Article

Research on Aging
2019, Vol. 41(8) 794–820
Financial Inclusion, ª The Author(s) 2019
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DOI: 10.1177/0164027519846604
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Outcomes Among
Older Adults in Ghana

Razak M. Gyasi1 , Anokye M. Adam2,

and David R. Phillips3

Abstract
Purpose: This study examines the associations between financial inclusion,
health-seeking behavior, and health-related outcomes in older persons in
Ghana. Method: Employing data from a 2016/2017 Aging, Health, Psycho-
logical Well-Being and Health-Seeking Behavior Study (N ¼ 1,200; mean age
¼ 66.2 years [standard deviation ¼ 11.9], we estimated regression models of
self-rated health (SRH), psychological distress (PD), and health-care use
(HCU) on a variable representing compositional characteristics of financial
inclusion. Results: Multivariate logistic and generalized Poisson models
showed that financial inclusion is positively associated with SRH (b ¼ .104,
standard error [SE] ¼ .033, p < .001) but inversely related to both PD (b ¼
.038, SE ¼ .032, p < .005) and HCU (b ¼ .006, SE ¼ .009, p < .05) inde-
pendent of other factors. However, after adjusting for socioeconomic and
health-related factors, the associations were tempered and the effect of SRH
decreased by 0.094 and PD increased by 0.065 points but HCU became

1
Aging and Development Unit, African Population and Health Research Center, Nairobi, Kenya
2
Department of Finance, School of Business, University of Cape Coast, Cape Coast, Ghana
3
Depatment of Sociology and Social Policy, Lingnan University, Tuen Mun, Hong Kong

Corresponding Author:
Razak M. Gyasi, Aging and Development Unit, African Population and Health Research Center,
Manga Close, Off-Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya.
Email: rgyasi@aphrc.org; rgyasi@ln.hk
Gyasi et al. 795

statistically insignificant (b ¼ .020, SE ¼ .0114, p > .05) Conclusions:

Financial services inclusion profoundly appears to buffer against and retard
health-related challenges in later life. Social and health policies targeted at
improving the health outcomes of older people should include and build on
the growing recognition of the importance of inclusive financial services and
strategies.

Keywords
bank account, financial inclusion, health-seeking behavior, older adults, psy-
chological distress, self-rated health

The considerable increase in the absolute numbers and proportion of older

people have led to profound public health and social policy concerns over the
past few decades (Aboderin & Hoffman, 2015; Phillips & Feng, 2018; World
Health Organization [WHO], 2015a). Studies have regularly noted that
although demographic aging in itself should be celebrated, it is now the most
distinctive demographic process and increasingly presents important socio-
economic and health implications (Domènech-Abella et al., 2017; Phillips &
Feng, 2018; United Nations, 2015). As a major risk factor for declining
health status, aging is often associated with increasing mental/cognitive
impairments and various forms of disabilities including mobility deficiencies
and limitations of daily living tasks (Gyasi & Phillips, 2018b; MacKenbach
& McKee, 2013; McCracken & Phillips, 2017; WHO, 2015a). While inno-
vative strategies such as effective engagement in and sustained access to
financial services and instruments for older persons are required, these
remain a major global socioeconomic and political challenge in the aging
process, especially in low- and middle-income countries (LMICs)
(McCracken & Phillips, 2017; WHO, 2015a).
Gerontological research, especially involving studies in developed coun-
tries, has increasingly reported the potential effects of social and economic
opportunities such as financial inclusion on health outcomes in later life
(Aguila, Angrisani, & Blanco, 2016; Agrigoroaei, Lee-Attardo & Lachman,
2017). The ability to maintain reasonable financial competence such as
having access to a bank and chequing account, involvement in a credit union
(microfinance), and having a mobile money account and access to credit
through loans from banking and nonbanking systems can be a relevant
determinant of health among older people (Agrigoroaei et al., 2017; Aguila
et al., 2016; Krause & Bastida, 2011; Mensah & Dzokoto, 2011). Some
796 Research on Aging 41(8)

evidence also suggests that individuals in lower income settings who are
involved in informal financial instruments, such as membership of co-
operative credit union and operating a Susu1 rotating savings account (which
is less formal account than traditional bank account), have higher odds of
reporting better health outcomes (Bank of Ghana, 2018; Goldberg, 2014).
Many sub-Saharan African nations have started to evaluate the effects of
financial literacy training for young people to empower them with good
savings habits for their future life course and also to assist their older parents’
spending and savings patterns (Adam, Boadu, & Frimpong, 2018; Goldberg,
2014). However, policies on this area remain slim although it is acknowl-
edged that developing conscious interests in providing evidence-based pol-
icies such as financial inclusion to address age-related health challenges is
crucial (WHO, 2015a).
In many richer countries, evidence is building about the effects of finan-
cial inclusion and exclusion on older persons’ health outcomes, but, regret-
tably, the topic remains very underinvestigated in most LMICs and in
sub-Saharan Africa in particular (Goldberg, 2014; Mensah & Dzokoto,
2011). Exploring these important relationships in a new and innovative con-
text is crucial due to this region’s distinct socioeconomic characteristics,
levels of technological advancement (Aker, Boumnijel, McClelland, & Tier-
ney, 2011), and its imminent considerable demographic aging. Drawing on
the capability framework, this study examines the associations among finan-
cial inclusion, health services use, and health outcomes among noninstitu-
tionalized older Ghanaians. As well as addressing the knowledge gap in the
literature, the findings have the potential to inform policy for older persons’
involvement in financial activities and to safeguard their health outcomes.
This will be crucial in rapidly aging environments such as sub-Saharan
Africa where the pace of growth of older populations is currently dramatic
(WHO, 2015b).

