Counting older women: Measuring the health and wellbeing of older women in LMICs
Authors: Rosemary Morgan, Anna Kalbarczyk, Diwakar Mohan, Choolwe Jacobs, Manasee Mishra, Prakash Tyagi, Cindy Cox-Roman, Camilla Williamson
Journal: Cell Reports Medicine (2024)

Health systems globally are unprepared for responding to the needs of aging populations—the majority of whom are women. This is exacerbated by data systems that exclude older women. There is an urgent need to address this gap to ensure policies and services promote healthy aging across the life course. Health systems globally are unprepared for responding to the needs of aging populations—the majority of whom are women. This is exacerbated by data systems that exclude older women. There is an urgent need to address this gap to ensure policies and services promote healthy aging across the life course. Women aged 50 and over account for 27% of the world's female population.1World Population Prospects - Population Division - United Nations. Accessed May 9, 2024. https://population.un.org/wpp/Google Scholar This estimate is set to rise in the coming years due to rapid population aging and increased feminization of older adults. Although men outnumber women until the age of 50, women outnumber men at older ages due to their longer life expectancies.1World Population Prospects - Population Division - United Nations. Accessed May 9, 2024. https://population.un.org/wpp/Google Scholar By 2030, 54% of the world's 2.3 billion people aged 50 and over will be female, rising to 60% of people aged 80 and over.1World Population Prospects - Population Division - United Nations. Accessed May 9, 2024. https://population.un.org/wpp/Google Scholar Statistics from low- and middle-income countries (LMICs) support these predicted changes.2Amuthavalli Thiyagarajan J. Mikton C. Harwood R.H. Gichu M. Gaigbe-Togbe V. Jhamba T. Pokorna D. Stoevska V. Hada R. Steffan G.S. et al.The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people.Age Ageing. 2022; 51afac147https://doi.org/10.1093/ageing/afac147Crossref Scopus (47) Google Scholar While the increase in numbers and proportions of older people is evident worldwide, the demographic change has more significant consequences in regions with more resource-strained health systems. Health systems in LMICs may be grappling with the dual burden of communicable and non-communicable diseases, increasing privatization and even conflict, making access to healthcare challenging.2Amuthavalli Thiyagarajan J. Mikton C. Harwood R.H. Gichu M. Gaigbe-Togbe V. Jhamba T. Pokorna D. Stoevska V. Hada R. Steffan G.S. et al.The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people.Age Ageing. 2022; 51afac147https://doi.org/10.1093/ageing/afac147Crossref Scopus (47) Google Scholar Due in part to their longer lives and as a result of gender-based discrimination throughout the life course, cisgender women spend a greater proportion of their life in ill health or with comorbidities and disability3Barman D. Mishra M. How does eye care seeking behaviour change with increasing age and visual impairment? Intersectional analysis of older adults in the Indian Sundarbans.BMC Geriatr. 2020; 20: 71https://doi.org/10.1186/s12877-020-1438-yCrossref Scopus (12) Google Scholar and typically need more frequent access to health systems in old age than cisgender men. They have unique health issues including those related to menopause and post-menopause, higher rates of heart disease, risk of stroke and osteoporosis, and long-term impacts of childbirth.4UNFPA ESARORapid Review of Healthy Ageing and Long-term Care Systems in East and Southern Africa.2022https://esaro.unfpa.org/en/publications/rapid-review-healthy-ageing-and-long-term-care-systems-east-and-southern-africaGoogle Scholar For example, women who have had multiple pregnancies and childbirth in earlier life can experience pelvic floor disorders and incontinence, which have a significant impact on quality of life and may lead to social isolation and mental health issues that are overlooked by health professionals.4UNFPA ESARORapid Review of Healthy Ageing and Long-term Care Systems in East and Southern Africa.2022https://esaro.unfpa.org/en/publications/rapid-review-healthy-ageing-and-long-term-care-systems-east-and-southern-africaGoogle Scholar Older women also have unique sexual health needs that are often ignored by service providers, contributing to the growing incidence and unattended burden of sexually transmitted infections (STIs), including HIV/AIDS, among this age group.4UNFPA ESARORapid Review of Healthy Ageing and Long-term Care Systems in East and Southern Africa.2022https://esaro.unfpa.org/en/publications/rapid-review-healthy-ageing-and-long-term-care-systems-east-and-southern-africaGoogle Scholar As a result of inequalities in power relations, unequal distribution of care responsibilities, and discrimination and exclusion on the grounds of gender across the life course, women are also more likely to face multi-dimensional poverty in older age.4UNFPA ESARORapid Review of Healthy Ageing and Long-term Care Systems in East and Southern Africa.2022https://esaro.unfpa.org/en/publications/rapid-review-healthy-ageing-and-long-term-care-systems-east-and-southern-africaGoogle Scholar,5United Nations & UN WomenOlder women: Inequality at the intersection of age and gender.2022https://data.unwomen.org/publications/older-women-inequality-intersection-age-and-genderGoogle Scholar In many LMICs, gender-based discrimination starts early in life, leading to malnutrition, anemia, lower immunity, musculo-skeletal diseases, and pelvic floor disorders. Indoor air pollution is another major risk faced by women and girls, leading to higher prevalence of chronic obstructive pulmonary disease (COPD) in old age. All of this has a profound