their sick children and are often also left to look after their grandchildren orphaned by HIV infection and AIDS. These emerging issues in their lives make them vulnerable to health, social, economic and psychological challenges, and place a burden on them as caregivers instead of being cared for in their old age. Apart from increased direct expenditures, taking care of victims of HIV infection and AIDS requires older people to stay away from social, religious and community activities. The results showed that the loss of a child to HIV infection and AIDS affects the economic/financial well-being, participation in social/religious interactions as well as the community activities of older people participants. The implications of these findings for caregiving and social policy are discussed.
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: Health care for people living with HIV has improved substantially in the past two decades. Robust estimates of how these improvements have affected prognosis and life expectancy are of utmost importance to patients, clinicians, and health-care planners. We examined changes in 3 year survival and life expectancy of patients starting combination antiretroviral therapy (ART) between 1996 and 2013. METHODS: We analysed data from 18 European and North American HIV-1 cohorts. Patients (aged ≥16 years) were eligible for this analysis if they had started ART with three or more drugs between 1996 and 2010 and had at least 3 years of potential follow-up. We estimated adjusted (for age, sex, AIDS, risk group, CD4 cell count, and HIV-1 RNA at start of ART) all-cause and cause-specific mortality hazard ratios (HRs) for the first year after ART initiation and the second and third years after ART initiation in four calendar periods (1996–99, 2000–03 [comparator], 2004–07, 2008–10). We estimated life expectancy by calendar period of initiation of ART. FINDINGS: 88 504 patients were included in our analyses, of whom 2106 died during the first year of ART and 2302 died during the second or third year of ART. Patients starting ART in 2008–10 had lower all-cause mortality in the first year after ART initiation than did patients starting ART in 2000–03 (adjusted HR 0·71, 95% CI 0·61–0·83). All-cause mortality in the second and third years after initiation of ART was also lower in patients who started ART in 2008–10 than in those who started in 2000–03 (0·57, 0·49–0·67); this decrease was not fully explained by viral load and CD4 cell count at 1 year. Rates of non-AIDS deaths were lower in patients who started ART in 2008–10 (vs 2000–03) in the first year (0·48, 0·34–0·67) and second and third years (0·29, 0·21–0·40) after initiation of ART. Between 1996 and 2010, life expectancy in 20-year-old patients starting ART increased by about 9 years in women and 10 years in men. INTERPRETATION: Even in the late ART era, survival during the first 3 years of ART continues to improve, which probably reflects transition to less toxic antiretroviral drugs, improved adherence, prophylactic measures, and management of comorbidity. Prognostic models and life expectancy estimates should be updated to account for these improvements.
Evaluating the predictive ability of mortality forecasts is important yet difficult. Death rates and mean lifespan are basic life table functions typically used to analyze to what extent the forecasts deviate from their realized values. Although these parameters are useful for specifying precisely how mortality has been forecasted, they cannot be used to assess whether the underlying mortality developments are plausible. We therefore propose that in addition to looking at average lifespan, we should examine whether the forecasted variability of the age at death is a plausible continuation of past trends. The validation of mortality forecasts for Italy, Japan, and Denmark demonstrates that their predictive performance can be evaluated more comprehensively by analyzing both the average lifespan and lifespan disparity—that is, by jointly analyzing the mean and the dispersion of mortality. Approaches that account for dynamic age shifts in survival improvements appear to perform better than others that enforce relatively invariant patterns. However, because forecasting approaches are designed to capture trends in average mortality, we argue that studying lifespan disparity may also help to improve the methodology and thus the predictive ability of mortality forecasts.
Electronic supplementary material
The online version of this article (doi:10.1007/s13524-017-0584-0) contains supplementary material, which is available to authorized users.
Background: Reliable and representative cause of death (COD) statistics are essential to inform public health policy, respond to emerging health needs, and document progress towards Sustainable Development Goals. However, less than one-third of deaths worldwide are assigned a cause. Civil registration and vital statistics (CRVS) systems in low- and lower-middle-income countries are failing to provide timely, complete and accurate vital statistics, and it will still be some time before they can provide physician-certified COD for every death.