Theoretical Framework
Capability theory, particularly associated with Sen (1999), has contributed to
research on financial inclusion and health by guiding specific economic
opportunities and empowerment particularly among older populations (All-
mark & Machaczek, 2015). The capability perspective provides a context for
analyzing financial capability which could provide practical implications for
public health and primary care for populations (Nussbaum, 2011; Robeyns,
2005). Financial capability reflects people’s ability to maintain reasonable
financial alertness; and having some finances to manage is better to deal with
Gyasi et al. 797

health risks than not having much (Allmark, Baxter, Goyder, Guillaume, &
Crofton-Martin, 2013; Atkinson, 2008). Financial capability provides oppor-
tunities for older people to take greater control of their finances, external
environments, and be able to manage economic resources better and to adopt
desired lifestyles and health outcomes (Allmark & Machaczek, 2015; Manor,
Matthews, & Power, 2000). Although being financially capable may relate to
a wide range of socioeconomic factors, it has a greater influence on mental/
physical health and health-seeking behavior (Nussbaum, 2011).
The intersecting subjects of social gerontology and health research
address important relationships between growing older and many aspects
of health status and change. These include psychological distress (PD;
Cheng, Chan, & Lo, 2017; Giné-Garriga, Roqué-Fı́guls, Coll-Planas, Sitjà-
Rabert, & Salvà, 2014), self-rated health (SRH; Akuamoah-Boateng, 2013;
Ameh, Gómez-Olivé, Kahn, Tollman, & Klipstein-Grobusch, 2014; Garata-
chea et al., 2015), and health services utilization (Ameh et al., 2014;
Cameron, Song, Manheim, & Dunlop, 2010; Song, Chang, Manheim, &
Dunlop, 2006). It has been noted that population aging can contribute to a
rising number of older adults with various types of disability, which adds a
greater potential burden to many already strained health- and social-care
systems (MacKenbach & McKee, 2013; McCracken & Phillips, 2017; WHO,
2015a). However, how well older persons are equipped socially and finan-
cially is very likely to influence their interaction with health services and
what their health outcomes might be (Gyasi, 2018). Several empirical studies
conducted outside sub-Saharan Africa have documented a positive relation-
ship between financial inclusion and mental health and well-being of popu-
lations. Others have noted that safeguarding older adults’ knowledge, access,
and the ability to deal with their finances will directly impact on their health
outcomes (Agrigoroaei et al., 2017; Aguila et al., 2016; Allmark & Machac-
zek, 2015). Unfortunately, these important relationships are almost totally
noninvestigated in most sub-Saharan African countries due to many institu-
tional, cultural, and socioeconomic challenges.
In their pioneering work on older Hispanics in the United States, Aguila,
Angrisani, & Blanco (2016) concluded that increasing financial sector par-
ticipation for minority and more disadvantaged socioeconomic status groups
such as older people may have positive implications for well-being and also
help to reduce health disparities. For example, bank account ownership was
associated with better mental health although no effect was established on
physical health (Aguila et al., 2016). Other studies in the United States
(Finkelstein et al., 2012) and Ghana (Gyasi, Phillips, & Buor, 2018) note
that some forms of financial inclusion such as ownership of a bank account
798 Research on Aging 41(8)

and access to health insurance are critical to providing individuals and com-
munities with financial protection. This may reduce cognitive stress and
improve mental health and the general well-being. Research in the United
Kingdom has also noted positive linkages between individuals’ abilities to
manage and to take control of their finances and their psychological comfort
(Taylor, Jenkins, & Sacker, 2009, 2011). Other similar studies relate bank
account ownership and financial inclusiveness to improved financial capa-
bility which has clear and important implications for dealing with daily
transaction costs, liquidity constraints, saving behavior, and matters such
as financial preparedness for retirement and personal security (Carbo, Gar-
dener, & Molyneux, 2005; Clark & d’Ambrosio, 2003; Mullainathan &
Shafir, 2011). Having a bank account may also provide the capacity to
develop financial awareness and alertness. However, among older popula-
tions in particular, with declining scores on instrumental activities of daily
living (IADLs) and overall greater health challenges, an individual’s ability
to manage finances is often seen as a first area to decline (McCracken &
Phillips, 2017). At the community level, various local and mini-savings
practice have emerged which are particularly seen in rural communities in
Ghana and several other sub-Saharan African settings. Membership of
“Susu” operations and mobile money account ownership have provided var-
ious financial services for older people, who often receive irregular incomes,
to gradually save and accumulate money for their future commitments (Bank
of Ghana, 2018; Gyasi, 2018; U.S. Agency for International Development,
2013). This local service model provides an important alternative to the
larger formal financial sector and may compensate for the frequent deficien-
cies in mainstream financial sector coverage and participation in such places.
Nevertheless, the literature is almost devoid of such matters relating to
financial inclusiveness and older persons in most LMICs. Therefore, it is
unclear how financial inclusion or exclusion may impact subjective health
status, stress and psychological health, and health services utilization, espe-
cially among vulnerable and disadvantaged groups in the sub-Saharan Afri-
can context. Exploring these relationships is important as they are groups
who may have irregular income sources and encounter barriers to participa-
tion in the formal financial sector. This will likely become of ever-increasing
importance, given that global financial regulation increasingly makes the
opening of bank accounts ever more difficult for those without established
financial histories and official proof of identity, by definition excluding
many persons in the informal or low-income sectors (McCracken & Phillips,
2017). In particular, in sub-Saharan Africa, the important trajectories and
relations between financial inclusion and health remain almost wholly
Gyasi et al. 799

unexamined and the contextual evidence on this topic remains minimal. The
present study, therefore, examined the specific associations of overall finan-
cial inclusion with older individuals’ SRH, psychological health outcomes,
and health services use in Ghana. Understanding these dynamics is likely to
be crucial for devising targeted interventions to protect the most vulnerable
in the rapidly aging populations in many LMICs.

