Growing old with multimorbidity : how our differences shape the years we live with disease

Abstract

This thesis aims to understand how population inequalities in multimorbid life expectancy and inequalities in disease accumulation vary within and between countries and over time. Using a combination of advanced demographic methods and sociological theory, this thesis estimates and interprets the extent of inequality due to various macro- and micro-level factors on MMLE and disease accumulation across five countries with different patterns of development and ageing: South Africa, Costa Rica, Mexico, the United States, and South Korea. Based on a foundation of demographic, epidemiologic, and health transition theories and the life course approach, this thesis applied intersectionality and cumulative (dis)advantage as frameworks to understand the extent and variation of inequalities in a comparative perspective and across several non-Western and/or non-high-income settings. It finds evidence for intersectional inequalities in multimorbid life expectancy across race, education, and sex in South Africa; substantial heterogeneity within and between countries in disability-free and disabling multimorbid life expectancy in Costa Rica, Mexico, and the United States; an increasing rate of disease accumulation amongst younger birth cohorts in South Korea; and considerable disparities in older age working life expectancy with and without multimorbidity across sex, education, and place of residence in South Korea. These findings highlight the flexibility and value of these data and methods for population health and ageing research. This thesis also identifies important social groups which should be targeted in policies aimed at reducing social, structural, and health inequalities, and raises the importance of contextual factors for guiding research and policy decisions. Lastly, it suggests incorporating ageing profiles into estimates of health expectancy and expanding on the relationships between work, family, social security, education systems, and health systems, as valuable areas for future research and policy.