Publications

2020
Guy Harling, Lindsay Kobayashi, Meagan Farrell, Wagner RG, Stephen M Tollman, and Lisa F Berkman. 9/2020. “Social contact, social support, and cognitive health in a population-based study of middle-aged and older men and women in rural South Africa.” Social Science & Medicine, 260. Publisher's VersionAbstract

Background
Several theories seek to explain how social connections and cognitive function are interconnected in older age. These include that social interaction protects against cognitive decline, that cognitive decline leads to shedding of social connections and that cognitive decline leads to increased instrumental support. We investigated how patterns of social contact, social support and cognitive health in rural South Africa fit with these three theories.

Method
We used data from the baseline of "Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa" (HAALSI), a population-based study of 5059 individuals aged ≥ 40 years. We evaluated how a range of social connectedness measures varied by respondents' cognitive function.

Results
We found that respondents with lower cognitive function had smaller, denser social networks that were more local and more kin-based than their peers. Lower cognitive function was associated with receipt of less social support generally, but this difference was stronger for emotional and informational support than for financial and physical support. Impairment was associated with greater differences among those aged 40-59 and those with any (versus no) educational attainment.

Conclusions
The patterns we found suggest that cognitively impaired older adults in this setting rely on their core social networks for support, and that theories relating to social connectedness and cognitive function developed in higher-income and highereducation settings may also apply in lower-resource settings elsewhere in the world.

Simone A Tomaz, Justine I Davies, Lisa K Micklesfield, Alisha N Wade, Kathleen Kahn, Stephen M Tollman, Catherine E Draper, and Miles D Witham. 8/31/2020. “Self-Reported Physical Activity in Middle-Aged and Older Adults in Rural South Africa: Levels and Correlates.” Int. J. Environ. Res. Public Health, 17, 17. Publisher's VersionAbstract
Little is known about physical activity (PA) levels and correlates in adults from rural settings in South Africa, where a rapid increase in the number of older people and marked disparities in wealth are evident, particularly between those living in rural and urban areas. This paper describes levels of self-reported PA in rural South African men and women and examines factors associated with meeting PA guidelines. Global Physical Activity Questionnaire (GPAQ) data from the Health and Aging in Africa: Longitudinal studies of INDEPTH communities (HAALSI) survey of 5059 adults aged over 40 years were assessed. Logistic regression analyses were used to assess socio-demographic, functional and cognitive capacity, and chronic disease measures associated with PA. In addition, 75.4% (n = 3421) of the participants with valid GPAQ data (n = 4538 of 5059) met the PA guidelines. Factors associated with not the meeting PA guidelines were being male, over the age of 80 years, being in a higher wealth category, obesity, and poorer functional capacity. These findings highlight worthwhile targets for future interventions to maintain or improve PA levels in this population and suggest that intervening earlier within this age range (from 40 years) may be crucial to prevent the ‘spiral of decline’ that characterizes the frailty syndrome. 
Lindsay C Kobayashi, Meagan T Farrell, Collin F Payne, Sumaya Mall, Livia Montana, Ryan G Wagner, Kathleen Kahn, Stephen Tollman, and Lisa F Berkman. 7/23/2020. “Adverse childhood experiences and domain-specific cognitive function in a population-based study of older adults in rural South Africa.” Psychology and Aging, online. Publisher's VersionAbstract
Research on early life adversity and later-life cognitive function is conflicting, with little evidence from low-income settings. We investigated associations between adverse childhood experiences and cognitive function in an older population who grew up under racial segregation during South African apartheid. Data were from 1,871 adults aged 40–79 in the population-representative “Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa” in 2015. The adverse childhood experiences were having a parent unemployed for > 6 months; having parents who argued or fought often; having a parent who drank excessively, used drugs, or had mental health problems; and physical abuse from parents. Executive function, language, visuospatial ability, and memory were assessed with the Oxford Cognitive Screen-Plus, a validated cognitive assessment designed for low-income, low-literacy settings. We estimated associations between adverse childhood experiences and latent cognitive domain z-scores using multiple-indicator, multiple-cause structural equation models. Childhood adversities were reported by 15% (parental unemployment for > 6 months), 25% (parents argued or fought often), 25% (a parent drank excessively, used drugs, or had mental health problems), and 35% (physical abuse from parent) of respondents. They were not associated with cognition, except that having a parent who drank excessively, used drugs, or had mental health problems was associated with lower memory z-scores (−0.07; 95% CI [−0.13, −0.01]). This is one of the first investigations into later-life cognitive outcomes associated with early adversity in a population with a historical context of pervasive trauma, and suggests that later-life memory may be vulnerable to early adversity.
Stephen B. Asiimwe, Livia Montana, Kathleen Kahn, Stephen M. Tollman, Kabudula W. Chodziwadziwa, Xavier F. Gómez-Olivé, Lisa F. Berkman, Maria M. Glymour, and Till Bärnighausen. 6/5/2020. “HIV Status and Antiretroviral Therapy as Predictors of Disability among Older South Africans: Overall Association and Moderation by Body Mass Index.” Journal of Aging and Health, Pp. 0898264320925323. Publisher's VersionAbstract
Objectives: Among older people living with HIV (PLWH) and comparable individuals without HIV, we evaluated whether associations of HIV and antiretroviral therapy (ART) with disability depend on body mass index (BMI). Methods: We analyzed 4552 participants in the “Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa.” (HAALSI) We compared prevalence of disability (≥1 impairment in basic activities of daily living) by HIV status, ART use, and BMI category, adjusting for age, sex, education, father’s occupation, country of origin, lifetime alcohol use, and primary health-care utilization. Results: Among PLWH, those underweight had 9.8% points (95% confidence interval (CI): 1.2 to 18.4) higher prevalence of disability than those with normal BMI. Among ART users, those underweight had 11.9% points (95% CI: 2.2 to 21.6) higher prevalence of disability than those with normal BMI. Conclusions: We found no evidence that weight improvement associated with ART use is likely to increase disability.
F. Xavier Gómez-Olivé, Brian Houle, Molly Rosenberg, Chodziwadziwa Kabudula, Sanyu Mojola, Julia K Rohr, Samuel Clark, Nicole Angotti, Enid Schatz, Kathleen Kahn, Till Bärnighausen, and Jane Menken. 6/2/2020. “HIV incidence among older adults in a rural South African setting, 2010-2015.” JAIDS Journal of Acquired Immune Deficiency Syndromes. Publisher's VersionAbstract