Method
Sample and Data
This analysis used data from a probability-based sample survey of
community-dwelling older Ghanaian adults aged 50 years or older who
participated in an Aging, Health, Psychological Well-Being and Health-
Seeking Behavior Study (AHPWHB; Gyasi, 2018). The AHPWHB study
was conducted between July 2016 and February 2017 in the Ashanti Region
of Ghana. The region was chosen for this study for three key factors: First,
it is the most populous of Ghana’s 10 regions, and it is also one of the
country’s major cosmopolitan and heterogeneous regions, illustrating
diverse demographic, cultural, and religious characteristics. Second, being
geographically located at the center of the country, the region is considered
the main nodal region and has vibrant commercial activities which attract
people to settle from other parts of the country and beyond. Third, and
importantly, Ghana Statistical Service’s (GSS; 2012) report on population
and housing census shows that Ashanti Region is home to the highest
proportion (17.5%) of the nation’s older population, making it the ideal
setting for the study.
Although the aging process is often perceived as largely biological, it is
crucially highly socially influenced, subject to the attitudes, conventions, and
support for people at different times in their life course. The categorization of
what constitutes being “aged” varies considerably between and among coun-
tries and also over time, with important social and workforce implications. In
the Ghanaian context, the Government of Ghana specifies 60 as the statutory
age of retirement (GSS, 2012), but by far, the greater proportion of older
people neither expect nor enter formal retirement and its associated benefits
because the labor market is dominated by low-earning subsistence self-
employment in the informal sector (GSS, 2013; International Labour Orga-
nization, 2015; Vasco & Pierella, 2015). Moreover, employment growth in
Ghana has largely occurred in the informal sector, with this sector represent-
ing 88% of employment in 2013. These activities often involve arduous
800 Research on Aging 41(8)

nonmechanized or labor-intensive primary economic activities which often

make many in the older groups vulnerable to many health challenges, and
these often manifest themselves at relatively younger ages.
Indeed, the WHO’s (2018) recent report estimates Ghana’s average life
expectancy at 63.4 years (62.5 years for males and 64.4 years for females).
Because of this relatively shorter life expectancy and early onset of ill-health,
as well as the double burden of noncommunicable and infectious diseases
compared with richer countries, we define individuals aged 50 years or older
as “older persons.” Indeed, “young olds” aged 50–60 constitute a key con-
temporary target population to be addressed for possible preventive measures
to tackle health-related problems in the coming decades (Poscia, Landi, &
Collamati, 2015; WHO, 2015b). This is not an unusual definition, but many
recent gerontology studies including the Minimum Data Set project on aging
and many other regional studies, including the WHO’s Study on Global
Aging and Adult Health in five developing countries, including Ghana,
adopted age 50þ to define older persons (see, e.g., Biritwum, Mensah,
Yawson, & Minicuci, 2013). While acknowledging it internationally as a
relatively low age, this study following these international and low-income
regional-based surveys adopted age 50 as the minimum threshold for older
persons.
The sample comprised individuals who met the inclusion criteria in six
randomly sampled districts which fully represented the socioeconomic and
cultural diversities of the country. Details of the sampling procedure have
been reported elsewhere (Gyasi, 2019; Gyasi & Phillips, 2018a, 2018b, 2019;
Gyasi, Phillips, & Abass, 2018; Gyasi, Phillips, & Amoah, 2018, Gyasi et al.,
2018; Gyasi, Phillips, & David, 2019). A multistage stratified sampling
procedure was used to reflect the heterogeneous population and socioeco-
nomic characteristics of people who have settled in the different parts of the
Ashanti Region. In the initial sampling stage, three subregional areas of the
northern, middle, and southern sectors of the region were defined as primary
sampling units based on their differences in demographic, cultural, and geo-
graphic characteristics. Two districts in each subregion were randomly
selected, with all districts having equal chances of selection. Urban and rural
sectors were identified in each selected district based on the GSS’s (2012)
classification. In total, 24 communities (9 urban and 15 rural) were selected
for the survey.
The sample size was estimated using a formula, assuming 5% margin of
error, 95% confidence interval, design effect of 1.5, 5% and 15% of type 1
and type 2 errors, respectively, and a conservative prevalence of 50%
(because the actual proportion of people aged 50þ years in the selected areas
Gyasi et al. 801

was unknown). The required sample size was, therefore, computed to be 901,
but considering a 35% nonresponse, the final proposed sample size for this
study was approximately 1,219. Moreover, the statistical power calculation
revealed that the sample size had 85% power to detect an odds ratio of 2. In
the final stage of the selection process, 1,247 older persons were selected by
systematic random sampling with the sampling interval varying by the rela-
tive size of the study communities. Of 1,247 approached, 1,219 (97.8%) were
eligible to participate. Of these eligible participants, 19 declined to partici-
pate in the study yielding a study sample of 1,200 representing a response
rate of 98.4%. Interviews were via an interviewer-administered questionnaire
conducted by trained research assistants with experience in health-related
research. The survey questionnaire was developed in English and then trans-
lated into Twi (the major local dialect) and back-translated into English to
ensure consistency in the meaning of items following WHO translation
guidelines for assessment of instruments (Üstun, Chatterji, Mechbal, Murray,
& WHS Collaborating Groups, 2005).

