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Introduction: The 1.2 °C rise of global ambient temperature since the pre-industrial era has led to an increase the intensity and frequency of heatwaves. Given the heightened vulnerability of pregnant women to heat stress, there is an urgent need for tools which accurately assess the knowledge, risk, and perception of pregnant woman toward heatwaves, enabling effective policy actions. In this research, we developed and validated tools to evaluate pregnant women’s perceptions of heat wave risks and behaviors.

Method: We developed 50 items across seven constructs using the Health Belief Model, identified through a systematic literature review. The constructs comprised 8 Knowledge(K) items, 4 in Perceived Vulnerability (PV), 5 in Perceived Severity (PS), 6 in Perceived Benefit (PB), 4 in Perceived Barrier (PBa), 5 in Cue to Action(Cu) and 18 in Adaptation(A). Cognitive testing was performed with a separate group of pregnant women(n = 20). The tested tools were then administered to 120 pregnant women residing during the spring-summer 2023. Construct validation utilized exploratory factor analysis.

Results: The Principal Axis Factoring Method was employed in the EFA with oblimin rotation for 51 items, considering communality > 0.20, and aiming to extract three factors. Across the three factors with Cronbach’s alpha > 0.70, a total of 11 items were distributed. Factor 1 included Perceived Severity (PS1, PS2, PS3 and PS5); Factor 2 included Cue to Action (Cu1, Cu2, Cu3, and Cu4); and Factor 3 encompassed Perceived Vulnerability (PV1, PV2, PV4). Only two of the retained items had factor loadings > 0.50, namely PV4 and PS5. Consequently, the three constructs measuring Perceived Severity, Cues to Action, and Perceived Vulnerability using the HBM among pregnant women were deemed valid.

Conclusion: Our study has successfully validated a highly reliable tool which stands ready for application in assessing pregnant women’s risk perception regarding heatwaves.

BACKGROUND: Unmet need for family planning (FP) is a global public health concern, particularly in low- and middle-income countries. In Ethiopia, although several studies have assessed unmet needs for FP, there have only been few empirical investigations into regional inequalities and their contributory factors. This study assessed urban-rural inequalities in unmet FP needs among reproductive-aged women in Ethiopia and particularly examined the contribution of material, cultural-behavioral, and psychosocial factors therein.

METHODS: A cross sectional study was conducted among 8811 reproductive-aged women derived from the nationally representative 2019 Ethiopian Performance Monitoring for Action (PMA) data. The outcome variable was unmet need for FP. The exposure variable was place of residence (urban or rural). Contributing factors were categorized into material, psychosocial and cultural-behavioral factors. Blinder-Oaxaca decomposition analysis was used to assess urban-rural inequalities in unmet need for FP as well as to disentangle the contributory factors in percentage points.

RESULT: In our study, 13.8% of reproductive-aged women in Ethiopia reported unmet FP needs. Urban-rural inequalities therein accounted for 6.8% points. Disparities in FP needs between urban and rural areas were mostly explained by psychosocial factors (81.0%) followed by material (21.0%), and cultural-behavioral (3.2%) factors. While women who were living with a partner (39.1%, p < 0.01) and multiparas (51%, p < 0.01) contributed to increasing inequalities, attending family planning counseling services with a healthcare provider (-1.7%, p = 0.03) reduced the gap in unmet need for FP between urban and rural areas. Women from the poorest and poor category contributed 14.1% (p = 0.02) and 11.1% (p = 0.04), respectively. Being from a Muslim religion also contributed to the disparity by 7.3% (p < 0.01).

CONCLUSION: This study showed that among reproductive-aged women in Ethiopia, inequalities in unmet FP needs show distinct urban-rural patterning. Most inequalities could be attributed to psychosocial factors, mainly parity and marital status, followed by material and cultural-behavioral factors. Policymakers should target these modifiable psychosocial factors to reduce urban-rural inequalities in unmet need for FP in Ethiopia.

Objectives: Targeted social distancing measures were widely implemented for nursing home residents when the extremely high coronavirus disease 2019 mortality in this setting became apparent. However, there is still scarce rigorous research examining how the pandemic and accompanying social distancing measures affected loneliness in this group. This prospective nationwide Swedish study of nursing home residents aimed to examine the impact on loneliness of the early phase of the pandemic and of a national visiting ban at nursing homes.