effect on the health and wellbeing of women and on their access to health and care services.4UNFPA ESARORapid Review of Healthy Ageing and Long-term Care Systems in East and Southern Africa.2022https://esaro.unfpa.org/en/publications/rapid-review-healthy-ageing-and-long-term-care-systems-east-and-southern-africaGoogle Scholar,5United Nations & UN WomenOlder women: Inequality at the intersection of age and gender.2022https://data.unwomen.org/publications/older-women-inequality-intersection-age-and-genderGoogle Scholar Documented gender barriers to women's access to health services, such as antenatal care (ANC) and family planning services, include women's reduced decision-making autonomy, restrictions on their physical mobility, and time poverty related to caregiving expectations.6Gahungu J. Vahdaninia M. Regmi P.R. The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: a systematic review of the literature.Reprod. Health. 2021; 18: 35https://doi.org/10.1186/s12978-021-01089-9Crossref PubMed Scopus (30) Google Scholar Older women often experience barriers related to gendered ageism—experience of both gender and age based discrimination.7HelpAge InternationalOlder women's lived experiences of gendered ageism.2023https://www.helpage.org/what-we-do/gender-equality/older-womens-lived-experiences-of-gendered-ageism/Google Scholar Available data suggests that older women are also more likely to experience unmet health needs and long-term care and support gaps than men, particularly when they face multiple and intersecting inequalities, including higher rates of poverty, lower education levels, higher rates of disability, and greater likelihood of living alone.8Rahman M.M. Rosenberg M. Flores G. Parsell N. Akter S. Alam M.A. Rahman M.M. Edejer T. A systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people.Health Econ. Rev. 2022; 12: 60https://doi.org/10.1186/s13561-022-00398-4Crossref Scopus (14) Google Scholar,9Kowal P. Corso B. Anindya K. Andrade F.C.D. Giang T.L. Guitierrez M.T.C. Pothisiri W. Quashie N.T. Reina H.A.R. Rosenberg M. et al.Prevalence of unmet health care need in older adults in 83 countries: measuring progressing towards universal health coverage in the context of global population ageing.Popul. Health Metr. 2023; 21: 15https://doi.org/10.1186/s12963-023-00308-8Crossref Scopus (0) Google Scholar Attention to women's health and wellbeing has overwhelmingly focused on their reproductive years (15–49), and this is reflected in the measures we use globally, particularly in data collection. Historically, gender norms have relegated women to the homes where they are viewed in their relationship to others—largely as daughters, wives, mothers, and grandmothers. Health issues outside of this space, such as non-communicable diseases (NCDs) including cancer, diabetes and cardiovascular conditions, and issues specific to women, including menopause and post-menopause, are often ignored or minimized. That said, the attention given to maternal health is not unwarranted particularly given the historic risk associated with pregnancy and childbirth, reducing women's expected total years of life. Despite great progress made around the world, maternal health continues to be an important public health concern, and according to the World Health Organization, almost 800 women die every day from preventable causes related to pregnancy and childbirth.10World Health OrganizationMaternal mortality.2024https://www.who.int/news-room/fact-sheets/detail/maternal-mortalityGoogle Scholar However, women's overall wellbeing is more than their reproductive health status alone, and the data we capture should reflect that. Older women (and men) have been historically excluded from data systems or rendered invisible by a lack of age and sex disaggregation.11HelpAge InternationalHow data systems leave older people behind.2017https://www.helpage.org/silo/files/how-data-systems-leave-older-people-behind.pdfGoogle Scholar,12Data 2XMapping Gender Data Gaps: An SDG Era Update.2020https://data2x.org/resource-center/mappinggenderdatagaps/Google Scholar The Demographic and Health Survey (DHS) is regularly administered in over 90 LMICs, covering the domains of population, health, and nutrition. However, the DHS sample excludes women over the age of 50 and men aged 60 and over. While the DHS incorporates a questionnaire on some demographic information on older people in the context of the household, this tool is limited. Similarly, the WHO STEPwise approach to surveillance (STEPS), a survey mechanism for collecting national level data on risk factors for NCDs, recommends that the target population be at minimum all adults aged 18 to 69 years. However, analysis from 2017 of around 40 countries in Africa that had conducted a STEPS survey found that only six have included people over age 64 in their most recent survey. In addition, surveys among older people and major longitudinal studies on aging, such as the WHO Study on Global Aging and Health (WHO SAGE) in LMICs and studies from the Health and Retirement Survey family, often exclude older women's specific health needs. More broadly, WHO points out that while nearly 60% of older people today live in LMICs, fewer than 10% of these countries have a national survey that routinely collects information about older people's health.2Amuthavalli Thiyagarajan J. Mikton C. Harwood R.H. Gichu M. Gaigbe-Togbe V. Jhamba T. Pokorna D. Stoevska V. Hada R. Steffan G.S. et al.The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people.Age Ageing. 