Proposals: Verbal autopsy (VA) is a method to ascertain the probable COD and, although imperfect, it is the best alternative in the absence of medical certification. There is extensive experience with VA in research settings but only a few examples of its use on a large scale. Data collection using electronic questionnaires on mobile devices and computer algorithms to analyse responses and estimate probable COD have increased the potential for VA to be routinely applied in CRVS systems. However, a number of CRVS and health system integration issues should be considered in planning, piloting and implementing a system-wide intervention such as VA. These include addressing the multiplicity of stakeholders and sub-systems involved, integration with existing CRVS work processes and information flows, linking VA results to civil registration records, information technology requirements and data quality assurance.
Conclusions: Integrating VA within CRVS systems is not simply a technical undertaking. It will have profound system-wide effects that should be carefully considered when planning for an effective implementation. This paper identifies and discusses the major system-level issues and emerging practices, provides a planning checklist of system-level considerations and proposes an overview for how VA can be integrated into routine CRVS systems.
The " Real " Old Age and the Transition between the Third and Fourth Age. My paper focuses on the relation between chronological age and health. I understand health decline as an indicator of the transition into the fourth age. Currently the definition of the fourth age has been somewhat unclear. Some of the authors consider the fourth age as a synonym of the oldest-old and they define individuals in the fourth age based on their chronological age, mostly between 75 and 80 years. From the perspective of social gerontology, however, such a view is insufficient. Fourth-agers might be characterized especially by the loss of agency, ability to care and to make decisions about themselves. The SHARE data analysis for the Czech Republic confirmed the connection between health decline, frailty and chronological age, but it is not easy to define the exact boundary of the fourth age. Ageing is undoubtedly very individual. The frequently used boundary of 75 years seems to be unsuitable since frailty and general health decline occur more after 80 in men and women. Although the quality of life of older adults declines apparently with age, the decline is more affected by health status than chronological age. Health and quality of life are significantly influenced by the cultural and economic capital of older adults. Older adults with basic education and low income are more at risk of poorer health and lower quality of life. There are also significant gender differences. Women are more fragile, the analysis of the impact of income and education showed, however, that the relationship of gender, health and quality of life is much more complicated. To reach higher quality of life, women benefit from higher income more than men, higher education, however, brings greater benefit to men. Generally, structural factors seem to intervene in health and quality of life significantly.
In Sub-Saharan Africa, censuses are a key source of data for estimating mortality because death registration is incomplete. To assess the reliability of census-based mortality estimates, we apply different methods to individual-level data extracted from the 2002 and 2013 Senegalese censuses covering three health and demographic surveillance systems (HDSS) in Bandafassi Mlomp and Niakhar. The under-five mortality rates inferred from reports on children ever born and surviving are lower than expected based on longitudinal demographic surveillance. Estimates derived from reports on parental survival are also much lower than the adult mortality levels observed in HDSS field sites. By contrast, age-specific death rates based on recent deaths reported in households are consistent with HDSS data, except for infant mortality, which is significantly under-reported in 2002. This evaluation confirms that indirect estimates of mortality obtained from census data should not be considered in isolation but must instead be systematically compared with each other. Direct evaluation studies conducted at the individual level using record linkages are needed to better identify the various sources of bias. © 2016, Union for African Population Studies. All Rights Reserved.
Global trends in HIV infection demonstrate an overall increase in HIV prevalence and substantial declines in AIDS related deaths largely attributable to the survival benefits of antiretroviral treatment. Sub-Saharan Africa carries a disproportionate burden of HIV, accounting for more than 70% of the global burden of infection. Success in HIV prevention in sub-Saharan Africa has the potential to impact on the global burden of HIV. Notwithstanding substantial progress in scaling up antiretroviral therapy (ART), sub-Saharan Africa accounted for 74% of the 1.5 million AIDS related deaths in 2013.
Of the estimated 6000 new infections that occur globally each day, two out of three are in sub-Saharan Africa with young women continuing to bear a disproportionate burden. Adolescent girls and young women aged 15-24 years have up to eight fold higher rates of HIV infection compared to their male peers. There remains a gap in women initiated HIV prevention technologies especially for women who are unable to negotiate the current HIV prevention options of abstinence, behavior change, condoms and medical male circumcision or early treatment initiation in their relationships.
The possibility of an AIDS free generation cannot be realized unless we are able to prevent HIV infection in young women. This review will focus on the epidemiology of HIV infection in sub-Saharan Africa, key drivers of the continued high incidence, mortality rates and priorities for altering current epidemic trajectory in the region. Strategies for optimizing the use of existing and increasingly limited resources are included.
Developing appropriate and equitable policies for older people in Africa requires accurate and reliable data. It is unclear whether existing data can accurately assess older African population structures, let alone provide the detailed information needed to inform policy decision making.
