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Objectives. We compared national prevalence and wealth-related inequality in disability across a large number of countries from all income groups. Methods. Data on 218 737 respondents participating in the World Health Survey 2002–2004 were analyzed. A composite disability score (0–100) identified respondents who experienced significant disability in physical, mental, and social functioning irrespective of their underlying health condition. Disabled persons had disability composite scores above 40. Wealth was evaluated using an index of economic status in households based on ownership of selected assets. Socioeconomic inequalities were measured using the slope index of inequality and the relative index of inequality. Results. Median age-standardized disability prevalence was higher in the low- and lower middle-income countries. In all the study countries, disability was more prevalent in the poorest than in the richest wealth quintiles. Pro-rich inequality was statistically significant in 43 of 49 countries, with disability prevalence higher among populations with lower wealth. Median relative inequality was higher in the high- and upper middle-income countries. Conclusions. Integrating equity components into the monitoring of disability trends would help ensure that interventions reach and benefit populations with greatest need.

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

Background Edentulism (loss of all teeth) is a final marker of disease burden for oral health common among older adults and poorer populations. Yet most evidence is from high-income countries. Oral health has many of the same social and behavioural risk factors as other non-communicable diseases (NCDs) which are increasing rapidly in low- and middle-income countries with ageing populations. The “common risk factor approach” (CRFA) for oral health addresses risk factors shared with NCDs within the broader social and economic environment. Methods The aim is to improve understanding of edentulism prevalence, and association between common risk factors and edentulism in adults aged 50 years and above using nationally representative samples from China ( N  = 11,692), Ghana ( N  = 4093), India ( N  = 6409) and South Africa ( N  = 2985). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007–2010). Multivariable logistic regression describes association between edentulism and common risk factors reported in the literature. Results Prevalence of edentulism: in China 8.9 %, Ghana 2.9 %, India 15.3 %, and South Africa 8.7 %. Multivariable analysis: in China, rural residents were more likely to be edentulous (OR 1.36; 95 % CI 1.09–1.69) but less likely to be edentulous in Ghana (OR 0.53; 95 % CI 0.31–0.91) and South Africa (OR 0.52; 95 % CI 0.30–0.90). Respondents with university education (OR 0.31; 95 % CI 0.18–0.53) and in the highest wealth quintile (OR 0.68; 95 % CI 0.52–0.90) in China were less likely to be edentulous. In South Africa respondents with secondary education were more likely to be edentulous (OR 2.82; 95 % CI 1.52–5.21) as were those in the highest wealth quintile (OR 2.78; 95 % CI 1.16–6.70). Edentulism was associated with former smokers in China (OR 1.57; 95 % CI 1.10–2.25) non-drinkers in India (OR 1.65; 95 % CI 1.11–2.46), angina in Ghana (OR 2.86; 95 % CI 1.19–6.84) and hypertension in South Africa (OR 2.75; 95 % CI 1.72–4.38). Edentulism was less likely in respondents with adequate nutrition in China (OR 0.68; 95 % CI 0.53–0.87). Adjusting for all other factors, compared with China, respondents in India were 50 % more likely to be edentulous. Conclusions Strengthening the CRFA should include addressing common determinants of health to reduce health inequalities and improve both oral and overall health.

Background Expenditure on medications for highly prevalent chronic conditions such as diabetes mellitus (DM) can result in financial impoverishment. People in developing countries and in low socioeconomic status groups are particularly vulnerable. China and India currently hold the world’s two largest DM populations. Both countries are ageing and undergoing rapid economic development, urbanisation and social change. This paper assesses the determinants of DM medication use and catastrophic expenditure on medications in older adults with DM in China and India. Methods Using national standardised data collected from adults aged 50 years and above with DM (self-reported) in China ( N  = 773) and India ( N  = 463), multivariable logistic regression describes: 1) association between respondents’ socio-demographic and health behavioural characteristics and the dependent variable, DM medication use, and 2) association between DM medication use (independent variable) and household catastrophic expenditure on medications (dependent variable) (China: N  = 630; India: N  = 439). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007–2010). Results Prevalence of DM medication use was 87% in China and 71% in India. Multivariable analysis indicates that people reporting lifestyle modification were more likely to use DM medications in China (OR = 6.22) and India (OR = 8.45). Women were more likely to use DM medications in China (OR = 1.56). Respondents in poorer wealth quintiles in China were more likely to use DM medications whereas the reverse was true in India. Almost 17% of people with DM in China experienced catastrophic healthcare expenditure on medications compared with 7% in India. Diabetes medication use was not a statistically significant predictor of catastrophic healthcare expenditure on medications in either country, although the odds were 33% higher among DM medications users in China (OR = 1.33). Conclusions The country comparison reflects major public policy differences underpinned by divergent political and ideological frameworks. The DM epidemic poses huge public health challenges for China and India. Ensuring equitable and affordable access to medications for DM is fundamental for healthy ageing cohorts, and is consistent with the global agenda for universal healthcare coverage.

