Financially securing lifelong happiness: how perceived income adequacy is associated with age and well-being in older adults from six low- and middle-income countries. Theresa E. Gildner1, Melissa A. Liebert1, Benjamin D. Capistrant2, Catherine D’Este3, Paul Kowal4, Geeta Eick1, J. Josh Snodgrass1  1Department of Anthropology, University of Oregon, Eugene, OR, United States of America; 2Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, United States of America; 3National Centre for Epidemiology & Population Health, Australian National University, College of Medicine, Biology & Environment, Canberra, Australia; 4World Health Organization, Geneva, Switzerland Introduction Perceived income adequacy has become an increasingly important measure of economic stability and well-being in recent years. Several individual characteristics appear to influence perceptions of income adequacy, including age. Despite the fact that individual income levels tend to decline later in life with retirement, older adults frequently report sufficient income adequacy compared to younger individuals [1]. This pattern has been attributed to decreased spending on grown children, combined with higher rates of home ownership and untaxed income [1]. Subjective income adequacy measures also exhibit a strong positive association with health and well-being, above and beyond the health benefits associated with objective income measures [2-3]. Yet, national differences in disease definitions, healthcare expectations, and gender roles result in differences in reported well-being [4]. To date, however, most research has been conducted to examine these patterns in high-income nations. The present study examined whether associations among age, income adequacy, and well-being are similar in low- and middle-income countries, or whether incongruent patterns emerge between culturally and economically distinct populations. Hypothesis Two: Associations between income adequacy and well-being were as hypothesized: SRH was significantly associated with perceived income adequacy in all countries, with consistently higher odds of poor and moderate (compared to good) SRH with increasing levels of income insecurity (Table 2). QOL exhibited a significant association with perceived income adequacy in all countries, with elevated odds of poor and moderate (compared to good) QOL as income insecurity increased (Table 3).   China (n=12,497) Ghana (n=4,173) India (n=6,508) Mexico (n=2,198) Russian Federation (n=3,781) South Africa (n=2,952) Poor Quality of Life Rating Income Adequacy Rating Insecure 50 (39-64)*** 12 (5.8-25)*** 20 (13-29)*** 4.2 (2.0-9.1)*** 21 (15-31)*** 18 (8.7-38)*** Moderate 7.1 (5.6-9.1)*** 3.7 (1.7-8.0)** 2.6 (1.7-3.9)*** 0.9 (0.4-2.3) 7.3 (5.0-10.7)*** (2.9-9.2)*** Secure ref Moderate Quality of Life Rating 5.4 (4.6-6.3)*** 3.4 (2.6-4.6)*** 5.9 (5.0-7.1)*** 2.0 (1.5-2.6)*** 4.0 (3.2-5.0)*** (3.1-5.7)*** 4.6 (4.1-5.1)*** (1.9-3.5)*** 3.5 (3.0-4.0)*** 1.7 (1.3-2.3)*** (3.3-5.0)*** 3.3 (2.4-4.6)*** Figure 2. SAGE participants completing questionnaire items. Key Findings Hypothesis One: Income adequacy was significantly associated with age group (18-49 vs. 50+) in all countries except Mexico and South Africa (Table 1); however, older adults did not uniformly exhibit higher income adequacy ratings across the countries as hypothesized: As expected when compared to older adults, younger individuals in China and Russia were significantly more likely to report that their income was insecure or moderately secure, rather than secure. The opposite pattern was seen in Ghana. Compared with older individuals, younger adults were significantly less likely to report their income as insecure (rather than as secure). Similarly, younger adults in India were significantly less likely to report their income as insecure or moderately secure (rather than secure), compared to older adults. Hypotheses One: Older individuals will exhibit greater levels of perceived higher income adequacy compared to their younger counterparts. Two: Income adequacy ratings will be positively associated with self-rated health and subjective measures of overall quality of life in older adults. Table 3. Relative Risk Ratio (RR) and 95% Confidence Intervals (CIs) of income adequacy category on multivariate quality of life, by country. Outcome variable reference group = Income Secure. Results are from multivariable adjusted models that accounted for: sex, age, rural/urban location, income quintile, employment status, education level, depression, mood, and marital status. Comparisons are statistically significant at: *= p < 0.05, **= p < 0.01, ***= p < 0.001. Study on global AGEing and adult health (SAGE) participants Data were drawn from the first wave of the World Health Organization’s SAGE project [5]. SAGE is a longitudinal study of nationally-representative samples of older adults (>50 years old) and comparative samples of younger adults (18-49 years old) in six low- and middle-income countries (China, Ghana, India, Russian Federation, South Africa, and Mexico) (Fig. 1). A household questionnaire administered to participants was used to measure perceived income adequacy, self-rated health (SRH), and quality of life (QOL) (n = 33,214; Fig. 2). Discussion Significant differences in income adequacy ratings were apparent between young and old adults, yet the direction of these differences varied by country. These dissimilarities are likely due to cultural differences, such as variation in levels of filial piety and the accessibility of social safety nets available to older adults (e.g., retirement-related benefits and programs). Support from adult children and government support programs have been shown to buffer older individuals from income inadequacy when effectively implemented and utilized [6-7]. The present study documented strong positive associations between ratings of