China and India: Neighboring Countries but Poles Apart in Their Older Populations’ Health

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Written by: Wan He

China and India sit next to each other on the Asian continent, sharing a thousand-mile long border. The Silk Road connected these two countries more than 2,000 years ago, allowing exchanges not only in trade but in religion and culture as well.

However, despite their geographical proximity, the health status of their older populations appear to be poles apart. Results from the Study on Global Ageing and Adult Health (SAGE) consistently placed China and India at opposite ends of the spectrum among the six countries included – China, Ghana, India, Mexico, Russia and South Africa.

Here are some examples: fewer than 4 percent of older Chinese women reported being current tobacco users, while 32 percent of Indian women did. About 74 percent of the oldest Chinese (70 and older) fell in the category of the least disability and best functioning, compared with only 26 percent of the oldest Indians. And a mere 1 percent of the older Chinese reported being diagnosed with depression compared with 14 percent of older Indians.

So, the question becomes: Why are older Chinese more likely to report being healthy and happy but Indians  less so? These findings may very well be true differences in health levels between the two populations, but there could also be many other factors that come into play. Could the results also be a reflection of their cultural differences; that is, differences in how the two populations respond to the same questions? Do the responses and outcomes reflect differences in health care systems and health care policies? These and many other intriguing questions can be further investigated with more in-depth analysis, using cross-sectional and longitudinal data from future waves of SAGE.

If you are interested in learning more about the differences in health and health care between China and India or among other SAGE countries, please see the Census Bureau’s newly released report Shades of Gray: A Cross-Country Study of Health and Well-Being of the Older Populations in SAGE Countries, 2007-2010, commissioned by the National Institute on Aging (NIA) of the National Institutes of Health.

 

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6 Responses to China and India: Neighboring Countries but Poles Apart in Their Older Populations’ Health

  1. Manisha Sengupta says:

    I would like to commend the authors, the Census Bureau, NIA, and WHO for developing this report. This report is the first of its kind and very timely in addressing population aging in a diverse set of countries that are traditionally young but currently undergoing significant aging. It is a very well-written report that provides a complete picture of aging in the study countries, by focusing on a host of important health and health-care issues.
    I have a few questions and thoughts:
    1. Table C2 of the report provides the sample size for each country. According to this table, the unweighted sample for India is 7,150. The WHO website (http://www.who.int/healthinfo/systems/sage/en/index1.html) aso has a table with sample size for SAGE WAVE 1. According to the WHO table, the sample size for India is 12,198. For other countries as well, there are differences in the numbers between these 2 tables. Did these differences arise because the authors had to drop cases because of item non-response, or am I looking at the wrong tables? The difference is largest for India: the Indian sample used in this report is less than 60% of the actual sample. If I’m comparing the right tables and if the Indian sample was reduced by 40%, I wonder whether this sample is still representative of the the Indian population aged 50 and over.

    2. The smoking patterns found in this report are very interesting. The authors find that 64% of the Chinese population never smoked and over 80% of the 70+ population never smoked. Other studies (for example, Liu et al., 1998) have found that smoking is a relatively recent habit among the Chinese. Also, in an earlier Census Bureau report (He et al., 2007), the authors found that the percent of older Chinese who never smoked was 64% for the 80+, 53% for those aged 60-69 and 55.5% for those aged 70 to 79. The current report shows a higher percent of non-smokers. Also, the earlier Census Bureau report found that 10% of women in the sample smoked as compared to 4% in this report. I’m not sure if these are true differences due to successful public health campaigns (?) or just simply data-related.
    The significantly higher percent of women tobacco smokers in India is unfortunate. According to the Global Adult Tobacco Survey, tobacco usage among Indian women has significantly increased in India during the last couple of decades. The latest Atlas of tobacco use published by the World Lung Foundation and American cancer Society found that 2.2% of chinese women and 3.6% of indian women of all ages smoke cigarettes.
    The report also shows that compared to the Chinese, Indian elders were less likey to be consumers of alcohol (not highlighted while assessing differences in health habits between the two countries).

    3. ‘Happiness’ is too broad and too complicated an idea to be successfully measured by 1 or a short list of questions. Having said that, I support the questions raised by the authors and would encourage researchers to use the rich data to address them so that we know whether there are real differences in health and life satisfaction between these countries, and whether these differences (if any) are related to health and health-care related policies. Apart from the questions raised by the authors, perhaps we should also address another factor that could lead to differences, particularly in terms of “happiness.” People’s assessment of whether they are happy is in large part related to their expectations from life. The authors have rightly drawn the similarities between the two countries of India and China. They share a common geography and history (in terms of being among the oldest civilizations in the world). However, perhaps more important than these similarities is the difference that India and China have in terms of more recent political structure and ideology. India is the largest democracy in the world and has sustained democratically elected governments since the British left the country in 1947. A large part of the Indian sample in this report (those between 50 and 65 years) was born in post independence India. Indian elders in general and those in the 50 to 65 age group (post-independence) have enjoyed life in a free country. As citizens of a free country, expectations of happiness for Indian elders may be very different from the Chinese cohort, most of whom have lived through the cultural revolution and experienced oppression. In other words, for the Chinese elders, even a small positive change (in comparison to the oppression they experienced in earlier years) may bring with it a lot of “happiness.” If that is the case, I’m not sure if this measure of “happiness” is a real reflection on met and unmet needs of older people in these countries.