OBJECTIVE
To evaluate the quality of nationally representative data on older Africans through examining the accuracy of age data collected from different sources.
METHODS
To measure the accuracy of age reporting overall we calculate Whipple’s Index, and a modified Whipple’s Index for older adults, using the single year age-sex distributions from (a) the household roster of 17 Demographic and Health Surveys (DHS) (b) the censuses of 12 of these countries and (c) the Living Standards Measurement Study (LSMS) for Ethiopia and Niger. We compare reported sex ratios by age.
RESULTS
The quality of age data is very poor for most countries outside Southern Africa, especially for older adults. In some Sahelian countries DHS surveys appear to omit a considerable proportion of older women. Data on population structure of older people by age and sex produced by the DHS and the census are inconsistent and contradictory.
CONCLUSIONS
Different field methodological approaches generate contradictory data on older Africans. With the exception of Southern Africa, it is impossible to assess accurately the basic demographic structure of the older population. The data available are so problematic that any conclusions about age-related health and welfare and their evolution over time and space are potentially compromised. This has ramifications for policy makers and practitioners who demand, fund and depend on large scale demographic data sources.
In China, sample-based mortality surveillance systems, such as the Chinese Center for Disease Control and Prevention’s disease surveillance points system and the Ministry of Health’s vital registration system, have been used for decades to provide nationally representative data on health status for health-care decision-making and performance evaluation. However, neither system provided representative mortality and cause-of-death data at the provincial level to inform regional health service needs and policy priorities. Moreover, the systems overlapped to a considerable extent, thereby entailing a duplication of effort. In 2013, the Chinese Government combined these two systems into an integrated national mortality surveillance system to provide a provincially representative picture of total and cause-specific mortality and to accelerate the development of a comprehensive vital registration and mortality surveillance system for the whole country. This new system increased the surveillance population from 6 to 24% of the Chinese population. The number of surveillance points, each of which covered a district or county, increased from 161 to 605. To ensure representativeness at the provincial level, the 605 surveillance points were selected to cover China’s 31 provinces using an iterative method involving multistage stratification that took into account the sociodemographic characteristics of the population. This paper describes the development and operation of the new national mortality surveillance system, which is expected to yield representative provincial estimates of mortality in China for the first time.
This paper examines adult and old-age mortality differentials in Canada between 1930 and 2007 at the provincial level, using the Canadian Human Mortality Database and the flexible smoothing P-spline method in two-dimensions well-suited to the study of small populations. Our analysis reveals that provincial disparities in adult mortality in general, and among the elderly population in particular, are substantial in Canada. Moreover, based on the modal age at death and the standard deviation of ages at death above the mode, provincial disparities at older ages have barely reduced over time, despite the great mortality improvements in all provinces since the early 20th century. In the last few years studied, evidence of the shifting mortality regime was found among females in most Western and Central provinces, while all males were still undergoing an old-age mortality compression regime.
In this paper, I examine progress in the field of mortality over the past 25 years. I argue that we have been most successful in taking advantage of an increasingly data-rich environment to improve aggregate mortality models and test pre-existing theories. Less progress has been made in relating our estimates of mortality risk at the individual level to broader mortality patterns at the population level while appropriately accounting for contextual differences and compositional change. Overall, I find that the field of mortality continues to be highly visible in demographic journals, including Population Studies. However much of what is published today in field journals could just as easily appear in neighbouring disciplinary journals, as disciplinary boundaries are shrinking.
Un nouveau-né sur vingt-deux meurt dans le monde avant son premier anniversaire. Et parmi ceux qui le fêtent, un sur quarante-trois meurt dans les quatre années suivantes. Au total, ce sont près de 7 % des nouveau-nés qui décèdent avant d’atteindre leur cinquième anniversaire. Les inégalités entre pays sont énormes dans ce domaine : dans les plus développés, la mortalité avant 5 ans a beaucoup baissé et n’est plus que de 0,5 %, voire inférieure. Elle est encore supérieure à 10 % dans beaucoup de pays du Sud, notamment en Afrique subsaharienne. Une partie des enfants meurent de maladies infectieuses évitables par la vaccination, l’un des actes médicaux les plus simples et les plus rentables en termes de prévention des maladies et de réduction de la mortalité.