Methods: A panel was selected from a total population survey of all nursing home residents in Sweden March–May 2019 and 2020 (N = 11,782; age range 70–110 years; mean age 88.2 years; 71% women). Prospective pretest–posttest and controlled interrupted time series (ITS) designs were employed, with time trends estimated by date of returned questionnaire. Generalized linear models were used for estimation of effects, adjusting for demographic-, survey-, and health-related covariates.

Results: Loneliness prevalence increased from 17% to 19% from 2019 to 2020 (risk ratio, RR (95% confidence interval, CI) = 1.104 (1.060; 1.150)), but which was explained by self-reported health (RR (95% CI) = 1.023 (0.982; 1.066)). No additional impact of the visiting ban on loneliness trends was found in the ITS analyses (RR (95% CI) = 0.984 (0.961; 1.008)).

Discussion: The moderate but health-dependent increased risk of loneliness, and the lack of impact of the nationwide visiting ban at nursing homes, suggests that this ostensibly vulnerable group of nursing home residents also shows signs of resilience, at least during the early phase of the pandemic.

Background: This thesis takes as a predicate that humans are social animals and as such, that their social networks and health are intrinsically connected. A guiding heuristic of this thesis was the Berkman model which conceptualizes how social networks impact health. Considering social networks as a ‘mesosocial’ level between individuals’ health and larger social structures permits assessments of four processes, or pathways: macro↔meso↔micro. The overall aim of this thesis was to contribute to a better understanding of the role of social networks for the health of aging populations in the Southeast Asian context of Indonesia. This work was divided into four sub-studies (I-IV) aiming to i) review existing evidence on social networks and adult health; ii) assess the health effects of social networks; iii) examine how macro-level conditions affect health behavioral pathways through social networks; and iv) understand the macro-level determinants of social network formations.

Methods: This thesis employed a mixed methods design integrating evidence syntheses (I) with quantitative (II, III) and qualitative (IV) approaches. The four sub-studies included different conceptual angles on structural, functional and quality aspects of social networks, i.e., network diversity (II), dynamics (III), deficits and loneliness (IV). Following the PRISMA guidelines, a systematic literature review covering the years 2000 to 2015 was conducted. For the two quantitative studies, data on older adults aged 50+ years from the fourth (2007/08) and fifth (2014/15) waves of the Indonesian Family Life Surveys, were analyzed. First, employing an outcome-wide epidemiological approach, evidence for causal effects of social network diversity on 19 outcomes along the disablement process spectrum were evaluated using multivariable regression adjustments, propensity score matching, and instrumental variable analyses. Second, following a systems-approach to conceptualize social networks on four ecological levels, causal mediation analyses were performed to cross-sectionally examine the mediating role of social networks and their dynamics between a latent socioeconomic position indicator and two healthcare utilization outcomes. Also, the socioeconomic patterning of healthcare utilization and network dynamics were analyzed longitudinally, i.e., before and after Indonesia’s Universal Health Coverage implementation. The qualitative study draws on eight focus group discussions with 48 ‘older adult children’. Data were collected in four rural villages in the Gunung Kidul regency during 2016. The theoretical framework was inspired by symbolic interactionism and sensitizing concepts of systemic networks and network deficits, interpersonal emotions, and the social construction of risks. Data were analyzed using Grounded Theory. The final mixed-methods synthesis (I-IV) was based on notions of systems-thinking, ecological transitions theory, and a framework for studying social processes in aging.

Results: The results showed (i) that despite an increased focus on social determinants of health, in Indonesia, social networks remained an under- and unresearched social determinant of non-communicable diseases and inequalities therein, respectively; (ii) that social network diversity conferred a vast array of strong and long-term – yet heterogeneous and gender-specific – effects across the entire disablement process, i.e. affecting pulmonary health outcomes, proinflammatory processes, physical and cognitive functioning, and disability states; (iii) that both social networks on various ecological levels and their dynamics were socio-economically patterned and mediated the association between socioeconomic position and healthcare utilization outcomes while showing stronger mediating effects after Universal Health Coverage implementation; (iv) that ‘older adult children’ experienced their own aging as a process of ‘bargaining for a sense of security’ which reified how and why loneliness emerged amidst the challenges of social, demographic and epidemiological transitions and how in response to this, unconventional compromises, which affected both their networks of caretakers and the places of old-age care, were being made.