In South Africa evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people’s HIV incidence.

Methods: 
We used a 2010-11 cohort of HIV negative adults in rural South Africa who were 40 years or older at retest in 2015-16, to estimate HIV incidence over a five-year period. We used Poisson regression to measure the association of HIV seroconversion with demographic and behavioral covariates. We used inverse probability sampling weights to adjust for nonresponse in 2015, based on a logistic regression with predictors of sex and age group at August 2010.

Results: 
HIV prevalence increased from 21% at baseline to 23% in the follow-up survey. From a cohort of 1360 individuals, 33 seroconverted from HIV-negative at baseline, giving an overall HIV incidence rate of 0.39 per 100 person-years (95% CI 0.28-0.57). Rate for women was 0.44 (95% CI 0.30-0.67), double that for men, 0.21 (95% CI 0.10-0.51). The IRRs again show women’s risk of seroconverting double that of men (IRR=2.04, p-value = 0.098). Past age 60 the IRR of seroconversion were significantly lower than for those in their 40s (60-69, IRR=0.09, p-value=0.002; 70-79, IRR=0.14, p-value = 0.010).

Conclusion: 
The risk of acquiring HIV is not zero for people over 50, especially women. Our findings highlight the importance of acknowledging that older people are at high risk of HIV infection and that HIV prevention and treatment campaigns must take them into consideration.

