Health and wellbeing in Ethiopian older adults: Evaluating the WHO Healthy Ageing Framework with local and global implications.

The WHO Healthy Ageing Framework defines healthy ageing as maintaining wellbeing and functional capacity despite age-related declines. This thesis explored healthy ageing in Ethiopia and other Low and Lower-Middle Income Countries (LLMIC). The research addressed critical knowledge gaps as existing literature has focused primarily on Western and developed nations. The study was particularly focused on Ethiopia, Africa's second most populous nation, given its projected significant population ageing over the next three decades. Moving beyond deficit-based models of health, this research adopted the WHO's Healthy Ageing Framework and emphasised a holistic approach to ageing by prioritizing wellbeing and functionality over the absence of disease. Two main objectives were pursued. First, the thesis identified healthy ageing prevalence, its contributing factors, and their impact on health service utilization. Second, the thesis evaluated whether meeting all five WHO framework criteria is necessary to be classified as a healthy ager. The thesis included a systematic review/meta-analysis of healthy ageing in LLMIC and a cross-sectional survey of 845 randomly selected community-living older adults living in Bahir Dar, Ethiopia. For the survey, data collection involved a structured interviewer-administered questionnaire, and physical and functional measurements. Analyses used descriptive and inferential statistics including Poisson regression, linear mixed modelling, and latent class analysis. The systematic review found healthy ageing prevalence rates varied widely (24.7% to 56.5%) based on different definitions of healthy ageing applied. Common frameworks included Rowe and Kahn's Successful Ageing Framework and a single global self-rated health; none assessed the WHO Healthy Ageing Framework. Modifiable factors promoting healthy ageing included social connections, physical activity, and education. The community-based survey identified that 36.7% of older adults in Ethiopia were healthy agers, as defined by the WHO criteria. Factors positively associated with healthy ageing included good nutritional status, lack of multimorbidity, and regular physical activity. While healthy agers demonstrated higher flourishing, both groups showed similar patterns in health service utilization, which was influenced by factors like health insurance and living close to health facility (time taken to reach the health facility). The Latent Class Analysis identified three distinct healthy ageing classes. A healthy ageing class (n = 405) comprised individuals who met fully some of the WHO criteria, as well as those who met some components of the healthy ageing criteria but did not fully satisfy all part. Notably, no significant functional differences emerged between this healthy ageing class and healthy agers who satisisfied or met all WHO Healthy Ageng framework, suggesting that meeting all functional criteria may not be essential for healthy ageing outcomes. In conclusion, healthy ageing rates in Ethiopia and other LLMICs lag behind developed nations. This disparity is influenced by a range of modifiable individual and societal factors including socio-economic status and poverty, lifestyle factors (e.g. physical activity), psychosocial factors (e.g. loneliness and perceptions of the ageing process), and inadequate access to healthcare facilities which adversely impacts health service use. Therefore, comprehensive interventions are necessary such as policies promoting workforce participation to address socio-economic factors, enhanced primary healthcare services to address the healthy needs of older adults, and broader social change to address negative stereotypes of ageing. While focused on Ethiopia, these findings may provide valuable insights for other LLMICs in devising culturally appropriate strategies and healthcare policies to address the challenges of ageing populations.