Conclusion: The results explicated several previously less understood pathways and particularly spoke to the so-called ‘downstream experiences’, ‘upstream questions’, and offered a holistic perspective. Notions of ‘transitions’ within different levels collectively conveyed an understanding that such transitions created risks, and that networks played a crucial interstitial role in both cushioning or exacerbating effects of and on these risks. The final mixed-methods synthesis allowed a comprehensive view on various dimensions of social networks and enabled a multi-contextual and multi-dimensional integration of findings. Collective insights were distilled into two main discussion points which were divided based on their ‘upstream’ and ‘downstream‘ foci. The first explicated the macro-social phenomena that appeared in this thesis i.e., epidemiological transitions, population aging, social change, and discussed – with a focus on network diversity, dynamics and deficits – the meso-social effects on and of such macro-level transitions. The later elucidated both the ‘social network-health’ nexus by explicating the ‘Janus face’ of social networks, as well as the transitions in the interplay of formal and informal social networks and their implications for old-age care. After presenting methodological considerations, the thesis concludes with selected implications for research, policy, and practice which emphasize on strengthening social network research in low and middle-income countries, addressing the precarious conditions of older adult women in rural economies, and promoting the role of the healthcare system.

Introduction: As a consequence of rising life expectancies, many families are no longer made up of one, but two simultaneously aging generations. This elderly parent–older adult child (OAC) dyad has emerged as a newly overserved yet little explored demographic phenomenon. Studies on this intergenerational aging dyad and the possible ramifications of when caregivers are simultaneously aging with care-receivers are scarce, especially in low and middle-income countries. This study explored the process by which rural Indonesian OACs experience their own aging, thereby gaining insights into how this newly evolving reality impacts the traditional ways of old-age care provision.

Methods: This study has a qualitative design and draws on eight focus group discussions with 48 community-dwelling OACs (23 men, 25 women; mean age 64 years) in four rural villages in the Yogyakarta Special Region, Indonesia. The theoretical framework was largely inspired by symbolic interactionism aided by the sensitizing concepts of social network deficits, interpersonal emotions, and the social construction of risks. Data were analyzed using Grounded Theory as outlined by Corbin and Strauss.

Results: Respondents’ accounts reflected four categories: 1) aging in a welt of chronic insecurity; 2) OACs: a generation “betwixt and between” expected demands and unmet expectations; 3) landscapes of loneliness; and 4) compromising against conventions. As depicted in a conceptual model, these categories interrelated with each other and were linked by a core category, “bargaining for a sense of security”, which collectively summarized a process by which OACs’ experienced their own course of aging.

Conclusion: Our study provided insights into how and why loneliness emerged amidst the challenges of social and demographic transformations and how in response to this unconventional compromises were made, which affect both the networks of caretakers and the places of old-age care. It is doing so by including the perspectives of rural Indonesian OACs. The results showed how multiple intersecting negative experiences constrained the aging experiences of OACs and produced precarious aging trajectories. Our findings highlight the importance of old-age loneliness as an emerging public health and social problem by discussing how intrinsically this emotion was interwoven with social life.

Background: Social networks (SN) have been proven to be instrumental for healthy aging and function as important safety nets, particular for older adults in low and middle-income countries (LMICs). Despite the importance of interpreting health outcomes in terms of SN, in many LMICs – including Indonesia – epidemiological studies and policy responses on the health effects of SN for aging populations are still uncommon. Using outcome-wide multi-method approaches to longitudinal panel data, this study aims to outline more clearly the role of SN diversity in the aging process in Indonesia. We explore whether and to what degree there is an association of SN diversity with adult health outcomes and investigate potential gender differences, heterogeneous treatment effects, and effect gradients along disablement processes.

Methods: Data came from the fourth and fifth waves of the Indonesian Family Life Survey fielded in 2007–08 and 2014–15. The analytic sample consisted of 3060 adults aged 50+ years. The primary exposure variable was the diversity of respondents’ SN at baseline. This was measured through a social network index (SNI), conjoining information about household size together with a range of social ties with whom respondents had active contact across six different types of role relationships. Guided by the disablement process model, a battery of 19 outcomes (8 pathologies, 5 impairments, 4 functional limitations, 2 disabilities) were included into analyses. Evidence for causal effects of SN diversity on health was evaluated using outcome-wide multivariable regression adjustment (RA), propensity score matching (PSM), and instrumental variable (IV) analyses.

