Richard B. Biritwum

Data Resource Profile: The World Health Organization Study on global AGEing and adult health (SAGE)

Population ageing is rapidly becoming a global issue and will have a major impact on health policies and programmes. The World Health Organizations Study on global AGEing and adult health (SAGE) aims to address the gap in reliable data and scientific knowledge on ageing and health in low- and middle-income countries. SAGE is a longitudinal study with nationally representative samples of persons aged 50+ years in China, Ghana, India, Mexico, Russia and South Africa, with a smaller sample of adults aged 18-49 years in each country for comparisons. Instruments are compatible with other large high-income country longitudinal ageing studies. Wave 1 was conducted during 2007-2010 and included a total of 34 124 respondents aged 50+ and 8340 aged 18-49. In four countries, a subsample consisting of 8160 respondents participated in Wave 1 and the 2002/04 World Health Survey (referred to as SAGE Wave 0). Wave 2 data collection will start in 2012/13, following up all Wave 1 respondents. Wave 3 is planned for 2014/15. SAGE is committed to the public release of study instruments, protocols and meta- and micro-data: access is provided upon completion of a Users Agreement available through WHOs SAGE website (www.who.int/healthinfo/systems/sage) and WHOs archive using the National Data Archive application (http://apps.who.int/healthinfo/systems/surveydata).

Prevalence of Monoclonal Gammopathy of Undetermined Significance Among Men in Ghana

OBJECTIVE To determine the prevalence of monoclonal gammopathy of undetermined significance (MGUS), a precursor of multiple myeloma (MM), in Ghanaian men vs white men and to test for evidence to support an underlying race-related predisposition of the 2-fold higher prevalence of MGUS in African Americans vs whites. PARTICIPANTS AND METHODS Between September 1, 2004, and September 30, 2006, 917 men (50-74 years) underwent in-person interviews and physical examinations. Serum samples from all participants were analyzed by electrophoresis performed on agarose gel; any serum sample with a discrete or localized band was subjected to immunofixation. Age-adjusted and standardized (to the 2000 world population) prevalence estimates of MGUS and 95% confidence intervals (CIs) were computed in the Ghanaian men and compared with MGUS prevalence in 7996 white men from Minnesota. Associations between selected characteristics and MGUS prevalence were assessed by the Fisher exact test and logistic regression models. RESULTS Of the 917 study participants, 54 were found to have MGUS, yielding an age-adjusted prevalence of 5.84 (95% CI, 4.27-7.40) per 100 persons. No significant variation was found by age group, ethnicity, education status, or prior infectious diseases. The concentration of monoclonal immunoglobulin was undetectable in 41 (76%) of the 54 MGUS cases, less than 1 g/dL in 10 patients (19%), and 1 g/dL or more in only 3 patients (6%). Compared with white men, the age-adjusted prevalence of MGUS was 1.97-fold (95% CI, 1.94-2.00) higher in Ghanaian men. CONCLUSION The prevalence of MGUS in Ghanaian men was twice that in white men, supporting the hypothesis that race-related genetic susceptibility could explain the higher rates of MGUS in black populations. An improved understanding of MGUS and MM pathophysiology would facilitate the development of strategies to prevent progression of MGUS to MM.

The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal?

BackgroundChronic diseases contribute a large share of disease burden in low- and middle-income countries (LMICs). Chronic diseases have a tendency to occur simultaneously and where there are two or more such conditions, this is termed as ‘multimorbidity’. Multimorbidity is associated with adverse health outcomes, but limited research has been undertaken in LMICs. Therefore, this study examines the prevalence and correlates of multimorbidity as well as the associations between multimorbidity and self-rated health, activities of daily living (ADLs), quality of life, and depression across six LMICs.MethodsData was obtained from the WHO’s Study on global AGEing and adult health (SAGE) Wave-1 (2007/10). This was a cross-sectional population based survey performed in LMICs, namely China, Ghana, India, Mexico, Russia, and South Africa, including 42,236 adults aged 18 years and older. Multimorbidity was measured as the simultaneous presence of two or more of eight chronic conditions including angina pectoris, arthritis, asthma, chronic lung disease, diabetes mellitus, hypertension, stroke, and vision impairment. Associations with four health outcomes were examined, namely ADL limitation, self-rated health, depression, and a quality of life index. Random-intercept multilevel regression models were used on pooled data from the six countries.ResultsThe prevalence of morbidity and multimorbidity was 54.2 % and 21.9 %, respectively, in the pooled sample of six countries. Russia had the highest prevalence of multimorbidity (34.7 %) whereas China had the lowest (20.3 %). The likelihood of multimorbidity was higher in older age groups and was lower in those with higher socioeconomic status. In the pooled sample, the prevalence of 1+ ADL limitation was 14 %, depression 5.7 %, self-rated poor health 11.6 %, and mean quality of life score was 54.4. Substantial cross-country variations were seen in the four health outcome measures. The prevalence of 1+ ADL limitation, poor self-rated health, and depression increased whereas quality of life declined markedly with an increase in number of diseases.ConclusionsFindings highlight the challenge of multimorbidity in LMICs, particularly among the lower socioeconomic groups, and the pressing need for reorientation of health care resources considering the distribution of multimorbidity and its adverse effect on health outcomes.