Collin F. Payne, Sumaya Mall, Lindsay Kobayashi, Kathy Kahn, and Lisa Berkman. 4/24/2020. “Life-Course Trauma and Later Life Mental, Physical, and Cognitive Health in a Postapartheid South African Population: Findings From the HAALSI study.” Journal of Aging and Health, Pp. 0898264320913450. Publisher's VersionAbstract
Objective: To investigate the relationships between exposure to life-course traumatic events (TEs) and later life mental, physical, and cognitive health outcomes in the older population of a rural South African community. Method: Data were from baseline interviews with 2,473 adults aged ≥40 years in the population-representative Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) study, conducted in 2015. We assessed exposure to 16 TEs, and used logistic regression models to estimate associations with depression, post-traumatic stress disorder (PTSD), activities of daily living disability, and cognitive impairment. Results: Participants reported an average of 5 (SD = 2.4) TEs over their lifetimes. Exposure was ubiquitous across sociodemographic and socioeconomic groups. Trauma exposure was associated with higher odds of depression, PTSD, and disability, but not with cognitive health. Discussion: Results suggest that TEs experienced in earlier life continue to reverberate today in terms of mental health and physical disability outcomes in an older population in rural South Africa.
Meagan T Farrell, Lindsay C Kobayashi, Livia Montana, Ryan G Wagner, Nele Demeyere, and Lisa Berkman. 3/25/2020. “Education Disparity Only Partially Explains Cognitive Gender Differences in Older Rural South Africans.” The Journals of Gerontology: Series B. Publisher's VersionAbstract
Direction and magnitude of gender differences in late-life cognitive function are inextricably tied to sociocultural context. Our study evaluates education and literacy in rural South Africa as primary drivers of gender inequality in late-life cognitive function.Data were collected on 1,938 participants aged 40-79 from Agincourt, South Africa. Cognitive function was measured via the Oxford Cognitive Screen-Plus, a tablet-based assessment with low literacy demands. Four cognitive domains were derived through confirmatory factor analysis: episodic memory, executive function, visual spatial, and language. Structural equation models tested domain-specific gender effects, incrementally controlling for demographic, education, health, and socioeconomic variables.In the model adjusting only for demographic factors, men outperformed women on executive function and visual spatial domains. Adding education and literacy to the model revealed a robust female advantage in episodic memory, and reduced the magnitude of male advantage in executive function and visual spatial by 47\% and 42\%, respectively. Health and socioeconomic factors did not alter patterns of gender associations in subsequent models.In this older South African cohort, gender inequality in cognitive performance was partially attributable to educational differences. Understanding biopsychosocial mechanisms that promote cognitive resilience in older women is critically important given the predominantly female composition of aging populations worldwide.
M. Rosenberg, FX Gómez-Olivé, RG Wagner, Julia K Rohr, CF Payne, L Berkman, K Kahn, Stephen Tollman, T Bärnighausen, and L Kobayashi. 3/23/2020. “The relationships between cognitive function, literacy and HIV status knowledge among older adults in rural South Africa.” J Int AIDS Soc, 23, 3, Pp. e25457. Publisher's Version
2019
Jennifer Manne-Goehler, Julia Rohr, Livia Montana, Mark Siedner, Guy Harling, F. Xavier Gómez-Olivé, Pascal Geldsetzer, Ryan Wagner, Lubbe Wiesner, Kathleen Kahn, Stephen Tollman, and Till W. Bärnighausen. 2019. “ART Denial: Results of a Home-Based Study to Validate Self-reported Antiretroviral Use in Rural South Africa.” AIDS and Behavior, 23, 8, Pp. 2072–2078. Publisher's VersionAbstract
There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40þinspace}+. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61–68%) and the specificity was 94% (95% CI 91–96%); the positive predictive value (PPV) was 96% (95% CI 94–98%) and negative predictive value (NPV) was 52% (95% CI 48–56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region.
Angela Y Chang, Francesc Xavier Gómez-Olivé, Collin Payne, Julia K Rohr, Jennifer Manne-Goehler, Alisha N Wade, Ryan G Wagner, Livia Montana, Stephen Tollman, and Joshua A Salomon. 2019. “Chronic multimorbidity among older adults in rural South Africa.” BMJ Global Health, 4, 4. Publisher's VersionAbstract