Hundreds of millions of people live in countries that do not have complete death registration systems, meaning that most deaths are not recorded and that critical quantities, such as life expectancy, cannot be directly measured. The sibling survival method is a leading approach to estimating adult mortality in the absence of death registration. The idea is to ask survey respondents to enumerate their siblings and to report about their survival status. In many countries and periods, sibling survival data are the only nationally representative source of information about adult mortality. Although a vast amount of sibling survival data has been collected, important methodological questions about the method remain unresolved. To help make progress on this issue, we propose reframing the sibling survival method as a network sampling problem. This approach enables a formal derivation of statistical estimators for sibling survival data. Our derivation clarifies the precise conditions that sibling history estimates rely on, leads to internal consistency checks that can help assess data and reporting quality, and reveals important quantities that could potentially be measured to relax assumptions in the future. We introduce the R package siblingsurvival, which implements the methods we describe.
Sibling survival histories are a major source of adult mortality estimates in countries with incomplete death registration. We evaluate age and date reporting errors in sibling histories collected during a validation study in the Niakhar Health and Demographic Surveillance System (Senegal). Participants were randomly assigned to either the Demographic and Health Survey questionnaire or a questionnaire incorporating an event history calendar, recall cues, and increased probing strategies. We linked 60–62 per cent of survey reports of siblings to the reference database using manual and probabilistic approaches. Both questionnaires showed high sensitivity (>96 per cent) and specificity (>97 per cent) in recording siblings’ vital status. Respondents underestimated the age of living siblings, and age at and time since death of deceased siblings. These reporting errors introduced downward biases in mortality estimates. The revised questionnaire improved reporting of age of living siblings but not of age at or timing of deaths.
Although the number of older people living with HIV (PLWH) is growing, prior research has focused on older PLWH as care recipients and psychosocial factors (e.g., stigma, social support) associated with their HIV care. Literature on HIV caregiving mainly focuses on family members providing care to PLWH or children of parents with HIV. There is a gap in the literature in terms of older PLWH's roles as caregivers to their family members. Thanks to combination antiretrovirals that help PLWH live longer and have healthier lives, many older PLWH now find themselves in a position to provide care to family members. To help older PLWH age successfully, it is important to understand their role as caregivers while they juggle responsibilities with their own health care needs. This article elucidates this gap in the literature on older PLWH who are caregivers and provides direction for a research agenda and potential clinical implications.
Disability is a crucial health and social concern in sub‐Saharan Africa, where a high prevalence of disabling diseases is compounded with insufficient care provision. There is a need for detailed analysis of the disability patterns. We provide a gender‐specific picture for the population in peripheral Ouagadougou (Burkina‐Faso), based on six disability dimensions following the United Nations’ recommendations. We computed disability‐free life expectancy (LE) using the Health and Demographic Surveillance System (Ouaga HDSS) (n = 1 902). Women have a longer partial LE in the 20–79 age range (+3.3 years), half of this LE being spent with a disability, versus 31% of the LE for men. Limitations in mobility, cognition, and eyesight occur in midadulthood and result in a considerable disadvantage for women in the number of years with these limitations. These findings highlight disability patterns that are detrimental to social participation and claim for better screening and care, especially for women.
Demographic data suffer from sampling errors and from biases arising from coverage and content errors that may be systematic and noncompensating. Common and problematic errors for demographic estimation are those affecting the reporting of age, parity, and deaths. Age misreporting affects population counts and vital rates. Techniques of data evaluation and correction relying on individual-level analysis include the postenumeration survey, imputation, capture-recapture methods, and statistical analysis. Techniques using aggregate-level data employ digit preference indices, sex and age ratios, and smoothing; demographic accounting and internal consistency; and parametric functions, relational models, statistical modeling, and time-based methods.
Regional mortality differences are one dimension of health inequalities, but its trends and determinants in Germany are widely unknown. This book examines and illustrates patterns of regional mortality in Germany—with focus on small-area differentials—and their changes over time. It identifies explanatory factors at individual and regional level. Mortality differences between eastern and western Germany exist, but small-area mortality differentials are often greater. Though the main spatial mortality patterns remain, this study provides evidence that some distinct changes in the small-area mortality patterns in Germany—especially among women—occurred within a short period of time. Mortality inequalities at younger ages and in behavior-related causes as well as differences in socioeconomic conditions contribute strongly to regional mortality differences in Germany. The book shows that the complex interplay between individual- and regional-level mortality risk factors requires a multidimensional approach to reduce regional mortality inequalities.
