Publications

2022
Collin Payne, Brian Houle, Chido Chinogurei, Carlos Riumallo Herl, Chodziwadziwa Whiteson Kabudula, Lindsay C Kobayashi, Joshua A Salomon, and Jennifer Manne-Goehler. 9/28/2022. “Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study.” The Lancet HIV, 9, 10, Pp. e709 - e716. Publisher's VersionAbstract
Background
The population of people living with HIV in South Africa is rapidly ageing due to increased survivorship attributable to antiretroviral therapy (ART). We sought to understand how the combined effects of HIV and ART have led to differences in healthy longevity by HIV status and viral suppression in this context.
Methods
In this observational cohort modelling study we use longitudinal data from the 2015 baseline interview (from Nov 13, 2014, to Nov 30, 2015) and the 2018 longitudinal follow-up interview (from Oct 12, 2018, to Nov 7, 2019) of the population-based study Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) to estimate life expectancy and disability-free life expectancy (DFLE) of adults aged 40 years and older in rural South Africa. Respondents who consented to HIV testing, responded to survey questions on disability, and who were either interviewed in both surveys or who died between survey waves were included in the analysis. We estimate life expectancy and DFLE by HIV status and viral suppression (defined as <200 copies per mL) using Markov-based microsimulation.
Findings
Among the 4322 eligible participants from the HAALSI study, we find a clear gradient in remaining life expectancy and DFLE based on HIV serostatus and viral suppression. At age 45 years, the life expectancy of a woman without HIV was 33·2 years (95% CI 32·0–35·0), compared with 31·6 years (29·2–34·1) a woman with virally suppressed HIV, and 26·4 years (23·1–29·1) for a woman with unsuppressed HIV; life expectancy for a 45 year old man without HIV was 27·2 years (25·8–29·1), compared with 24·1 years (20·9–27·2) for a man with virally suppressed HIV, and 17·4 years (15·0–20·3) for a man with unsuppressed HIV. Men and women with viral suppression could expect to live nearly as many years of DFLE as HIV-uninfected individuals at ages 45 years and 65 years.
Interpretation
These results highlight the tremendous benefits of ART for population health in high-HIV-prevalence contexts and reinforce the need for continued work in making ART treatment accessible to ageing populations.
Carlos Riumallo Herl, Chodziwadziwa Kabudula, Kathleen Kahn, Stephen Tollman, and David Canning. 9/6/2022. “Pension exposure and health: Evidence from a longitudinal study in South Africa.” The Journal of the Economics of Ageing, 23, Pp. 100411. Publisher's VersionAbstract
Social protection schemes have been expanding around the world with the objective of protecting older persons during retirement. While theoretically they have been seen as tools to improve individual wellbeing, there are few studies that evaluate whether social pensions can improve health. In this study, we exploit the change in eligibility criteria for the South African Old Age grant to estimate the association between pension exposure eligibility and health of older persons. For this, we use data from the Health and Aging in Africa: A longitudinal Study of an INDEPTH Community in South Africa (HAALSI) and model pension exposure in terms of its cumulative effect. Our results show that pension exposure is associated with better health as measured by a set of health indices. Disentangling these effects, we find that pension exposure is most likely to improve health through the delayed onset of physical disabilities in the elderly population. Our study highlights the relevance of social protection schemes as a mechanism to protect older persons physical health.
Shao-Tzu Yu, Brian Houle, Lenore Manderson, Elyse A. Jennings, Stephen M. Tollman, Lisa F. Berkman, and Guy Harling. 7/8/2022. “The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study.” SSM - Population Health, 19, Pp. 101154. Publisher's VersionAbstract
Background Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings. We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa. Method We used baseline survey data from the HAALSI study (“Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa”) among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members’ literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health. Results In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network. Conclusions Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.
Collin F Payne, Brian Houle, Chido Chinogurei, Carlos Riumallo Herl, Chodziwadziwa Whiteson Kabudula, Lindsay C Kobayashi, Joshua Salomon, and Jennifer Manne-Goehler. 3/2022. “Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study.” The Lancet Healthy Longevity, 3, Pp. S1. Publisher's VersionAbstract
