Health and wellbeing of older people in LMICs: a call for research-informed decision making

An estimated 80% of the world's older people (defined as those aged ≥60 years) will live in low-income or middle-income countries (LMICs) by 2030.1United Nations Department of Economic and Social AffairsWorld Population Ageing 2019. United Nations, New York2020Crossref Google Scholar Ageing well requires addressing the complex financial, health, and social care needs of older people. But, despite economic growth and investment in health, LMICs continue to struggle with fragile and under-resourced health and social care systems to support older people.2Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1242) Google Scholar Such issues can be particularly problematic in rural areas, from which younger people often leave to find economic opportunities, leading to a loss of labour and depletion of carers for older people, and worsening unmet needs for social care.3Agree EM Demography of aging and the family.in: Majmundar MK Hayward MD Future directions for the demography of aging: proceedings of a workshop. National Academies Press (US), Washington, DC2018Google Scholar Compounding matters, in addition to an increasing prevalence of multimorbidity with ageing,4Afshar S Roderick PJ Kowal P Dimitrov BD Hill AG Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys.BMC Public Health. 2015; 15: 776Crossref PubMed Scopus (174) Google Scholar older people are disproportionately vulnerable to the health effects of two of the most pressing health issues of our time, climate change5Watts N Amann M Arnell N et al.The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises.Lancet. 2021; 397: 129-170Summary Full Text Full Text PDF PubMed Scopus (801) Google Scholar and COVID-19.6Lloyd-Sherlock P Guntupalli A Sempé L Age discrimination, the right to life, and COVID-19 vaccination in countries with limited resources.J Soc Issues. 2022; (published online Sept 30.)https://doi.org/10.1111/josi.12561Crossref PubMed Scopus (7) Google Scholar In recognition of these issues, the need to invest in health and social support for older people living in LMICs has been well articulated.7The Lancet Healthy LongevityCare for ageing populations globally.Lancet Healthy Longev. 2021; 2: e180Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar But as we enter another year in the UN Decade of Healthy Ageing, 75% of LMICs have little or no data to inform this health and social care planning.8WHOUN Decade of Healthy Ageing (2021–2030).https://www.who.int/initiatives/decade-of-healthy-ageingDate accessed: October 13, 2022Google Scholar In all settings, but especially those that are resource poor, changes to policy and practice must be evidence based to efficiently deliver the expanded health and social care services required. However, there is a mismatch between where knowledge is needed and allocation of funding for ageing research, which almost entirely goes to projects in high-income countries (HICs). For example, the US National Institute of Aging (NIA; part of the National Institutes of Health NIH) has only four actively funded projects in LMICs—0·9% of total NIH active projects in LMICs and equivalent to 0·01% of total NIA funding. In the UK, of the 30 projects funded in the most recent National Institute of Health and Care Research Global Health Research Groups funding call, none were about ageing per se, although a few were on diseases likely to be present in an ageing population. This underinvestment in ageing research in LMICs does not bode well for data-driven practice or policy making in lower-income settings. It is inadvisable to extrapolate knowledge from high-income settings directly to LMICs, where epidemiology, demographics, culture, socioeconomics, gender power relations, and considerations around what healthy ageing and wellbeing mean might be very different.9Sudharsanan N Bloom DE The demography of aging in low- and middle-income countries: chronological versus functional perspectives.in: Majmundar MK Hayward MD Future directions for the demography of aging: proceedings of a workshop. National Academies Press (US), Washington, DC2018Google Scholar Additionally, the small amount of data that are being collected in LMICs might not be fully representative of or pertinent to all ageing populations in those countries. For example, between 2014 and 2019, almost 70% of publications in the Brazilian Journal of Geriatrics and Gerontology were from the south or southeast of the country.10Cesário VAC Silva CRDV Soares JP Mendonça PBS Reis MKS de Lima KC Bibliometric study of the scientific production of Brazilian Journal of Geriatrics and Gerontology between 2014 and 2019.Rev Bras Geriatr Gerontol. 2021; 24e210092Google Scholar The Gateway to Global Aging Data—which hosts epidemiological surveys of older populations—is a valuable resource to capture information on and study diseases associated with ageing, and houses data from nearly all nationally representative ageing studies done worldwide. However, of the 132 World Bank-defined LMICs, only 12 have data in this repository, and only ten have longitudinal data. To counter the reluctance to do further studies, given there is already knowledge from a small number of countries or areas within them, it is also important to recognise that LMICs are not homogenous, and research to inform policy and practice needs to be representative of the ageing populations in these countries. In September, 2022, a group of eight global health researchers from four LMICs and two HICs convened in Dubai to share knowledge on the global gaps in ageing research and define important research questions on ageing in LMICs. We identified several research priorities that must be urgently addressed to improve the health and wellbeing of older people in LMICs, including, but not limited to, those identified in the panel.PanelA selection of research priorities on the health and wellbeing of ageing populations in LMICsThis list is neither ranked nor exhaustive, but rather an example of the myriad of research questions left unanswered in ageing research in LMICs.•Understand priorities for older people and their caretakers in otherwise understudied areas•Expand the diversity and robustness of epidemiological studies of ageing populations outside high-income populations, including, but not limited to, nationally representative studies•Describe how climate change might disproportionally affect ageing populations and design appropriate interventions to mitigate this Develop and implement standardised indicators for frailty and resilience•Document predictors for early disability•Understand compression of morbidity (a reduction in the amount of time spent with a chronic disability until death)•Understand access to quality health services for older people•Describe primary health-care needs of older adults in diverse settings•Explore the effect of gender on the above factors•Understand how the feminisation of the older population (older population having more women than men) affects care needs•Understand social care needs and how these may be met•Design context-appropriate needs-driven interventions to improve the health and wellbeing of vulnerable ageing populationsLMICs=low-income or middle-income countries. This list is neither ranked nor exhaustive, but rather an example of the myriad of research questions left unanswered in ageing research in LMICs. •Understand priorities for older people and their caretakers in otherwise understudied areas•Expand the diversity and robustness of epidemiological studies of ageing populations outside high-income populations, including, but not limited to, nationally representative studies•Describe how climate change might disproportionally affect ageing populations and design appropriate interventions to mitigate this Develop and implement standardised indicators for frailty and resilience•Document predictors for early disability•Understand compression of morbidity (a reduction in the amount of time spent with a chronic disability until death)•Understand access to quality health services for older people•Describe primary health-care needs of older adults in diverse settings•Explore the effect of gender on the above factors•Understand how the feminisation of the older population (older population having more women than men) affects care needs•Understand social care needs and how these may be met•Design context-appropriate needs-driven interventions to improve the health and wellbeing of vulnerable ageing populations LMICs=low-income or middle-income countries. We recognise that needs vary depending on the demographics and development of each country, and that those best placed to determine these needs are the people living in these countries. The need for knowledge is great and urgent, along with a comittment to act on that knowledge. We call for more research to inform the development of policy, and for priotisation of systems and services to address the medical and psychosocial needs of older people in LMICs. In particular, this work will require a substantial investment on the part of research funders. We additionally call for a consortium of researchers, with a deliberate effort to include stakeholders from LMICs, who can bring a multi-disciplinary and intersectional lens to collaborate and set a research agenda, and work with policy makers and funders to ensure that the need for more research on ageing in LMICs is recognised and addressed. We declare no competing interests. We would like to acknowledge the Institute for Global Innovation at the University of Birmingham and the Robert J Havey Institute of Global Health Ryan Family Center for Global Primary Care, Northwestern University for funding the workshop in Dubai.