Two susceptibility loci identified for prostate cancer aggressiveness

Most men diagnosed with prostate cancer will experience indolent disease; hence discovering genetic variants that distinguish aggressive from non-aggressive prostate cancer is of critical clinical importance for disease prevention and treatment. In a multistage, case-only genome-wide association study of 12,518 prostate cancer cases, we identify two loci associated with Gleason score, a pathological measure of disease aggressiveness: rs35148638 at 5q14.3 (RASA1, P=6.49×10-9) and rs78943174 at 3q26.31 (NAALADL2, P=4.18×10-8). In a stratified case-control analysis, the SNP at 5q14.3 appears specific for aggressive prostate cancer (P=8.85×10-5) with no association for non-aggressive prostate cancer compared to controls (P=0.57). The proximity of these loci to genes involved in vascular disease suggests potential biological mechanisms worthy of further investigation.

Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: results from the WHO Study on global AGEing and adult health (SAGE)

BackgroundIn 2010 falls were responsible for approximately 80 % of disability stemming from unintentional injuries excluding traffic accidents in adults 50 years and over. Falls are becoming a major public health problem in low- and middle-income countries (LMICs) where populations are ageing rapidly.MethodsNationally representative standardized data collected from adults aged 50 years and over participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, the Russian Federation and South Africa are analysed. The aims are to identify the prevalence of, and risk factors for, past-year fall-related injury and to assess associations between fall-related injury and disability. Regression methods are used to identify risk factors and association between fall-related injury and disability. Disability was measured using the WHO Disability Assessment Schedule Version 2.0 (WHODAS 2.0).ResultsThe prevalence of past-year fall-related injuries ranged from 6.6 % in India to 1.0 % in South Africa and was 4.0 % across the pooled countries. The proportion of all past-year injuries that were fall-related ranged from 73.3 % in the Russian Federation to 44.4 % in Ghana. Across the six countries this was 65.7 %. In the multivariable logistic regression, the odds of past-year fall-related injury were significantly higher for: women (OR: 1.27; 95 % CI: 0.99,1.62); respondents who lived in rural areas (OR: 1.36; 95 % CI: 1.06,1.75); those with depression (OR: 1.43; 95 % CI: 1.01,2.02); respondents who reported severe or extreme problems sleeping (OR: 1.54; 95 % CI: 1.15,2.08); and those who reported two or more (compared with no) chronic conditions (OR: 2.15; 95 % CI: 1.45,3.19). Poor cognition was also a significant risk factor for fall-related injury.The association between fall-related injury and the WHODAS measure of disability was highly significant (P<0.0001) with some attenuation after adjusting for confounders. Reporting two or more chronic conditions (compared with none) was significantly associated with disability (P<0.0001).ConclusionsThe findings provide a platform for improving understanding of risk factors for falls in older adults in this group of LMICs. Clinicians and public health professionals in these countries must be made aware of the extent of this problem and the need to implement policies to reduce the risk of falls in older adults.

Sexual behaviour and contraception among unmarried adolescents and young adults in greater accra and eastern regions of ghana

A fertility survey of unmarried adolescents and young adults (953 males and 829 females) in Greater Accra and Eastern regions of Ghana revealed that a substantial proportion of the respondents were sexually experienced. Overall, 66.8% of the males and 78.4% of the females were sexually experienced. The mean ages (+/- SD) of the males and females were 15.5 +/- 2.5 and 16.2 +/- 2.0 years, respectively. Most respondents claimed to have received adequate information on reproductive health and sexually transmitted diseases (STDs), including AIDS. However, 20% and 30% of the respondents in peri-urban and rural areas, respectively, did not know that a girl could get pregnant the first time she has sexual intercourse. The incidence of pregnancy among the unmarried female respondents was relatively high (37%), and was higher in urban than in rural areas. Approximately 47% of those who had ever been pregnant reported that they had had an abortion. Levels of contraceptive awareness were high (98.2% among males and 95.5% among females) but many still engaged in unprotected sexual relations. The most commonly used methods were the condom and the pill. The main reasons given for non-use were that they did not think about contraception, were concerned about the safety of contraceptives, and partner objection. These findings point to the need for targeting of unmarried adolescents and young adults with information on reproductive health and family planning to increase their awareness of the risks of pregnancy, STDs and HIV infection.