Results: At baseline, 60% of respondents had a low SNI. Results from the RA and PSM models showed greatest concordance and that among women a diverse SN was positively associated with pulmonary outcomes and upper and lower body functions. Both men and women with a high SNI reported less limitations in performing activities of daily living (ADL) and instrumental ADL (IADL) tasks. A high SNI was negatively associated with C-reactive protein levels in women. The IV analyses yielded positive associations with cognitive functions for both men and women.

Conclusions: Diverse SN confer a wide range of strong and heterogeneous long-term health effects, particularly for older women. In settings with limited formal welfare protection, intervening in the SN of older adults and safeguarding their access to diverse networks can be an investment in population health, with manifold implications for health and public policy.

Objective: The objective is to identify and describe thesociodemographic and behavioral characteristics of adults,aged 50 years and over, who self-reported having beendiagnosed and treated for diabetes mellitus (DM) in Ghanaand South Africa.

Research design and methods: This is a cross-sectionalstudy based on the WHO Study on global AGEing and adulthealth (SAGE) wave 1. Information on sociodemographicfactors, health states, risk factors and chronic conditionsis captured from questionnaires administered in face-tofaceinterviews. Self-reported diagnosed and treated DM isconfirmed through a ‘yes’ response to questions regarding1having previously been diagnosed with DM, and2 havingtaken insulin or other blood sugar lowering medicines.Crude and adjusted logistic regressions test associationsbetween candidate variables and DM status. Analysesinclude survey sampling weights. The variance inflationfactor statistic tested for multicollinearity.

Results: In this nationally representative sample ofadults aged 50 years and over in Ghana, after adjustingfor the effects of sex, residence, work status, bodymass index, waist-hip and waist-height ratios, smoking,alcohol, fruit and vegetable intake and householdwealth, WHO-SAGE survey respondents who were older,married, had higher education, very high-risk waistcircumference measurements and did not undertakehigh physical activity, were significantly more likelyto report diagnosed and treated DM. In South Africa,respondents who were older, lived in urban areas andhad high-risk waist circumference measurements weresignificantly more likely to report diagnosed andtreated DM.

Conclusions: Countries in sub-Saharan Africa arechallenged by unprecedented ageing populations andtransition from communicable to non-communicablediseases such as DM. Information on those who arealready diagnosed and treated needs to be combinedwith estimates of those who are prediabetic or, as yet,undiagnosed. Multisectoral approaches that includesocioculturally appropriate strategies are needed toaddress diverse populations in SSA countries.

BACKGROUND: Chronic noncommunicable diseases (NCDs) have emerged as a huge global health problem in low- and middle-income countries. The magnitude of the rise of NCDs is particularly visible in Southeast Asia where limited resources have been used to address this rising epidemic, as in the case of Indonesia. Robust evidence to measure growing NCD-related burdens at national and local levels and to aid national discussion on social determinants of health and intra-country inequalities is needed. The aim of this review is (i) to illustrate the burden of risk factors, morbidity, disability, and mortality related to NCDs; (ii) to identify existing policy and community interventions, including disease prevention and management strategies; and (iii) to investigate how and why an inequitable distribution of this burden can be explained in terms of the social determinants of health.

METHODS: Our review followed the PRISMA guidelines for identifying, screening, and checking the eligibility and quality of relevant literature. We systematically searched electronic databases and gray literature for English- and Indonesian-language studies published between Jan 1, 2000 and October 1, 2015. We synthesized included studies in the form of a narrative synthesis and where possible meta-analyzed their data.

RESULTS: On the basis of deductive qualitative content analysis, 130 included citations were grouped into seven topic areas: risk factors; morbidity; disability; mortality; disease management; interventions and prevention; and social determinants of health. A quantitative synthesis meta-analyzed a subset of studies related to the risk factors smoking, obesity, and hypertension.

CONCLUSIONS: Our findings echo the urgent need to expand routine risk factor surveillance and outcome monitoring and to integrate these into one national health information system. There is a stringent necessity to reorient and enhance health system responses to offer effective, realistic, and affordable ways to prevent and control NCDs through cost-effective interventions and a more structured approach to the delivery of high-quality primary care and equitable prevention and treatment strategies. Research on social determinants of health and policy-relevant research need to be expanded and strengthened to the extent that a reduction of the total NCD burden and inequalities therein should be treated as related and mutually reinforcing priorities.

Background: Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability.

Methods: We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity.

Results: We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses.

Conclusions: The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.