Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model
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GHME 2013 Conference Session: Global and national Burden of Disease III Date: June 18 Presenter: Collin Payne Institute: University of Pennsylvania Population Studies Center
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Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model
- 1. Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model Collin F Payne, UPenn GGD & PSC James Mkandawire, IKI Malawi Hans-Peter Kohler, UPenn PSC GHME 2013 June 18
- 2. Population growth by age group in SSA 2010– 2060 (2010 = 100), share of total population by age groups Source: authors’ calculations based on United Nations World Population Prospects 2010 population projections.
- 3. SSA: Person Years Lived Above Age 25 By Age Group Source: authors’ calculations based on United Nations World Population Prospects 2010 population projections.
- 4. • Evidence about health and disability among older adults in SSA is very limited • High levels of labor force participation: 98% for age 50–64, 90% for age 65+ based on the 2009 Malawi Welfare Monitoring Survey (WMS) • Individuals are very poorly served by the existing health infrastructure in SSA—government health clinics are not equipped to deal with the chronic diseases of aging Focus on Mature Adults (= individuals aged 45+)
- 5. Our Research • Focus on day-to-day activities in domains relevant to the subsistence-agriculture context of rural Malawi. – Analyze patterns of transition between levels of disability across age – Estimate health expectancies (HEs) in levels of disability • Characterize processes of health, aging, and functional limitations in rural Malawi • Seek to provide insights into the potential gains in well-being and economic productivity which could arise from investments in the health of older adults in SSA.
- 6. Malawi Longitudinal Survey of Families and Health (MLSFH) • Longitudinal household panel conducted by UPenn • Our analyses use data from 2006, 2008, and 2010 rounds • Parent sample added in 2008, bringing number of individuals age 45+ to ~1,200 • HIV testing among individuals aged 45+ y in the 2008 MLSFH found an overall HIV prevalence of 3.3%. • Basic demographic and socioeconomic characteristics are similar between our 2010 study population and the 45+ y rural population in the nationally representative Malawi 2010–2011 Third Integrated Household Survey (IHS3).
- 7. • Classification of physical limitations (―disability‖) based on 2 questions from SF12 module – limitations in cooking and cleaning, walking to meetings in the village, or tending to cattle and livestock – limitations in carrying heavy loads, working on the farm, pounding maize, or digging a pit latrine • Response categories of ―limited a lot‖, ―limited a little‖, or ―not limited‖ • Disability Status (―lived experience with disability‖) – healthy: no limitations in either set of activities – moderately limited: ―limited a little‖ in either set of activities – severely limited: ―limited a lot‖ in either set of activities Disability Status
- 8. Self-Reported disability, % working for income, pain interfering with work, and subjective well-being Source: Payne CF, Mkandawire J, Kohler H-P (2013) Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model. PLoS Med 10(5): e1001435. doi:10.1371/journal.pmed.1001435
- 10. Estimated Annual Transition Probabilities between Health Statuses Source: Payne CF, Mkandawire J, Kohler H-P (2013) Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model. PLoS Med 10(5): e1001435. doi:10.1371/journal.pmed.1001435 A) From Healthy B) From Moderately Limited
- 11. Estimated Annual Transition Probabilities between Health Statuses Source: Payne CF, Mkandawire J, Kohler H-P (2013) Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model. PLoS Med 10(5): e1001435. doi:10.1371/journal.pmed.1001435 C) From Severely Limited D) Mortality Probabilities
- 12. Health expectancies: Average remaining life expectancy (LE) at ages 45–75 Source: Payne CF, Mkandawire J, Kohler H-P (2013) Disability Transitions and Health Expectancies among Adults 45 Years and Older in Malawi: A Cohort-Based Model. PLoS Med 10(5): e1001435. doi:10.1371/journal.pmed.1001435
- 13. Discussion • Functional limitations are associated with a lower likelihood of working for income and reduced work efforts in agriculture • Risks of experiencing an onset of functional limitations are high compared to developed contexts • Onset of functional limitations happens earlier in life – Proportion of remaining life spent in severe limitation at age 45 is comparable to 80-year olds in the US
- 14. Implications • Older population in SSA has been largely left out of health-focused interventions and policies, particularly those focusing on MDGs. • Many policy makers in SSA hesitant to direct money to the elderly population, and see investment in the aging population as ―irrelevant to core national development interests‖. • Based on our findings, we believe that sentiment is misguided—the high burden of disability among mature adults is associated with substantial loss of labor output.