Interest in healthy living outweighs presumed cultural norms for obesity for Ghanaian women

BackgroundCultural norms indicate that obesity reflects increased wealth and prosperity. Yet obesity is linked to serious medical illnesses. The purpose of this study was to determine if Ghanaian women would change their body image if it meant a healthier life.MethodsA questionnaire was administered to 305 Ghanaian women waiting for clinic appointments at Korle Bu Teaching Hospital, Accra Ghana. This survey included questions on current health, selection of figural stimuli, decision making on health and social determinants and 5 questions on self-perception of health from SF-36. Anthropometric measures were taken and body mass index calculated. Women were also provided with health related information at the conclusion of the interview.ResultsThe majority of all women surveyed would reduce their current body image if it meant that they would have an overall healthier life and reduce the risks of obesity-linked illnesses and complications. Currently obese women were significantly more likely than non-obese women to reduce their body image to reduce the risk of hypertension (OR 2.03 [1.64 – 2.51],<0.001); cardiovascular accident (OR 1.96 [1.61 – 2.38],<0.001); diabetes (OR 2.00 [1.63 – 2.44],<0.001); myocardial infarction (OR 2.27 [1.80 – 2.86],<0.001); if requested by a spouse(OR 2.64 [1.98 – 3.52],<0.001); and to improve overall health (OR 1.95 [1.60 – 2.37], <0.001). There was no association with current body image and responses to SF-36. The decision to select a new body image was not influenced by education, income, marital status or parity. Age 50 years old and less was significantly associated with the body image size reduction to reduce the risk of hypertension, diabetes, and a cardiovascular accident.ConclusionThe Ghanaian women interviewed in this study are interested in living a healthy life and are willing to reduce their body size to reduce the risk of obesity-linked illnesses. The target group for any interventional studies and measures to reduce obesity appears to be women age 50 and younger.

Risk Factors and Disability Associated with Low Back Pain in Older Adults in Low- and Middle-Income Countries. Results from the WHO Study on Global AGEing and Adult Health (SAGE)

Background 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. Methods 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. Results 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. Conclusions 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.

Common risk factors for chronic non-communicable diseases among older adults in China, Ghana, Mexico, India, Russia and South Africa: the study on global AGEing and adult health (SAGE) wave 1

BackgroundBehavioral risk factors such as tobacco use, unhealthy diet, insufficient physical activity and the harmful use of alcohol are known and modifiable contributors to a number of NCDs and health mediators. The purpose of this paper is to describe the distribution of main risk factors for NCDs by socioeconomic status (SES) among adults aged 50 years and older within a country and compare these risk factors across six lower- and upper-middle income countries.MethodsThe study population in this paper draw from SAGE Wave 1 and consisted of adults aged 50-plus from China (N=13,157), Ghana (N=4,305), India (N=6,560), Mexico (N=2,318), the Russian Federation (N=3,938) and South Africa (N=3,836). Seven main common risk factors for NCDs were identified: daily tobacco use, frequent heavy drinking, low level physical activity, insufficient vegetable and fruit intake, high risk waist-hip ratio, obesity and hypertension. Multiple risk factors were also calculated by summing all these risk factors.ResultsThe prevalence of daily tobacco use ranged from 7.7% (Ghana) to 46.9% (India), frequent heavy drinker was the highest in China (6.3%) and lowest in India (0.2%), and the highest prevalence of low physical activity was in South Africa (59.7%). The highest prevalence of respondents with high waist-to-hip ratio risk was 84.5% in Mexico, and the prevalence of self-reported hypertension ranging from 33% (India) to 78% (South Africa). Obesity was more common in South Africa, the Russia Federation and Mexico (45.2%, 36% and 28.6%, respectively) compared with China, India and Ghana (15.3%, 9.7% and 6.4%, respectively). China, Ghana and India had a higher prevalence of respondents with multiple risk factors than Mexico, the Russia Federation and South Africa. The occurrence of three and four risk factors was more prevalent in Mexico, the Russia Federation and South Africa.ConclusionThere were substantial variations across countries and settings, even between upper-middle income countries and lower-middle income countries. The baseline information on the magnitude of the problem of risk factors provided by this study can help countries and health policymakers to set up interventions addressing the global non-communicable disease epidemic.