Background China and India are the world’s two most populous countries. Although their populations are growing in number and life expectancies are extending they have different trajectories of economic growth, epidemiological transition and social change. Cross-country comparisons can allow national and global insights and provide evidence for policy and decision-making. The aim of this study is to measure and compare disability in men and women, and in urban and rural dwellers in China and India, and assess the extent to which social and other factors contribute to the inequalities. Methods National samples of adults aged 50 to 79 years in China ( n  = 11,694) and India ( n  = 6187) from the World Health Organization (WHO) longitudinal Study on global AGEing and adult health (SAGE) Wave 1 were analysed. Stratified multiple linear regressions were undertaken to assess disability differences by sex and residence, controlling for other biological and socioeconomic determinants of disability. Oaxaca-Blinder decomposition partitioned the two-group inequalities into explained and unexplained components. Results In both countries women and rural residents reported more disability. In India, the gender inequality is attributed to the distribution of the determinants (employment, education and chronic conditions) but in China about half the inequality is attributed to the same. In India, more than half of the urban rural inequality is attributed to the distribution of the determinants (education, household wealth) compared with under 20% in China. Conclusions Education and employment were important drivers of these measured inequalities. Overall inequalities in disability among older adults in China and India were shaped by gender and residence, suggesting the need for policies that target women and rural residents. There is a need for further research, using both qualitative and quantitative methods, to question and challenge entrenched practices and institutions and grasp the implications of global economic and social changes that are impacting on population health and ageing in China and India.

Background Globally people are living longer and enduring non-communicable diseases (NCDs) many of which co-occur as multimorbidity. Demographic and socioeconomic factors are determinants of inequalities and inequities in health. There is a need for country-specific evidence of NCD inequalities in developing countries where populations are ageing rapidly amid economic and social change. The study measures and decomposes socioeconomic inequality in single and multiple NCD morbidity in adults aged 50 and over in China and Ghana. Methods The data source is the World Health Organization Study on Global AGEing and Adult Health (SAGE) Wave 1 (2007–2010). Nationally representative cross-sectional data collected from adults in China ( n  = 11,814) and Ghana ( n  = 4,050) are analysed. Country populations are ranked by a socioeconomic index based on ownership of household assets. The study uses a decomposed concentration index (CI) of single and multiple NCD morbidity (multimorbidity) covering arthritis, diabetes, angina, stroke, asthma, depression, chronic lung disease and hypertension. The CI quantifies the extent of overall inequality on each morbidity measure. The decomposition utilises a regression-based approach to examine individual contributions of demographic and socioeconomic factors, or determinants, to the overall inequality. Results In China, the prevalence of single and multiple NCD morbidity was 64.7% and 53.4%, compared with 65.9% and 55.5% respectively in Ghana. Inequalities were significant and more highly concentrated among the poor in China (single morbidity CI = −0.0365: 95% CI = −0.0689,–0.0040; multimorbidity CI = −0.0801: 95% CI = −0.1233,-0.0368;). In Ghana inequalities were significant and more highly concentrated among the rich (single morbidity CI = 0.1182; 95% CI = 0.0697, 0.1668; multimorbidity CI = 0.1453: 95% CI = 0.0794, 0.2083). In China, rural residence contributed most to inequality in single morbidity (36.4%) and the wealth quintiles contributed most to inequality in multimorbidity (39.0%). In Ghana, the wealth quintiles contributed 24.5% to inequality in single morbidity and body mass index contributed 16.2% to the inequality in multimorbidity. Conclusions The country comparison reflects different stages of economic development and social change in China and Ghana. More studies of this type are needed to inform policy-makers about the patterning of socioeconomic inequalities in health, particularly in developing countries undergoing rapid epidemiological and demographic transitions.