Low survival prospects, especially among adults, are holding back African development and reducing the chance of reaping a demographic dividend. Gains in life expectancy have lagged far behind those experienced in other regions, despite impressive mortality declines among children under age five in the last decade. With a life expectancy still below 60 in 2015, sub-Saharan Africa is also the region where uncertainty about levels and trends in mortality is the greatest. This is because the vital registration systems operating in the vast majority of countries fail to provide full national coverage. Few deaths have a cause certified by a medical practitioner, and there is limited evidence on the leading causes of death to make informed decisions about how to spend scarce human and financial resources. This chapter provides a cursory overview of the different data sources, and present trends in mortality among children and adults, using survey reports on the survival of close relatives. The chapter then describes major changes in the leading causes of death and highlights specific characteristics of the process of demographic aging in SSA.
OBJECTIVE: To quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa. METHODS: We reviewed data from Demographic and Health Surveys (DHS). Although in these surveys all female respondents are
Sub-Saharan Africa (SSA) has traditionally had a low life expectancy due to the onslaught of the HIV epidemic, high levels of chronic diseases, injuries, conflict and undernutrition. Therefore, research into public health concerns of older persons has largely been overlooked. With a growing population, the roll-out of antiretroviral treatment, and the effects of globalisation, SSA is experiencing an increase in the number of people over 50 years of age as well as an increase in the prevalence of non-communicable diseases (NCD). The aim of this review is to highlight available research on the health status of older persons in SSA, and to identify the current gaps that warrant further investigation. A literature search was conducted across multiple databases to identify studies in SSA on older persons (aged 50 years and older) related to health indicators including nutritional status, NCD and HIV burden. While it was concluded that older persons are at an increased risk of poor health, it was also determined that significant gaps exist in this particular area of research; namely nutrient deficiency prevalence. Resources should be directed towards identifying the health concerns of older persons and developing appropriate interventions.
English
At the first International Congress of Demography held in Paris in 1878, the German statistician Wilhelm Lexis argued for the notion of a normal length of human life governed by a law of nature. His conception was based on Quetelet’s “average man” and the law of normal distribution of errors formulated by Laplace and Gauss.
The normal length of life, which differs from the average length of life, is, according to Lexis, a “true value” characteristic of the mortality of the human species.
Lexis classifies ages at death into three groups, of which the most important is “the normal group”. He seeks to define its boundaries by distinguishing normal deaths from “premature” ones. Normal mortality is then described by three values: normal age at death, the proportion of deaths included in the normal group, and probable error.
The discussions generated by Lexis’s paper, most notably Bertillon’s remarks on infant mortality, reveal distinct perceptions of the mortality process. A few years later, specialists such as Bodio, Perozzo, Levasseur, and Pareto took up the theory and method of Lexis, acknowledging the originality of his mathematical and statistical analysis of mortality, though not endorsing his hypothesis of a law of nature.
English
Over the last ten years, the modal age at death has become a focus of research on human longevity, notably because it provides information about the most frequent adult age at death without being influenced by mortality conditions at early ages. Little is known about levels and trends in adult modal age at death in historical populations. The RPQA is a historical data source recognized for its reliability which sheds new light on adult longevity in the eighteenth century. The data used, detailed by sex and year of age, cover the period 1740-1799. To estimate modal age at death, this study uses an innovative nonparametric P-spline smoothing method known to be flexible and highly effective. The analysis reveals that the most frequent age at death of adult French-Canadians increased over the period, rising from around 73 years to almost 76 among women, and from around 71 years to more than 74 for men. The specific living conditions of the French-Canadian population at that time may explain this substantial rise.
Keywords
• modal age at death
• longevity
• mortality
• French-Canadians
• Registre de la population du Québec ancien
• P-spline smoothing
• historical demography
• eighteenth century
BACKGROUND. The majority of countries in Africa and nearly one third of all countries require mortality models to infer complete age schedules of mortality, required for population estimates, projections/forecasts and many other tasks in demography and epidemiology. Models that relate child mortality to mortality at other ages are important because all countries have measures of child mortality. OBJECTIVE. 1) Design a general model for age-specific mortality that provides a standard way to relate covariates to age-specific mortality. 2) Calibrate that model using the relationship between child or child/adult mortality and mortality at other ages. 3) Validate the calibrated model and compare its performance to existing models. METHODS. A general, parametrizable component model of mortality is designed using the singular value decomposition (SVD-Comp) and calibrated to the relationship between child or child/adult mortality and mortality at other ages in the observed mortality schedules of the Human Mortality Database. Cross validation is used to validate the model, and the predictive performance of the model is compared to that of the Log-Quad model, designed to do the same thing. RESULTS. Prediction and cross validation tests indicate that the child mortality-calibrated SVD-Comp is able to accurately represent the observed mortality schedules in the Human Mortality Database, is robust to the selection of mortality schedules used to calibrate it, and performs better than the Log-Quad Model. CONCLUSIONS. The child mortality-calibrated SVD-Comp is a useful tool that can be used where child mortality is available but mortality at other ages is unknown. Together with earlier work on an HIV prevalence-calibrated version of SVD-Comp, this work suggests that this approach is truly general and could be used to develop a wide range of additional useful models.