2022; 51afac147https://doi.org/10.1093/ageing/afac147Crossref Scopus (47) Google Scholar We have also seen an increase in the use of digital applications for health and wellness, but older adults (particularly women) often lack the access, skills, and abilities necessary to participate.13UNECEDigital gender divide persists among older persons in the UNECE region.2023https://unece.org/media/news/376424Google Scholar This digital divide may be exacerbated in low-resource settings. The WHO and the Titchfield City Group on Ageing-related statistics14United NationsTitchfield Group on Ageing-related Statistics and Age-disaggregated Data.2024https://unstats.un.org/unsd/methodology/citygroups/Titchfield.cshtmlGoogle Scholar recently released a report titled "Making older persons visible in the SDG framework,"15World Health OrganizationMaking older persons visible in the sustainable development goals' monitoring framework and indicators.2024https://www.who.int/publications/i/item/9789240090248Google Scholar which provides some information on approaches at national level to improving data on aging and older people—such as collecting mortality data of older persons through death certificates or through an annual survey on deaths, and collecting information on household expenditure on health through a household budget survey. As part of the Decade of Healthy Aging, WHO and other UN and international agencies established a Technical Advisory Group for Measurement of Healthy Aging (TAG4MHA) to provide advice on the measurement, monitoring and evaluation of programs related to the action areas.2Amuthavalli Thiyagarajan J. Mikton C. Harwood R.H. Gichu M. Gaigbe-Togbe V. Jhamba T. Pokorna D. Stoevska V. Hada R. Steffan G.S. et al.The UN Decade of healthy ageing: strengthening measurement for monitoring health and wellbeing of older people.Age Ageing. 2022; 51afac147https://doi.org/10.1093/ageing/afac147Crossref Scopus (47) Google Scholar To address survey issues, with the advice of the TAG4MHA, WHO plans to develop valid and reliable survey instruments for measuring health and wellbeing related to aging. The intention is for this tool to be used and validated in a multi-country pilot study in the coming years. Whether or not this tool includes a focused look at older women's health, including their sexual and reproductive and other health needs, remains to be seen. While progress has been made on making older persons visible, much of this progress continues to aggregate data of older persons, making invisible the unique health needs and outcomes of older women and men. On this International Day of Action for Women's Health, we call for greater attention to older women's health and well-being. Sex-, age-, and (where possible) disability-disaggregated data are needed to capture the specific health needs and outcomes of older women (and men). Research studies that use an age cap should remove these, and tools that currently capture data for older people should disaggregate data by age and sex, as well as disability and other important characteristics, to ensure that older women's unique needs and considerations are clearly enumerated in analyses. When data on older people are collected and disaggregated by sex and age, that data can provide context specific and nuanced understanding of the experiences of older individuals, which can help inform the development and implementation of interventions and policies that promote health and well-being across the life course.15World Health OrganizationMaking older persons visible in the sustainable development goals' monitoring framework and indicators.2024https://www.who.int/publications/i/item/9789240090248Google Scholar Survey instruments can also be used to capture data relevant to older women's health. Surveys can generate robust estimates of prevalence for key indicators of health in this age group, including women's specific health needs related to perimenopause, menopause, post-menopause, experience of violence, and health-related decision-making and autonomy. Since older women's health issues are so closely connected with transitions at different stages of life, integration of data relevant to older women's health may also be of great use to understand health needs and to plan healthy aging interventions with a life course approach. The intentional inclusion of older women in study design and data collection can also help to ensure older women are visible in the data collection process and that their unique health experiences and needs are being included. We must also ensure digital inclusion, in terms of access to hardware and services, for older women. This demographic group has been the most lagging in terms of digital inclusion and has not benefited optimally from the ongoing digital revolution in health. Tools can measure and quantify older women's access to services provided through digital health, such as use of telemedicine services. Efforts should also be made to facilitate greater access, skills, and abilities necessary to participate in digital health surveys or other data collection methods. Population aging is resulting in a growing number and proportion of older women globally, the majority of whom are living in LMICs where the demographic transition is happening fastest. Yet systems and services are unprepared for meeting the needs and upholding the rights of these women. This situation is reinforced by data systems that exclude older women or render them invisible by a lack of sex- and age-disaggregated data. Data systems urgently need to adapt to population aging to ensure we are capturing the diverse needs, experiences, and preferences of women beyond the reproductive age. These women not only have a right to be counted, but such data are critical to ensure funding, policies, services, and programs respond to their unique health and care needs. This will bring benefits for older women, systems, and societies alike and ensure no one is left behind in progress toward Sustainable Development Goal 3, ensuring healthy lives and well-being for all at all ages.