Human Subjects’ Protection

In line with the Declaration of Helsinki (Carlson, Boyd, & Webb, 2004;
World Medical Association, 1964), the Human Subjects Certification was
received ahead of the interview. First, the study protocol was reviewed and
approved by the Committee on Human Research Publication and Ethics,
School of Medical Sciences, Kwame Nkrumah University of Science and
Technology, and Komfo Anokye Teaching Hospital, Kumasi, Ghana (ref.:
CHRPE/AP/507/16). Ethics approval was also granted by the Research
Ethics Committee of Lingnan University, Hong Kong. The participants were
fully briefed on the research objectives and they provided informed written
and or oral consent as appropriate, after the assurance of confidentiality and
anonymity of the information they provided. Personal identifying items such
as names were not taken.

PD Outcome
PD construct was assessed by a composite 10-item question measuring the
psychological health and depressive symptomatology of the participants on a
range of health complaints adapted from the Kessler Psychological Distress
Scale (Kessler, Andrews, et al., 2002; Kessler, Barker, et al., 2003). These
items included, “In the last 30 days about how often did you feel . . . (1) ‘tired
out for no good reason?’ (2) ‘nervous or uneasy?’ (3) ‘so nervous that nothing
802 Research on Aging 41(8)

could calm you down?’ (4) ‘hopeless?’ (5) ‘restless or fidget?’ (6) ‘so restless
you could not sit still?’ (7) ‘depressed?’ (8) ‘that everything was an effort?’
(9) ‘so sad that nothing could cheer you up?’ and (10) ‘worthless?’” Respon-
dents rated the items with a 5-point response scale from 1 ¼ none of the time,
2 ¼ a little of the time, 3 ¼ some of the time, 4 ¼ most of the time, to 5 ¼ all of
the time. Cronbach’s a of the scale was assessed to be .88. Scores of the 10
items were then summed, yielding a minimum score of 10 and a maximum
score of 50.
In our analysis, we used a cutoff point of 20 to define PD (1) while
the range 10–19 was adjudged psychologically not distressed (0) accord-
ing to a previous validation study by the Victorian Population Health
Survey (2001). It has also been argued that the dichotomized PD variable
in community-based studies is an effective way to identify people who
may need further clinical evaluation for diagnosis and treatment (Herr-
man et al., 2002).

SRH
SRH was assessed with a single item from the 36-item short-form survey
instrument (Rand Health, 2007; Ware & Sherbourne, 1992). The item
inquired about the self-reported current general health status of individuals
using the item: “In general, how would you rate your health?” on a 5-point
response scale, 1 ¼ excellent, 5 ¼ poor. These were later collapsed and
dichotomized into 0 ¼ fair/poor, 1 ¼ excellent/very good/good mainly
because the data were highly skewed against the extremes. Manor, Mat-
thews, & Power (2000) also note that the dichotomization of SRH does not
present problems but rather tends to increase the robustness of the analysis,
especially with skewed data.

Health-Seeking Behavior
We obtained data on health services utilization involving the use of
health professional or health facility in dealing with health challenges
over the last 12 months preceding the survey. This was assessed using
the item “how many times did you seek treatment for your health chal-
lenges from a health facility (e.g., health center, clinic, or hospital) over
the past 12 months?” This included physician/general practitioner/medi-
cal specialist visits, outpatient service use, and inpatient hospitalization
of one night or longer. The responses were recorded as count data on a
ratio/continuous scale.
Gyasi et al. 803

Financial Inclusion
The participants were asked to give no (0) or yes (1) responses to a 7-item
question regarding the most regular financial activities they have been
involved in. These included, over the past 12 months: ownership of personal
current/savings bank account, recent withdrawal of money from an account,
use of automatic teller machines, membership of any credit union activities,
ownership of Susu accounts and contribution to savings with local banking
operators/managers, opportunities of obtaining a loan from a financial insti-
tution, and ownership or operation of a mobile money service account. A
possible total score from 0 to 7 was recorded. Higher scores indicated an
older person had been involved in a larger number of financial inclusion
activities.

Individual Characteristics
We included health-related, lifestyle, and sociodemographic factors as con-
trol variables. The prevalence of chronic illnesses (comorbidities) was
assessed via stated or self-reported diagnoses often chronic illnesses by a
health-care professional: diabetes, respiratory diseases, cancers, stroke,
chronic kidney diseases, asthma, arthritis, depression, and insomnia with
yes/no responses. The total score ranged from 0 to 5 with a higher score
indicating a higher comorbidity level. ADLs decline was assessed via
responses to self-reported functioning (WHO, 2012). Older participants were
asked to rate their level of difficulty in carrying out six ADLs including
eating, bathing, getting dressed/undressed, toileting, getting in/out of bed,
and continence. Responses were recorded on a 4-point scale: (1) not limited
at all, (2) less limited, (3) somewhat limited, and (4) much limited. The total
score ranged from 6 to 24 with a higher score indicating a higher level of
ADL decline.
Alcohol intake was assessed by asking respondents to indicate a no/yes
response if they consumed any drink that contains alcohol such as beer, wine,
or hard spirits over the past 30 days. Physically active level was measured
with 3 items adapted from the General Physical Activity Questionnaire
(United Kingdom Department of Health & Social Care, 2013): “How many
days in the last week did you (1) walk for at 30 min in total; do moderate
activities such as dancing for about 30 min in total? Do vigorous activities
such as running, gardening”? The responses were recorded on a ratio scale.
Sociodemographic variables included were age (years), gender (1 ¼ male, 2
¼ female), marital status (1 ¼ married/cohabiting, 2 ¼ single/widowed/
804 Research on Aging 41(8)

divorced/separated), residence (1 ¼ rural, 2 ¼ urban), living arrangement (1

¼ living with others, 2 ¼ living alone), level of schooling (1 ¼ primary/none,
2 ¼ secondary, 3 ¼ tertiary), employment status (1 ¼ not employed/retired,
2 ¼ currently employed), and household monthly income (in Ghana Cedis).