Sociodemographic and socioeconomic patterns of chronic non-communicable disease among the older adult population in Ghana.

Background In Ghana, the older adult population is projected to increase from 5.3% of the total population in 2015 to 8.9% by 2050. National and local governments will need information about non-communicable diseases (NCDs) in this population in order to allocate health system resources and respond to the health needs of older adults. Design The 2007/08 Study on global AGEing and adult health (SAGE) Wave 1 in Ghana used face-to-face interviews in a nationally representative sample of persons aged 50-plus years. Individual respondents were asked about their overall health, diagnosis of 10 chronic non-communicable conditions, and common health risk factors. A number of anthropometric and health measurements were also taken in all respondents, including height, weight, waist and hip circumferences, and blood pressure (BP). Results This paper includes 4,724 adults aged 50-plus years. The highest prevalence of self-reported chronic conditions was for hypertension [14.2% (95% CI 12.8-15.6)] and osteoarthritis [13.8%, (95% CI 11.7-15.9)]. The figure for hypertension reached 51.1% (95% CI 48.9-53.4) when based on BP measurement. The prevalence of current smokers was 8.1% (95% CI 7.0-9.2), while 2.0 (95% CI 1.5-2.5) were infrequent/frequent heavy drinkers, 67.9% (95% CI 65.2-70.5) consume insufficient fruits and vegetables, and 25.7% (95% CI 23.1-28.3) had a low level of physical activity. Almost 10% (95% CI 8.3-11.1) of adults were obese and 77.6% (95% CI 76.0-79.2) had a high-risk waist-to-hip ratio (WHR). Risks from tobacco and alcohol consumption continued into older age, while insufficient fruit and vegetable intake, low physical activity and obesity increased with increasing age. The patterns of risk factors varied by income quintile, with higher prevalence of obesity and low physical activity in wealthier respondents, and higher prevalence of insufficient fruit and vegetable intake and smoking in lower-income respondents. The multivariate analysis showed that only urban/rural residence and body mass index (BMI) were common determinates of both self-reported and measured hypertension, while all other determinants have differing patterns. Conclusions The findings show a high burden of chronic diseases in the older Ghanaian population, as well as high rates of modifiable health risk factors. The government could consider targeting these health behaviors in conjunction with work to improve enrolment rates in the National Health Insurance Scheme.Background In Ghana, the older adult population is projected to increase from 5.3% of the total population in 2015 to 8.9% by 2050. National and local governments will need information about non-communicable diseases (NCDs) in this population in order to allocate health system resources and respond to the health needs of older adults. Design The 2007/08 Study on global AGEing and adult health (SAGE) Wave 1 in Ghana used face-to-face interviews in a nationally representative sample of persons aged 50-plus years. Individual respondents were asked about their overall health, diagnosis of 10 chronic non-communicable conditions, and common health risk factors. A number of anthropometric and health measurements were also taken in all respondents, including height, weight, waist and hip circumferences, and blood pressure (BP). Results This paper includes 4,724 adults aged 50-plus years. The highest prevalence of self-reported chronic conditions was for hypertension [14.2% (95% CI 12.8–15.6)] and osteoarthritis [13.8%, (95% CI 11.7–15.9)]. The figure for hypertension reached 51.1% (95% CI 48.9–53.4) when based on BP measurement. The prevalence of current smokers was 8.1% (95% CI 7.0–9.2), while 2.0 (95% CI 1.5–2.5) were infrequent/frequent heavy drinkers, 67.9% (95% CI 65.2–70.5) consume insufficient fruits and vegetables, and 25.7% (95% CI 23.1–28.3) had a low level of physical activity. Almost 10% (95% CI 8.3–11.1) of adults were obese and 77.6% (95% CI 76.0–79.2) had a high-risk waist-to-hip ratio (WHR). Risks from tobacco and alcohol consumption continued into older age, while insufficient fruit and vegetable intake, low physical activity and obesity increased with increasing age. The patterns of risk factors varied by income quintile, with higher prevalence of obesity and low physical activity in wealthier respondents, and higher prevalence of insufficient fruit and vegetable intake and smoking in lower-income respondents. The multivariate analysis showed that only urban/rural residence and body mass index (BMI) were common determinates of both self-reported and measured hypertension, while all other determinants have differing patterns. Conclusions The findings show a high burden of chronic diseases in the older Ghanaian population, as well as high rates of modifiable health risk factors. The government could consider targeting these health behaviors in conjunction with work to improve enrolment rates in the National Health Insurance Scheme.