Population forecasts for small areas within a country are an important planning tool. Standard methods for forecasting demographic rates do not, however, perform well with the noisy data that are typical of small areas. We develop a Bayesian model that combines ideas from the demographic, time series, and small area estimation literatures. We apply the model to the problem of forecasting emigration rates, disaggregated by age and sex, for 73 regions within New Zealand for the period of 2014-2038. We also deal with missing regional information and a change of geographic boundary. We test the calibration of the model using held-out data, and present extensions to accommodate age profiles and regional shares that vary over time. A key advantage of our approach is to provide meaningful uncertainty measures about forecasting. The prediction intervals for long-term forecasting are necessarily wide, engaging users to confront the substantial uncertainty about long-term trends.
Reliable mortality estimates at the subnational level are essential in the study of health inequalities within a country. One of the difficulties in producing such estimates is the presence of small populations, where the stochastic variation in death counts is relatively high, and so the underlying mortality levels are unclear. We present a Bayesian hierarchical model to estimate mortality at the subnational level. The model builds on characteristic age patterns in mortality curves, which are constructed using principal components from a set of reference mortality curves. Information on mortality rates are pooled across geographic space and smoothed over time. Testing of the model shows reasonable estimates and uncertainty levels when the model is applied to both simulated data which mimic US counties, and real data for French departments. The estimates produced by the model have direct applications to the study of subregional health patterns and disparities.
Bayesian statistics offers an alternative to classical (frequentist) statistics. It is distinguished by its use of probability distributions to describe uncertain quantities, which leads to elegant solutions to many difficult statistical problems. Although Bayesian demography, like Bayesian statistics more generally, is around 250 years old, only recently has it begun to flourish. The aim of this paper is to review the achievements of Bayesian demography, address some misconceptions, and make the case for wider use of Bayesian methods in population studies. We focus on three applications: demographic forecasts, limited data, and highly structured or complex models. The key advantages of Bayesian methods are the ability to integrate information from multiple sources and to describe uncertainty coherently. Bayesian methods also allow for including additional (prior) information next to the data sample. As such, Bayesian approaches are complementary to many traditional methods, which can be productively re-expressed in Bayesian terms.
Perhaps the greatest of all human achievements has been the enormous increase of human longevity that has occurred over the past few centuries. The average length of life in the early history of our species was probably in the range of 20 to 35 years (Table 1). By 1900, this value had already risen to around 45 to 50 years in industrialized countries. Slightly more than a century later, the world’s healthiest countries now have a life expectancy at birth of around 80 years. Thus, roughly half of the historical increase in human life expectancy occurred during the twentieth century. Of course, much of the increase in this average value has been due to the near elimination of infant and childhood deaths. According to the available evidence, in the distant past, around a quarter of all babies died in their first year of life. Today, in the most advantaged countries, less than a half percent of infants meet a similar fate.
Worldwide, the number of persons aged 60 and over has been increasing at an unparalleled rate. Africa, like other parts of the world, is undergoing rapid demographic changes, and, while the population is largely youthful, the proportion of older persons has increased tremendously over the past few decades. This chapter discusses the context of population ageing in Africa and its demographic determinants. In Africa, there are more women aged 60 years and over than men in the population. However, at older ages a far greater percentage of men are married than women. Labour force participation of those aged 60 years and over remains high, but men tend to dominate the elderly workforce. In terms of geographical distribution, the older population are evenly dispersed between rural and urban areas. Life expectancy will increase in all regions of the continent. However, the fastest growth of the ageing population will occur in Northern Africa, followed by Southern Africa. The ageing population of Africa will grow at an accelerated rate over the next few decades, and the inevitability of these demographic trends call for prompt and applicable policy-making and development initiatives.