Introduction The rapid ageing of populations around the world is accompanied by increasing prevalence of multimorbidity. This study is one of the first to present the prevalence of multimorbidity that includes HIV in the complex epidemiological setting of South Africa, thus filling a gap in the multimorbidity literature that is dominated by studies in high-income or low-HIV prevalence settings.Methods Out of the full sample of 5059 people aged 40+, we analysed cross-sectional data on 10 conditions from 3889 people enrolled in the Health and Ageing in Africa: A longitudinal study of an INDEPTH Community in South Africa (HAALSI) Programme. Two definitions of multimorbidity were applied: the presence of more than one condition and the presence of conditions from more than one of the following categories: cardiometabolic conditions, mental disorders, HIV and anaemia. We conducted descriptive and regression analyses to assess the relationship between prevalence of multimorbidity and sociodemographic factors. We examined the frequencies of the most prevalent combinations of conditions and assessed relationships between multimorbidity and physical and psychological functioning.Results 69.4 per cent (95% CI 68.0 to 70.9) of the respondents had at least two conditions and 53.9% (52.4–55.5) of the sample had at least two categories of conditions. The most common condition groups and multimorbid profiles were combinations of cardiometabolic conditions, cardiometabolic conditions and depression, HIV and anaemia and combinations of mental disorders. The commonly observed positive relationships between multimorbidity and age and decreasing wealth were not observed in this population, namelydue to different epidemiological profiles in the subgroups, with higher prevalence of HIV and anaemia in the poorer and younger groups, and higher prevalence of cardiometabolic conditions in the richer and older groups. Both physical functioning and well-being negatively associated with multimorbidity.Discussion More coordinated, long-term integrated care management across multiple chronic conditions should be provided in rural South Africa.
Brian Houle, Thomas Gaziano, Meagan Farrell, Xavier F Gómez-Olivé, Lindsay C Kobayashi, Nigel J Crowther, Alisha N Wade, Livia Montana, Ryan G Wagner, Lisa Berkman, and Stephen M Tollman. 2019. “Cognitive function and cardiometabolic disease risk factors in rural South Africa: baseline evidence from the HAALSI study.” BMC Public Health, 19, 1, Pp. 1579.Abstract
BACKGROUND: Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa. METHODS: We use baseline data from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0-26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders. RESULTS: In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50-67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = - 1.11 [95% confidence interval: - 2.01, - 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = - 0.87 [CI: - 1.48, - 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive). CONCLUSIONS: We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.
Carlos Riumallo-Herl, David Canning, and Chodziwadziwa Kabudula. 2019. “Health inequalities in the South African elderly: The importance of the measure of social-economic status.” The Journal of the Economics of Ageing. Publisher's VersionAbstract
A common approach when studying inequalities in health is to use a wealth index based on household durable goods as a proxy for socio-economic status. We test this approach for elderly health using data from an aging survey in a rural area of South Africa and find much steeper gradients for health with consumption adjusted for household size than with the wealth index. These results highlight the importance of the measure of socioeconomic status used when measuring health gradients, and the need for direct measures of household consumption or income in ageing studies.
Supa Pengpid and Karl Peltzer. 2019. “High Sedentary Behavior Is Associated with Depression among Rural South Africans.” International Journal of Environmental Research and Public Health, 16, 8. Publisher's VersionAbstract
The study aimed to investigate the association between sedentary behavior and depression among rural South Africans. Data were analyzed from the cross-sectional baseline survey of the “Health and Aging in Africa: A Longitudinal Study of an INDEPTH community in South Africa (HAALSI)”. Participants responded to various measures, including sociodemographic information, health status, anthropometric measures, and sedentary behavior. The sample included 4782 persons (40 years and above). Overall, participants engaged in <4 h (55.9%), 4–<8 h (34.1%), 8–<11 h (6.4%), or 11 or more h a day (3.5%) of sedentary behavior, and 17.0% screened positive for depression. In multivariable logistic regression, which was adjusted for sociodemographic variables (Model 1) (Odds Ratio, or OR: 2.45, Confidence Interval, or CI: 1.74, 3.46) and adjusted for sociodemographic and health variables, including physical activity (Model 2) (OR: 3.00, CI: 2.00, 4.51), high sedentary time (≥11 h) was independently associated with depression. In combined analysis, compared to persons with low or moderate sedentary behavior (<8 h) and moderate or high physical activity, persons with high sedentary behavior (≥8 h) and low physical activity were more likely to have depression in Model 1 (OR: 1.60, CI: 1.65, 3.13) and Model 2 (OR: 1.60, CI: 1.05, 2.44). Findings support that sedentary behavior and combined sedentary behavior and low physical activity may be a modifiable target factor for strategies to reduce depression symptoms in this rural population in South Africa.