Statistical Analyses
We first conducted descriptive analyses of univariate and correlation matrix
to describe the sample. Diagnostics were conducted to check multicollinear-
ity prior to regression analyses and the variance inflation factor (VIF) for all
variables was 2.38. We then performed various multivariate analyses taking
into consideration the different measurements of the outcome variables.
Specifically, while logistic regression models examined the effects of finan-
cial inclusion on SRH and PD levels, generalized Poisson regression models
were employed to assess the association between financial inclusion status
and the frequency of health services use among older persons. Models 1, 3,
and 5 were the base models which included financial inclusion status and
control variables of age and gender only. Models 2, 4, and 6 for each outcome
measure added the socioeconomic, lifestyle, and health-related factors to
investigate whether these variables play any role and might temper the
effects of financial inclusion on health outcomes and health services use.
A sensitivity analysis for the measure of PD was conducted using the log
scale transformation of this outcome measure to chiefly address the potential
challenge associated with the skewness of the data. However, the results
were essentially the same as the originally dichotomized measure in terms
of the direction and effect size. In addition, we performed an auxiliary
analysis for each of the financial instruments included in the financial inclu-
sion composite measure to ascertain their individual effects on the health
outcomes and health-care use (HCU) among the older sample by running
series of models isolating each financial instrument per model. A statistical
significance threshold of p < .05 was set and we used SPSS Version 21.0
(IBM, Armonk, NY) in all analyses.

Results
The average age of respondents was 66.2 years (standard deviation [SD] ¼
11.9) and 38.2% were married or cohabiting with their spouses. The majority
of respondents were female (63.3%), had had no or up to primary formal
schooling (86.2%), were unemployed (55.6%) and lived alone (55.2%), and
lived in the urban areas (55.0%). Income levels were generally low with the
Gyasi et al. 805

average monthly income of GH¢308.2 (where US$1.00 ¼ ¢4.80) and with

widespread inequality (SD ¼ GH¢338.9, range ¼ GH¢100–GH¢4000; Table
1). In addition to the lower socioeconomic status, respondents reported a
wide range of physical and psychological health challenges. Typically, aver-
age levels of ADLs (13.7, SD ¼ 5.1, range ¼ 9–36), comorbidities (0.67, SD
¼ 0.79, range ¼ 1–5), and physical activity (8.8, SD ¼ 4.4, range ¼ 1–15)
were revealed. Moreover, 31.4% of the participants had consumed alcohol
over the past 4 weeks. More importantly, while responses on SRH were very
good (19.9%), good (30.8%), fair (29.0%), and poor (20.3%), 45.3% of the
respondents revealed depressive symptoms. The average number of visits to
a health facility was 3.6 (SD ¼ 1.6) and a financial inclusion score of 1.9 (SD
¼ 1.8, range ¼ 0–7) was also reported.
Table 2 is a matrix showing the Pearson product–moment correlation,
point–biserial correlation, and f correlation values for the dependent and
independent variables. The analysis found a positive correlation between
financial inclusion and SRH, but it is negatively correlated with PD. Apart
from residential status, all the control variables showed significant correla-
tions with financial inclusion. Negative associations were observed for
higher age, living alone, and having comorbidities with financial inclusion.
Also, being male, married, schooling, employed, higher income, physically
active, and using alcohol were positively related to financial inclusion. SRH
correlated with all the study variables except for residence, educational level,
and alcohol intake. Finally, PD did not correlate with alcohol use, income,
schooling residence, and age.
Results of the logistic and Poisson regression analyses used to examine
the associations between financial inclusion and health outcomes are pre-
sented in Table 3. Model 1 showed that older people with higher levels of
financial inclusion had 0.104 points (standard error [SE] ¼ .033, p < .001)
higher than their nonincluded counterparts to reveal excellent/very good
SRH, adjusting for age and gender. The inclusion of all socioeconomic and
health-related variables in Model 2 slightly reduced the magnitude of the
positive association between financial inclusion and SRH by 0.094 points,
but the significant positive relationship remained statistically robust (b ¼
.010, SE ¼ .044, p < .005). In Model 3, the logistic regression results showed
that financial inclusion reduced PD levels controlling for age and gender (b
¼ .038, SE ¼ .032, p < .005). Although the magnitude increased by 0.065
points, the inverse effect of financial inclusion on PD persisted after adjust-
ing for the theoretically relevant variables (b ¼ .103, SE ¼ .044, p < .05;
Model 4). For health services utilization, the Poisson regression results in
Model 5 showed that financial inclusion decreased the likelihood to use
806 Research on Aging 41(8)

Table 1. Univariate Analysis of Selected Outcome and Explanatory Variables (Older

Persons in Ghana Survey).