Background The 2015 Global Burden of Disease Study estimated that oral conditions affect 3.5 billion people worldwide with a higher burden among older adults and those who are socially and economically disadvantaged. Studies of inequalities in the use of oral health services by those in need have been conducted in high-income countries but evidence from low- and middle-income countries (LMICs) is limited. This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India. Methods A cross-sectional analysis of national survey data from the WHO SAGE Wave 1 (2007–2010) was conducted. Study samples in China ( n  = 1591), Ghana ( n  = 425) and India ( n  = 1307) were conditioned on self-reported need for oral health services in the previous 12 months. The binary dependent variable, unmet need for oral health services, was derived from questions about self-reported need and service use. Prevalence was estimated by country. Unmet need was measured and compared in terms of relative levels of education and household wealth. The methods were logistic regression and the relative index of inequality (RII). Models were adjusted for age, sex, area of residence, marital status, work status and self-rated health. Results The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted RII for education was statistically significant for China (1.5, 95% CI:1.2–1.9), Ghana (1.4, 95% CI: 1.1–1.7), and India (1.5, 95% CI:1.2–2.0), whereas the adjusted RII for wealth was significant only in Ghana (1.3, 95% CI:1.1–1.6). Male sex was significantly associated with self-reported unmet need for oral health services in India. Conclusions Given rapid population ageing, further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in LMICs is needed to inform policies to mitigate inequalities in the availability of oral health services. Oral health is a universal public health issue requiring attention and action on multiple levels and across the public private divide.

Women and men share similar health challenges yet women report poorer health. The study investigates the social determinants of self-reported health in women and men, and male-female differences in health. Data on 103154 men and 125728 women were analysed from 57 countries in the World Health Survey 2002-2004. Item Response Theory was used to construct a composite measure of health. Associations between health and determinants were assessed using multivariate linear regression. Blinder-Oaxaca decomposition partitioned the inequality in health between women and men into an \"explained\" component that arises because men and women differ in social and economic characteristics, and an \"unexplained\" component due to the differential effects of these characteristics. Decomposition was repeated for 18 countries in the World Health Organization (WHO) African region and 19 countries in the WHO European region. Women's health was significantly lower than men's. Health was associated with education, household economic status, employment, and marital status after controlling for age. In the pooled analysis decomposition showed that 30% of the inequality was \"explained\", of which almost 75% came from employment, education, marital status. The differential effects of being in paid employment increased the inequality. When countries in Africa and Europe were compared, the \"explained\" component (31% and 39% respectively) was largely attributed to the social determinants in the African countries and to women's longevity in the European countries. Being in paid employment had a greater positive effect on the health of males in both regions. Ways in which age and the social determinants contribute to the poorer health status of women compared with men varies between groups of countries. This study highlights the need for action to address social structures, institutional discrimination and harmful gender norms and roles that differently influence health with ageing.

ObjectivesTo conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.DesignA cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.SettingThe Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.ResultsMorbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.ConclusionInvesting in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

The use of large quantities of antimicrobial drugs for human health and agriculture is advancing the predominance of drug resistant pathogens in the environment. Antimicrobial resistance is now a major public health threat posing significant challenges for achieving the Sustainable Development Goals. In Bangladesh, where over one third of the population is below the poverty line, the achievement of safe and effective antibiotic medication use for human health is challenging. To explore factors and practices around access and use of antibiotics and understanding of antimicrobial resistance in rural communities in Bangladesh from a socio-cultural perspective. This qualitative study comprises the second phase of the multi-country ABACUS (Antibiotic Access and Use) project in Matlab, Bangladesh. Information was collected through six focus group discussions and 16 in-depth interviews. Informants were selected from ten villages in four geographic locations using the Health and Demographic Surveillance System database. The Access to Healthcare Framework guided the interpretation and framing of the findings in terms of individuals' abilities to: perceive, seek, reach, pay and engage with healthcare. Village pharmacies were the preferred and trusted source of antibiotics for self-treatment. Cultural and religious beliefs informed the use of herbal and other complementary medicines. Advice on antibiotic use was also sourced from trusted friends and family members. Access to government-run facilities required travel on poorly maintained roads. Reports of structural corruption, stock-outs and patient safety risks eroded trust in the public sector. Some expressed a willingness to learn about antibiotic resistance. Antimicrobial resistance is both a health and development issue. Social and economic contexts shape medicine seeking, use and behaviours. Multi-sectoral action is needed to confront the underlying social, economic, cultural and political drivers that impact on the access and use of antibiotic medicines in Bangladesh.