Julia K Rohr, Jennifer Manne-Goehler, Francesc Xavier Gómez-Olivé, Ryan G Wagner, Molly Rosenberg, Pascal Geldsetzer, Chodziwadziwa Kabudula, Kathleen Kahn, Stephen Tollman, Till Bärnighausen, and Joshua A Salomon. 2019. “HIV treatment cascade for older adults in rural South Africa.” Sexually Transmitted Infections. Publisher's VersionAbstract
Objectives The HIV treatment cascade is a powerful framework for understanding progress from initial diagnosis to successful treatment. Data sources for cascades vary and often are based on clinical cohorts, population cohorts linked to clinics, or self-reported information. We use both biomarkers and self-reported data from a large population-based cohort of older South Africans to establish the first HIV cascade for this growing segment of the HIV-positive population and compare results using the different data sources.Methods Data came from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) 2015 baseline survey of 5059 adults aged 40+ years. Dried blood spots (DBS) were screened for HIV, antiretroviral drugs and viral load. In-home surveys asked about HIV testing, diagnosis and antiretroviral therapy (ART) use. We calculated proportions and CIs for each stage of the cascade, conditional on attainment of the previous stage, using (1) biomarkers, (2) self-report and (3) both biomarkers and self-report, and compared with UNAIDS 90-90-90 targets.Results 4560 participants had DBS results, among whom 1048 (23%) screened HIV-positive and comprised the denominator for each cascade. The biomarker cascade showed 63% (95% CI 60 to 66) on ART and 72% (95% CI 69 to 76) of those on ART with viral suppression. Self-reports underestimated testing, diagnosis and ART, with only 47% (95% CI 44 to 50) of HIV-positive individuals reporting ART use. The combined cascade indicated high HIV testing (89% (95% CI 87 to 91)), but lower knowledge of HIV-positive status (71% (95% CI 68 to 74)).Conclusions Older South Africans need repeated HIV testing and sustained ART to reach 90-90-90 targets. HIV cascades relying on self-reports are likely to underestimate true cascade attainment, and biomarkers provide substantial improvements to cascade estimates.
Jennifer Manne-Goehler, Mark J Siedner, Livia Montana, Guy Harling, Pascal Geldsetzer, Julia Rohr, F Xavier Gómez-Olivé, Alexander Goehler, Alisha Wade, Thomas Gaziano, Kathleen Kahn, Justine I Davies, Stephen Tollman, and Till W Bärnighausen. 2019. “Hypertension and diabetes control along the HIV care cascade in rural South Africa.” Journal of the International AIDS Society, 22, 3, Pp. e25213. Publisher's VersionAbstract
Abstract Introduction Participation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators. Methods The Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population-based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV-1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV-negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots. Results and discussion Compared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV-negative. Conclusions Participants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV-negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease.
Lindsay C Kobayashi, Farrah J Mateen, Livia Montana, Ryan G Wagner, Kathleen Kahn, Stephen M Tollman, and Lisa F Berkman. 2019. “Cognitive Function and Impairment in Older, Rural South African Adults: Evidence from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in Rural South Africa".” Neuroepidemiology, 52, 1-2, Pp. 32-40. Publisher's VersionAbstract
BACKGROUND/AIMS: We aimed to estimate the prevalence of cognitive impairment, and the sociodemographic and comorbid predictors of cognitive function among older, rural South African adults. METHODS: Data were from a population-based study of 5,059 adults aged ≥40 years in rural South Africa in 2015. Cognitive impairment was defined as scoring ≤1.5 SDs below the mean composite time orientation and memory score, or requiring a proxy interview with "fair" or "poor" proxy-reported memory. Multiple linear regression estimated the sociodemographic and comorbid predictors of cognitive score, with multiplicative statistical interactions between each of age and sex with education. RESULTS: Cognitive impairment increased with age, from 2% of those aged 40-44 (11/516) to 24% of those aged ≥75 years (214/899). The independent predictors of lower cognitive score were being older, female, unmarried, not working, having low education, low household wealth, and a history of cardiovascular conditions. Education modified the negative associations between female sex, older age, and cognitive function score. CONCLUSIONS: The prevalence of cognitive impairment increased with age and is comparable to rates of dementia reported in other sub-Saharan African countries. Age and sex differences in cognitive function scores were minimized as education increased, potentially reflecting the power of even poor-quality education to improve cognitive reserve.
Guy Harling, Collin F. Payne, Justine I. Davies, F. Xavier Gomez-Olive, Kathleen Kahn, Lenore Manderson, Farrah J. Mateen, Stephen M. Tollman, and Miles D. Witham. 2019. “Impairment in Activities of Daily Living, Care Receipt, and Unmet Needs in a Middle-Aged and Older Rural South African Population: Findings From the HAALSI Study.” Journal of Aging and Health, Pp. 0898264318821220. Publisher's VersionAbstract