Variable Valid N (%) Mean SD Range

Frequency of health services 3.56 1.62

utilization
Self-rated health
Poor/fair 592 (49.3)
Good/very good/excellent 608 (50.7)
Psychological health
Nondistressed 656 (54.7)
Distressed 544 (45.3)
Financial inclusion 1.91 1.79 0–7
Age (years) 66.15 11.85 50–111
Gender
Women 759 (63.3)
Men 441 (36.8)
Marital status
Single 742 (61.8)
Married or cohabiting 458 (38.2)
Residential status
Rural 540 (45.0)
Urban 660 (55.0)
Living arrangement
Living with others 538 (44.8)
Living alone 662 (55.2)
Level of schooling
Primary or below 1,034 (86.2)
Secondary 104 (8.7)
Tertiary 62 (5.2)
Employment status
Unemployed 667 (55.6)
Employed 533 (44.4)
Average monthly income GH¢308.18 GH¢338.89 GH¢100–
(in Ghana Cedis) GH¢4000
Comorbidities 0.67 0.79 0–5
Activities of daily living 13.70 5.09 9–36
decline
Physical activity levels 8.75 4.43 1–15
Alcohol intake
No 823 (68.6)
Yes 377 (31.4)
 Table 2. Pearson Product–Moment, Point–Biserial, and j Correlation Matrix for Financial Inclusion, Sociodemographic, and Health-Related
Variables.
Variable M + SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1. Self-rated 0.51 (0.50) 1

health
2. Psychological 0.45 (0.50) .233** 1
distress
3. Health services 3.56 (1.62) .189** .134** 1
use
4. Financial 1.91 (1.79) .093** .034* .023 1
inclusion
5. Age 66.15 (11.85) .159** .017 .128** .245** 1
6. Gender 0.37 (0.48) .130** .118** .098** .178** .003 1
7. Marital status 0.38 (0.49) .175** .209** .105** .238** .203** .333** 1
8. Residence 0.55 (0.49) .011 .034 .080* .015 .057* .044 .111** 1
9. Living 1.55 (0.49) .202** .400** .115** .191** .060* .112** .275** .071* 1
arrangement
10. Schooling 1.19 (0.51) .041 .044 .006 .311** .095** .219** .166** .009 .098** 1
11. Employment 1.44 (0.50) .265** .127** .258** .127** .363** .129** .254** .095 .138** .075** 1
status
12. Income 308.18 (338.89) .133** .057 .060 .186** .168** .179** .247** .114** .188** .223** .241** 1
13. Comorbidities 0.67 (0.79) .223** .131** .314** .098** .178** .109** .081** .072* .090** .016 .180** .050 1
14. Activities of 13.70 (5.09) .462** .239** .334** .218** .401** .173** .227** .019 .256** .109** .408** .218** .388** 1
daily living
decline
15. Physical 8.75 (4.43) .256** .141** .168** .180** .342** .181** .186** .068* .161** .019 .265** .180** .283** .492** 1
activity
16. Alcohol use 0.31 (0.46) .039 .010 .061 .133** .045 .359** .063* .023 .065* .065* .027 .005 .099** .127** .006

*p < .05. **p < .005.

807
808
Table 3. Multivariate Analyses of Associations Between Self-Rated Health, Psychological Distress, and Frequency of Health Services
Utilization Among Older Respondents.
Self-Reported Health: Coefficients for Psychological Distress: Coefficients for Health Services Use: Coefficients for
Logit Models Logit Models Poisson Models

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6

Variable b (SE) b (SE) b (SE) b (SE) b (SE) b (SE)

Financial inclusion .104 (.033)*** 0.010 (.044)** .038 (.032)** 0.103 (.044)* .006 (.0093)* 0.020 (.0114)
Age (in years) .021 (.009)* 0.012 (.007) .033 (.009)*** 0.023 (.007)*** .009 (.0071) 0.008 (.0019)
Gender (ref: male) .128 (.155) 0.131 (.176) .310 (.195) 0.259 (.174) .008 (.0550)** 0.007 (.0460)
Marital status (ref: single) 0.192 (.166) 0.469 (.164)*** 0.031 (.0425)
Residence (ref.: urban) 0.180 (.153) 0.076 (.149) 0.047 (.0387)
Living alone 0.289 (.153) 1.602 (.154)*** 0.015 (.0396)
Schooling
Primary/none (ref.) 1.00 1.00 1.00
Secondary 0.046 (.275) 0.170 (.274) 0.006 (.0715)
Tertiary 0.303 (.341) 0.236 (.341) 0.007 (.0835)
Employed 0.322 (.162)* 0.125 (.165) 0.134 (.0437)
Income (in Cedis) 0.019 (.0121) 0.015 (.0113)* 0.021 (.0012)
Comorbidities 0.178 (.103) 0.063 (.097) 0.098 (.0232)***
Activities of daily living decline 0.195 (.020)*** 0.077 (.019)*** 0.019 (.0047)***
Physically active 0.003 (.019) 0.012 (.019) 0.002 (.0050)
Alcohol intake 0.077 (.170) 0.271 (.170) 0.045 (.0442)
Two log pseudolikelihood 1,653.006 1,152.290 1,651.713 1,187.383 1,939.611 1,607.359
Model significance (Wild w2) 32.118 (1)*** 58.025 (14)*** 26.587 (1)*** 72.910 (14)*** 4,826.232 (1)*** 65.684 (14)***
Sample size 1,200 1,200 1,200 1,200 1,200 1,200

Note. Coefficients (b) are adjusted for clustering with robust standard errors (SE) in parentheses.
*p < .05. **p < .005. ***p < .001.
Gyasi et al. 809

health care (b ¼ .006, SE ¼ .009, p < .05). In Model 6, however, while

health variables of comorbidities and ADLs significantly increased fre-
quency of HCU, the association between financial inclusion and frequency
of HCU remained negative but lost its significance (b ¼ .020, SE ¼ .011,
p > .05). This implies that the frequency of HCU among older people is
largely explained by physical health status.
A sensitivity analyses were conducted (results not shown). The results
showed that the ownership of bank account and Susu account significantly
improved both mental and SRH outcomes, but their relationships with health
services use were not robust. Also, being a member of credit union and
ownership of Mobile Money account were associated with increased health
services use and reduced PD among older people.