- 15. Thanks! • Any post-discussion questions: – collinp@sas.upenn.edu – Paper is available at PLOS Medicine • doi:10.1371/journal.pmed.1001435 • Acknowledgements: – I am supported by the NSF Graduate Research Fellowship (Grant No. DGE-0822)
Editor's Notes
- I want to start off by saying thanks to IHME, the session chair, and to you in the audience—I know there are a lot of interesting sessions going on right now.My name is Collin Payne, I’m a PhD candidate in the Graduate group in Demography at UPenn, and I’m presenting today on a portion of my dissertation research
- I want to first talk a little about population aging in SSA—not a topic that comes instantly to mind when speaking about sub-Saharan Africa, but recent trends of falling fertility and increasing life expectancy foreshadow a growing elderly population in the coming decades.Focusing here on adults 45+--in a context such as rural Malawi, this represents late-middle age, and is generally past reproductive agesThe population of adults aged 45+ y will expand substantially in many SSA countries over the next 50 years, both in terms of aggregate growth and share of the total population. By 2060, persons aged 45+ y are projected to be 25% of SSA’s population, up from 10% in 2010
- Projected gains in person-years lived in the next 50 years occur disproportionately among the older population--In sub-Saharan Africa, 80% of the additional person-years lived a result of increasing adult life expectancy will occur among individuals 45 years or olderSo: The aging population will be both growing and living longer in the coming decades
- In SSA, this is a population that, in terms of data, is almost invisible--most studies (including the DHS) only collect data on persons under 50High labor force participation--this population has the potential to contribute significantly to economic growth during the next decades. In the absence of social security and health insurance programs, mature adults can be key economic providers.--
- We seek to understand how physical health limits the ability of individuals to perform Together, these measures…
- HIV prevalence will likely rise in the coming years—preliminary estimates from the 2012 MLSFH data show that prevalence has grown to 4.8%Our analyses pool HIV-positive and HIV-negative individuals. Both HIV-positive and -negative individuals confront a high-disease-risk environment characterized by poverty, malnutrition, poor sanitation, a high prevalence of infectious diseases, and limited access to health-care facilities. We treat HIV/AIDS as just one of the many pressures effecting this population.
- The first set focuses on activities that require an ability to sustain a moderate amount of physical effort for a longer period of time, the second set of activities requires a larger ability to exert physical strength.
- We see that with increasing age, proportionately more individuals report moderate or severe limitationsLooking at individuals in the 2010 sample, percentage of individuals working for income within the past week declined steadily with increasing disabilityIndividuals who reported limitations on physical activity also reported that their work efforts (both within and outside the household) had been substantially limited by painLife satisfaction was negatively related to increasing level of disability, with over a quarter of severely limited individuals reporting that they were somewhat or very unsatisfied with their life.These gradients persist in regression analyses controlling for age and gender, and additional regression analyses showed that increasing disability was also associated with fewer hours of family farm work
- These analyses represent a methodological shift from previous measures of health expectancies calculated for SSA. Previous metrics have primarily focused on LE at birth, which is not a readily applicable metric to the life-course experience of an adult.
- High rates of transitioning--Among respondents observed for all three MLSFH waves, 59% experienced at least one and 22% experienced two transitions between different disability states In panel A, we see that rates of entry into a disabled state rise sharply with age—with each year, individuals are less and less likely to remain in the healthy status. Panel B shows transition probabilities from moderate limitation. This state is characterized by relatively high rates of entry and exit. At younger ages, individuals of both sexes are relatively likely to recover to healthy from stays in moderate limitation, but probabilities of recovery decline sharply with age, and probabilities of worsening to severe limitation increase.
- Panel C displays transition probabilities from the severely limited state. This is a fairly retentive state, with low probabilities of exit. As would be expected given the severity of the state, the probability of experiencing recovery to healthy or moderately limited declines sharply with age. For both men and women, the probability of full recovery to healthy life is almost zero afterage 75 yPanel D shows the association of the three alive states with mortality. We find that initial health status is highly associated with mortality probabilities. At younger ages in particular, annual mortality rates among individuals with severe limitation are orders of magnitude higher than healthy or moderately limited individuals—a 45-y-old severely limited woman is about six times more likely to die before age 46 than a healthy woman (5.3 times for a man).
- Moving on to health and life expectancies , we see that a 45 year old female in our sample at will expect to live to age 73 (70 for males)—a figure in line with Malawi Census and WHO estimates. Females expect to live slightly longer than males at all ages. BUT:We find that mature adults in rural Malawi expect to live many of their remaining years subject to disability. Our analyses show that the average 45-y-old woman is expected to live almost 60% her remaining 28 y in a limited status, while the average man will be limited for about 40% of his remaining life. The high rates of transition between health states across the life course mean that time spent in limited status does not occur solely at the end of life. Analysis of the synthetic cohort of 45-y-olds shows that, on average, a woman at age 45 y will spend 2.7 y in moderate limitation and 0.6 y in severe limitation before she reaches age 55 y (these corresponding values for men are 1.6 and 0.4 y). By age 75, the vast majority of remaining life for both males and females is spent in some limited state.
- And proportion of remaining life spent in limitation is high --proportion of remaining life spent in severe limitation among 45-year olds in Malawi is comparable to that of 80-year olds in the US
- Mature adults with disabilities are likely to be a drain on the scarce time and resources of families, and may contribute less time and money towards children and younger adults.Investments in improving the health of this growing population have the potential to significantly improve aggregate economic growth, and our analyses provide empirical support to recent arguments for greater attention to older adults within national health policies in less-developed countries