Objectives: The objective of this study is to analyze the degree to which care needs are met in an aging rural African population. Method: Using data from the Health and Aging in Africa: Longitudinal Study of an INDEPTH Community (HAALSI) baseline survey, which interviewed 5,059 adults aged older than 40 years in rural South Africa, we assessed the levels of limitations in activities of daily living (ADLs) and in unmet care for these ADLs, and evaluated their association with sociodemographic and health characteristics. Results: ADL impairment was reported by 12.2% of respondents, with the proportion increasing with age. Among those with ADL impairment, 23.9% reported an unmet need and 51.4% more a partially met need. Relatives provided help most often; formal care provision was rare. Unmet needs were more frequent among younger people and women, and were associated with physical and cognitive deficits, but not income or household size. Discussion: Unmet care needs in rural South Africa are often found among individuals less expected to require care.
Angela Y Chang, FX Gómez-Olivé, Jennifer Manne-Goehler, Alisha N Wade, Stephen M Tollman, Thomas A Gaziano, and Joshua A. Salomon. 2019. “Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa.” Bulletin of the World Health Organization, 97, 1, Pp. 10-23. Publisher's VersionAbstract
Objective To examine how multimorbidity might affect progression along the continuum of care among older adults with hypertension, diabetes and human immunodeficiency virus (HIV) infection in rural South Africa.
Methods We analysed data from 4447 people aged 40 years or older who were enrolled in a longitudinal study in Agincourt sub-district. Household-based interviews were completed between November 2014 and November 2015. For hypertension and diabetes (2813 and 512 people, respectively), we defined concordant conditions as other cardiometabolic conditions, and discordant conditions as mental disorders or HIV infection. For HIV infection (1027 people) we defined any other conditions as discordant. Regression models were fitted to assess the relationship between the type of multimorbidity and progression along the care continuum and the likelihood of patients being in each stage of care for the index condition (four stages from testing to treatment).
Findings People with hypertension or diabetes plus other cardiometabolic conditions were more like to progress through the care continuum for the index condition than those without cardiometabolic conditions (relative risk, RR: 1.14, 95% confidence interval, CI: 1.09–1.20, and RR: 2.18, 95% CI: 1.52–3.26, respectively). Having discordant comorbidity was associated with greater progression in care for those with hypertension but not diabetes. Those with HIV infection plus cardiometabolic conditions had less progress in the stages of care compared with those without such conditions (RR: 0.86, 95% CI: 0.80–0.92).
Conclusion Patients with concordant conditions were more likely to progress further along the care continuum, while those with discordant multimorbidity tended not to progress beyond diagnosis. 
2018
Elyse A. Jennings, Nolwazi Mkhwanazi, and Lisa Berkman. 12/6/2018. “Receipt of emotional support among rural South African adults.” Ageing and Society, Pp. 1–25. Publisher's Version
Gómez-Olivé FX, Julia K Rohr, Laura C Roden, Dale E Rae, and Malcolm von Schantz. 11/23/2018. “Associations between sleep parameters, non-communicable diseases, HIV status and medications in older, rural South Africans.” Scientific Reports, 8, 1. Publisher's VersionAbstract
As part of the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we investigated sleep habits and their interactions with HIV or non-communicable diseases (NCDs) in 5059 participants (median age: 61, interquartile range: 52—71, 54% females). Self-reported sleep duration was 8.2 ± 1.6h, and bed and rise times were 20:48 ± 1:15 and 05:31 ± 1:05 respectively. Ratings of insufficient sleep were associated with older age, lack of formal education, unemployment, and obesity (p < 0.05). Ratings of restless sleep were associated with being older, female, having more education, being unemployed, and single. Hypertension was associated with shorter self-reported sleep duration, poor sleep quality, restless sleep, and periods of stopping breathing during the night (p < 0.05). HIV positive individuals not on antiretroviral treatment (ART) reported more nocturnal awakenings than those on ART (p = 0.029) and HIV negative individuals (p = 0.024), suggesting a negative net effect of untreated infection, but not of ART, on sleep quality. In this cohort, shorter, poor-quality sleep was associated with hypertension, but average self-reported sleep duration was longer than reported in other regions globally. It remains to be determined whether this is particular to this cohort, South Africa in general, or low- to middle-income countries undergoing transition.

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