    Again, thanks for this report. I look forward to reading it in its entirety.

  2. Wan He says:

    Excellent questions and comments! Thanks for the feedback.

    1. The sample size one downloads from the WHO SAGE site is for the entire survey, while our report focuses on the 50+ population. However, Table C-2 includes the sample sizes for both the 50+ and 18-49. Take India for example. The sample size for 50+ is 7,150, and 18-49 is 5,048. That adds up to 12,198. The same applies to the other five countries as well.

    2. The very low proportion of older Chinese, especially women, reporting (current or past) smoking does raise questions, along with some other intriguing results about the Chinese that we discussed in this blog and in the report. Please note that the findings included in this report were based on self reporting, not administrative records or in-field medical examinations. We stated in “Introduction” and “Summary and Discussion” and throughout the text that the analysis in this report is based on self-reported responses. Whether these responses reflect true health levels should be further explored in the future.

    In an effort to adjust for systematic reporting biases and improve comparability, WHO created various composite variables to measure health and were used in this report, and SAGE also adopted the vignettes method (see Appendix C). How to improve the comparability among surveys and across cultures is certainly one of the major tasks for health data collection.

    3. The report included some discussions on how one’s assessment of happiness or quality of life may not be solely determined by, or dependent on, single item measures, and may not be directly linked to health conditions (p.22). The tendency of the Chinese not to reveal negative feelings to people outside their family (p.30, footnote 1) and the cohort effects of the older Chinese who have been through the great famine, the Cultural Revolution, and other historical periods are discussed in footnote 2 on page 30.

    Thanks again for your feedback, especially your input on Indians. This is the dialogue we would like to start on why the differences between the Chinese and Indians.

  3. Paul Kowal says:

    Dear Manisha,
    I appreciate your considered thoughts and comparisons to other available data. I can provide additional information to the response by the lead author of the report.

    1) The SAGE Wave 1 sample in India was supplemented by a nested study of (younger) adult women, arranged by the SAGE India team with additional external funding. This provided an cost-efficient manner to collect additional health data, and demonstrates the flexibility of the SAGE data collection platform. This nested study and sample accounts for the difference in numbers in the report as compared to the full sample in India, and the dissimilarity compared to the other five countries. The samples in each country are nationally representative of the older adult population (those aged 50-plus).

    2. The strategy used to identify smoking is based on WHO STEPS approach to NCD risk factor surveillance. The results of this work provide the estimates for the World Health Statistics 2012 and the WHO Report on the Global Tobacco Epidemic 2009, with rather broad age grouping (adults >=15 years old), and show 2009 current smoking rates of 51% for men and 2% for women in China, and 26% and 4%, respectively, in India. Results from the CHARLS pilot study (www.rand.org/content/dam/rand/pubs/working_papers/2010/RAND_WR774.pdf) show similar smoking rates as found in SAGE for older adults in China.

    3. The call for governments to focus on the well-being of its population as a means of measuring progress has meant that the science of well-being is now being mainstreamed in health and social policy. However, the science is still nascent and several controversies abound with regard to conceptualization, measurement and translation of findings into interventions at the individual and population level.

    SAGE approach to measuring happiness included both experienced well-being (through the Day Reconstruction Method developed by Daniel Kahneman, Nobel laureate economist) and the evaluative well-being (through the WHO Quality of Life (WHOQOL) instrument). Results from validation studies of the DRM in different countries will be published soon, while the WHOQOL has been well tested and validated across many different countries. The single question results shown in this report, are largely equivalent to the few questions included in the Gallup study and World Values Survey. SAGE complements, and possibly furthers, the understanding of happiness in older adults.

    However, the way happiness (or subjective well-being) is conceptualized and measured may influence our understanding of the relationships between health and happiness over time. And certainly, the relationship between SWB and aging is not quite clear. As you suggest, we hope researchers will use SAGE data to help clear up the relationship between health, happiness and ageing – in China, India, the US, and other countries.

  4. Bala Kammela says:

    While the attitudes differ from countries, many variables are also missing.
    Taking Geography alone, only Urban/Rural were considered. There are others like Altitude/Water Quality/Climate etc. in Geography alone which could have made this more granular. It would have been better Statistic if lot of small granules (each with lot of variables) were used for comparision.
    eg(too futuristic): If every Nation compared here allowed the “UN Researcher” to pass a small granule of information to scan their entire Country Census knowledge base, he can provide a better picture of the problem.

    Regarding different attitudes of respondents, that is upto the Policy makers of those Nations to make them more open. Hoping Census is free from any political influence in all these nations, lot of visibility can be gained about the problems of the world.

  5. Bala Kammela says:

    Both my post and Paul Kowal’s post were revealed simultaneously in this blog by the moderator. The context of my earlier post was about 6 countries involved in this study.

  6. Raul says:

    Nice post,
    Its good to know your views on Older Populations’ Health between Neighboring Countries China and India.
    thanks a lot for sharing this with us.

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