Discussion and Implications

Most nation states including the majority of those in sub-Saharan Africa
generally claim to seek to achieve the aging well paradigm, encompassing
not only an absence of ill-health but also an enhancement of health-related
quality of life and well-being in later life (Jivraj, Nazroo, Vanhoutte, &
Chandola, 2014). By employing a financial capability perspective within the
capability concept, this study sought to evaluate the associations between
financial inclusion and health and health care for community-dwelling older
people in Ghana. This study addresses an important but regionally very much
neglected topic in a local setting and provides empirical information and a
policy relevant contribution to the gerontological literature, given that it
appears to be the first study to investigate these relationships in a sub-
Saharan African context.
Adjusting for age and gender, the findings suggest that older people with
some level of financial engagement were more likely to report better SRH
and lower levels of PD but were, perhaps surprisingly, less likely to use
health services. These results suggest that in Ghana, financial capability and
security likely have profound implications for health and well-being out-
comes of older people. Again, one might suggest that healthy people use
fewer health care services and that having money or monetary knowledge
and resources are strongly associated with better health and other socioeco-
nomic resources. The findings partly reinforce certain previous findings
although these are predominantly from high-income countries such as the
United States (Aguila et al., 2016) and the United Kingdom (Finkelstein
et al., 2012; Taylor et al., 2009), which show that financial inclusion posi-
tively affects the health status of older people. For example, social health
810 Research on Aging 41(8)

insurance protection and ownership of a bank account had the tendency to

reduce mental ill-health among older people in the United States and some
emerging economies (Aguila et al., 2016) despite sociocultural differences.
Other studies note that gains in financial services inclusion potentially
enabled older persons to maintain independence, reduced stigma, and stereo-
typing (Adams, White, Moffatt, Howel, & Mackintosh, 2006).
Moreover, being engaged in financial markets can reduce stress, anxiety,
and worries which may enhance psychological health and well-being of older
adults, irrespective of their income statuses (Abbott, Hobby, & Cotter, 2005;
Aguila, Kapteyn, & Smith, 2015; Aguila et al., 2016). Better psychological
well-being could also potentially improve a myriad of physical health prob-
lems which intend to reduce the rate of medical consultations and health
service consumption, as noted in the popular perspective of the biopsycho-
social model (Engel, 1977, 1980; Hajek et al., 2017). Our findings, therefore,
support the view that financial inclusion is a relevant pathway to empower
older people toward improving their general health-related quality of life and
well-being.
Although the significant positive associations between financial inclusion
and health outcomes persisted after adjusting for all socioeconomic, lifestyle,
and health-related factors, the findings showed a reduced magnitude for SRH
and an increased effect size of PD. This suggests that, while paid employ-
ment and absence of ADLs contribute to better SRH (Gyasi & Phillips,
2018b), factors such as marriage, living with meaningful others, and lack
of NCDs and ADLs also play an important role in reducing PD among older
people. Typically, marital cohabitation and wider social support have strong
linkages with older persons’ capacities to achieve and to maintain both better
physical and mental health outcomes (Gyasi & Phillips, 2019; Gyasi et al.,
2018; Hajek et al., 2017; Kauppi et al., 2017; Kemp, Arias, & Fisher, 2017;
Stoeckel & Litwin, 2016). Marriage may also provide a sense of cohesion,
security, be a coping resource and potentially offset stress among older
persons. Further, those who are embedded in larger, stronger or denser con-
stellations of supportive social networks also tend to live healthier and longer
lives with less evidence of PD compared with the socially isolated (Gyasi,
Phillips, & Abass, 2018; Holt-Lunstad, Smith, & Layton, 2010; Smith &
Christakis, 2008; Yang et al., 2016).
Supplementary findings of our analyses showed that the ownership of
bank, Susu, and mobile money accounts, as well as membership of credit
union, were significantly important financial instruments relating to health
and health care of older people. While to a larger extent, the findings are not
surprising because of the view that the identified financial services are most
Gyasi et al. 811

commonly patronized among the Ghanaian general population (Bank of

Ghana, 2018), these observations may present key implications for policy.
Efforts to improve financial inclusion among older people should be cogni-
zance of the specific financial instruments.
Moreover, while not our focus here, higher socioeconomic and better
health status as a whole accounted for some portion of the effects of financial
inclusion on SRH and psychological health outcomes in older Ghanaians.
The analysis also showed an insignificant relationship between financial
inclusion and HCU with the introduction of theoretically relevant covariates.
This indicates that the frequency of health services use is more a function of
health-related variables (Gyasi et al., 2018) rather than financial inclusion
instruments per se. Importantly, the finding that financial inclusion does not
predict health care use in the presence of other variables is an interesting one.
Further exploratory analysis pursuing this relationship may be instructive.
Some evidence suggests that countries such as India and South Africa
among other LMICs have started operating universal opening of checking
bank accounts for their general populations as a means to reduce cash han-
dling and transfers in cash (Adam et al., 2018; Aker et al., 2011; Goldberg,
2014). Engaging in electronic payments may indeed reduce the costs of
economic transactions and increase financial inclusion of poor and vulnera-
ble groups including older people. In the context of LMICs, for example,
South Africa has transitioned to electronic payments including shifting from
cash distribution to mobile money distribution to aid payments. Other coun-
tries like Kenya and Ghana are introducing similar practices through “M-
Pesa” and “MoMo” respectively (Aker et al., 2011; Goldberg, 2014; Mensah
& Dzokoto, 2011). Although these arrangements may vary with the quality
of the local banking infrastructure, especially in terms of saving capacities,
opportunities to consume a wider variety of goods and to incorporate welfare
of beneficiaries, stakeholders in various sub-Saharan African countries
including Ghana are increasingly expected which may potentially safeguard
the general well-being in later life.
Despite the novelty and strengths of the current study, we need to
consider a number of limitations associated with these findings. The
cross-sectional data used mean that findings are restricted as they are
unable to account for unobserved individual characteristics. This does
not allow the establishment of causal relationships between variables of
interest. While our measure for financial inclusion, a composite of seven
individual financial activities, appears unique, a self-created indicator
that has not been previously tested in the literature could be limited in
strength and incomparability with previous findings. However, it
812 Research on Aging 41(8)