perceived income adequacy and well-being (using both SRH and QOL measures) in all countries. It is therefore apparent that although care should be taken when comparing these variables across distinctive populations, it is possible to examine these relationships cross-culturally. Further, these associations are robust in low- and middle-income nations, suggesting perceived financial situation uniformly influences measures of well-being across different levels of national wealth and development. Implications and Conclusions The present study provides a unique examination of the links between perceived income adequacy and various measures of subject well-being in older individuals using an extensive and unparalleled collection of cross-cultural measurements. These results support previous findings in high-income populations and suggest that higher ratings of income adequacy are associated with increased subjective well-being measures in this diverse set of nations. However, it appears that the relationship between age and income security varies across countries. This information can be used to reduce health disparities resulting from income inequality through targeted measures, such as improving educational, occupational, and social protection opportunities.   China (n=14,099) Ghana (n=4,968) India (n=11,143) Mexico (n=2,618) Russian Federation (n=4,228) South Africa (n=3,214) Income Insecure Age 18-49 (ref: 50+) 1.8 (1.5-2.0)*** 0.6 (0.5-0.9)** 0.8 (0.7-0.9)*** 1.1 (0.8-1.6) 1.5 (1.2-2.0)** 1.2 (0.8-1.8) Moderately Insecure 1.4 (1.2-1.5)*** 0.8 (0.6-1.0) 1.0 (0.7-1.3) 1.6 (1.2-2.1)** 0.9 (0.6-1.4) Table 1. Relative Risk Ratio (RR) and 95% Confidence Intervals (CIs) of age 18-49 (reference: 50+) associated with multinomial income adequacy ratings, by country. Outcome variable reference group = Income Secure. Results are from multivariable adjusted models that accounted for: sex, rural/urban location, income quintile, employment status, education level, depression, mood, and marital status. Comparisons are statistically significant at: *= p < 0.05, **= p < 0.01, ***= p < 0.001. Figure 1. Map of SAGE countries, showing study locations. http://www.who.int/healthinfo/systems/sage/en/   China (n=12,510) Ghana (n=4,188) India (n=6,515) Mexico (n=2,200) Russian Federation (n=3,820) South Africa (n=2,951) Poor Self-Rated Health Income Adequacy Rating Insecure 5.9 (5.1-6.9)*** 2.2 (1.4-3.4)** 5.7 (4.5-7.3)*** 3.6 (2.2-5.8)*** 6.6 (4.7-9.2)*** (3.7-11.9)*** Moderate 2.6 (2.3-3.0)*** 1.5 (0.9-2.4) 1.7 (1.3-2.1)*** 1.5 (0.9-2.5) 3.8 (2.7-5.2)*** 3.0 (1.6-5.6)** Secure ref Moderate Self-Rated Health 2.1 (1.9-2.4)*** 1.6 (1.2-2.2)** (2.1-3.1)*** 1.9 (1.4-2.4)*** 2.3 (1.8-3.1)*** 2.7 (2.0-3.7)*** (1.7-2.1)*** 2.0 (1.5-2.7)*** (1.9-2.5)** (1.2-2.1)** (1.8-3.0)*** 2.5 (1.8-3.4)*** Methods Perceived Income Adequacy: Participants were asked whether they had enough money to meet their needs (using a 5-point response scale) and these responses were recoded into three categories: (1) income insecure (rating of “a little” or “not at all”); (2) moderately secure (“moderately”); and, (3) income secure (“completely” or “mostly”). Well-Being Variables: Participants were asked to rate their general health (SRH) that day and overall QOL on a scale of 1 (very poor) to 5 (very good). These categories were collapsed into three categories: (1) low SRH or QOL (rating of “very poor” or “poor”); (2) moderate SRH or QOL (“moderate”); and, (3) high SRH or QOL (“good” or “very good”). Statistics: A series of multinomial logistic regressions were run to determine if age contributed to variation in perceived income adequacy and to test if perceived income adequacy was significantly associated with variation in SRH or QOL. All regressions controlled for various sociodemographic and health factors (sex, household setting, income quintile, current employment status, highest level of education, marital status, depression diagnosis, and self-reported mood). Acknowledgments We thank Nirmala Naidoo for her efforts in data analysis. Support for the research was provided by NIH NIA Interagency Agreement YA1323-08-CN-0020; NIH R01-AG034479. References Litwin, H., & Sapir, E. V. (2009). Perceived income adequacy among older adults in 12 countries: findings from the survey of health, ageing, and retirement in Europe. The Gerontologist, 49(3), 397-406. Cheng, Y. H., Chi, I., Boey, K. W., Ko, L. S. F., & Chou, K. L. (2002). Self-rated economic condition and the health of elderly persons in Hong Kong. Social Science & Medicine, 55(8), 1415-1424. Nummela, O. P., Sulander, T. T., Heinonen, H. S., & Uutela, A. K. (2007). Self-rated health and indicators of SES among the ageing in three types of communities. Scandinavian Journal of Public Health, 35(1), 39-47. Hunt, S. M. (1993). Cross-cultural comparability of quality of life measures. Drug Information Journal, 27(2), 395-400. Kowal, P., Chatterji, S., Naidoo, N., et al. (2012). Data resource profile: the World Health Organization Study on global AGEing and adult health (SAGE). International Journal of Epidemiology, 41(6), 1639-1649. Chen, X., & Silverstein, M. (2000). Intergenerational social support and the psychological well-being of older parents in China. Research on aging, 22(1), 43-65. Gavrilova, N. S., & Gavrilov, L. A. (2009). Rapidly aging populations: Russia/Eastern Europe. In International handbook of population aging (pp. 113-131). Springer. Table 2. Relative Risk Ratio (RR) and 95% Confidence Intervals (CIs) of income adequacy category on multivariate self-rated health, by country. Outcome variable reference group = Income Secure. Results are from multivariable adjusted models that accounted for: sex, age, rural/urban location, income quintile, employment status, education level, depression, mood, and marital status. Comparisons are statistically significant at: *= p < 0.05, **= p < 0.01, ***= p < 0.001.