provides a new insight which may be replicated in future research. Most

studies break down the components and often use ownership of a bank
account as the most basic level of financial inclusion; though as men-
tioned, a bank account is often an unrealistic expectation especially in
the informal economies of most rural areas in this group of countries. In
addition, as financial inclusion and HCU variables were collected retro-
spectively through self-reporting, recall and reporting biases become
almost inevitable. Nevertheless, most epidemiological studies have used
self-reported data, and these biases are generally not deemed substantial
enough to severely undermine the value of the findings. We also
acknowledge a two-way causality limitation regarding health outcomes
and financial inclusion since health indicators of SRH and PD could also
potentially influence financial inclusion. However, this was not included
in the objectives of the current study. Therefore, we suggest that future
studies consider an investigation into the two-way causal relationship
between health outcomes and financial inclusion in later life.

Conclusions
The findings of this study provide some compelling evidence to support the
general premise that financial services inclusion and engagement enhance
health-related outcomes and may help to protect older adults from many
catastrophic consequences of health shocks. However, certain socioeco-
nomic and health factors contribute to the associations between financial
inclusion and SRH, mental health, and health-seeking behavior. Providing
opportunities for older persons’ involvement in financial inclusion as a
means to improve health outcomes appears likely to be a strategic and viable
approach within a smart-aging agenda. Social policies and microlevel efforts
targeted at maintaining and restoring the good health of older persons should
include expanding financial inclusion options as a way to improve well-
being and health-related quality of life among community-dwelling older
people in sub-Saharan Africa and Ghana in particular.

Authors’ Note
Razak M. Gyasi conceived and designed the study under the PhD supervision of
David R. Phillips, supervised the fieldwork, analyzed the data, and wrote the initial
version of the manuscript. David R. Phillips and Anokye M. Adam undertook
critical review and revision of the manuscript. All authors read and approved the
final manuscript.
Gyasi et al. 813

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This work was supported by Lingnan
University, Hong Kong, through its Studentship Package for Research Postgraduates
(RPG-1129310). The funders, however, played no role in designing the study, col-
lecting and analyzing data, manuscript preparation, and the decision to publish the
manuscript.

ORCID iD
Razak M. Gyasi https://orcid.org/0000-0002-6733-1539

Note
1. The model of Susu connotes a system of informal credit and savings club arrange-
ment scheme between a small group of people (particularly among friends and
family members) which has been popularized in most parts of West Africa and
Caribbean. In its operation, each member of the group makes a standard contri-
bution to a common fund once per time period (mostly daily or weekly), and the
total contribution is reimbursed to a single member of the group within a specified
time frame (Alabi, Alabi, & Ahiawodzi, 2007; Bank of Ghana, 2018). This is an
important and alternative means of accessing capital when traditional lending is
not readily available particularly among the low-income groups in the informal
sector.

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Author Biographies
Razak M. Gyasi, PhD, is a Postdoctoral Research Scientist at the Aging and Devel-
opment Unit of the African Population and Health Research Center, Nairobi, Kenya.
His research/publications focus on aging and health, social protection for older peo-
ple, experiences of old age, and behavioral change and later life health-seeking
behavior. His recent publications appear in The Gerontologist, Journals of Gerontol-
ogy Social Sciences, Journal of Aging and Health, Archives of Gerontology and
Geriatrics, International Psychogeriatrics, Women & Health, Journal of Alternative
and Complementary Medicine, Ageing International, and among others.
Anokye M. Adam, PhD, is a Senior Lecturer at the Department of Finance, School of
Business, University of Cape Coast. His research interests include aging, retirement
and financial planning, financial literacy, currency and monetary union, and applied
financial macroeconomics. His recent publications on financial literacy, retirement,
and financial planning appear in International Journal of Social Economics and
820 Research on Aging 41(8)

Business and Economic Horizons including a book on Financial Econometrics (A. M.

Adam & P. J. Owusu, 2017) published by Nova Science Publishers.

David R. Phillips, PhD, is Chair Professor of Social Policy at the Department of

Sociology and Social Policy, Lingnan University. He has research interests in social
gerontology, aging, global health, and social epidemiology. He has published widely
in these research areas. His book Global Health recently appeared in a second edition
(K. McCracken & D. R. Phillips, Routledge, 2017) and has been an advisor/resource
person to the World Health Organization and other international agencies. Other
papers appear in The Gerontologist, Journals of Gerontology Social Sciences, Jour-
nal of Aging and Health, International Psychogeriatrics, and Women & Health.