Background The population of people living with HIV in South Africa is rapidly ageing. The co-incidence of demographic ageing and a high HIV burden means that understanding the combined impacts of HIV and antiretroviral therapy (ART) on healthy longevity is of key importance in South Africa. Methods We use longitudinal data from the 2015 and 2018 waves of the population-based study, Health and aging in Africa: a longitudinal study of an INDEPTH community in South Africa, to explore life expectancy and disability-free life expectancy of adults aged 45 years and older in rural South Africa. Individuals were classified into one of three health states: disability-free (defined as no reported activities of daily living [ADL] limitations), ADL disabled individuals (defined as difficulty with ≥1 ADL activities), and dead. Annual transition probabilities were modelled using multinomial logistic regression, stratified by initial disability state. We used these estimated transition probabilities as the input for a microsimulation model generating 100 000 simulated life courses, which were used to estimate life expectancy and disability-free life expectancy. CIs, which reflect both the uncertainty of the estimated parameters and the uncertainty from the microsimulation, were created by re-estimating the above analysis sequence using 499 bootstrap re-samples for each age group under study. We took the central 95% of the distribution of these bootstrapped parameters as the 95% CI. Findings We found a gradient in remaining life expectancy based on HIV serostatus and viral suppression. At age 45 years, an HIV-negative man could expect to live an additional 27·2 years (95% CI 25·8–29·1), compared with 24·1 years (20·9–27·2) for an HIV-positive, virally suppressed man (defined as <200 copies/mL) and 17·4 years (15·0–20·3) for an HIV-positive, unsuppressed man. Patterns were similar among women. Individuals achieving viral control could expect to live nearly as many disability-free years as HIV-negative individuals at age 45 years. By age 65 years, the healthy longevity of these two groups was indistinguishable. Interpretation These findings highlight the major population health and longevity gains that are possible when the 90–90–90 goals are realised. We found that viral suppression of HIV-positive individuals through ART has increased lifespan and healthspan to similar levels as observed among HIV-negative individuals. Achievement of viral suppression for millions of people with HIV, especially in high prevalence contexts such as South Africa, is critical for ensuring healthy population ageing. Funding National Institutes of Health.
Elyse A. Jennings, Chido Chinogurei, and Leslie Adams. 2022. “Marital experiences and depressive symptoms among older adults in rural South Africa.” SSM - Mental Health, 2, Pp. 100083. Publisher's VersionAbstract
This paper advances the understanding of how marital transitions may influence mental health by investigating these associations among a population of rural, Black South Africans aged 40+ that was directly impacted by apartheid. Using two waves of data from 4,176 men and women in Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we investigated associations between marital experiences and depressive symptoms, by gender, and explored whether economic resources is a moderator of these associations. We found that experiencing a marital dissolution was associated with more depressive symptoms than remaining married for both men and women. We also found that men, but not women, report greater depressive symptoms if they remained separated/divorced, remained widowed, or remained never married between waves. We found no evidence that a decline in wealth moderated the impact of marital dissolution on depressive symptoms for women or men. These findings suggest that the documented benefits of marriage for mental health, and differences by gender in those benefits, may extend to older, rural South Africans, despite the unique experiences of this population.
2021
Darina T Bassil, Meagan T Farrell, Ryan G Wagner, Adam M Brickman, Maria M Glymour, Kenneth M Langa, Jennifer J Manly, Joel Salinas, Brent Tipping, Stephen Tollman, and Lisa F Berkman. 12/6/2021. “Cohort Profile Update: Cognition and dementia in the Health and Aging in Africa Longitudinal Study of an INDEPTH community in South Africa (HAALSI dementia).” International Journal of Epidemiology. Publisher's VersionAbstract

KEY FEATURES: The Health and Aging in Africa Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) is a harmonized sister study to the US Health and Retirement Study (HRS). Established in 2015, it includes 5059 individuals aged 40 and over, in a rural community in Agincourt, South Africa.

In light of the projected rise of dementia burden in sub-Saharan Africa, the HAALSI Dementia study was launched in 2019 to investigate the prevalence, incidence and risk factors of cognitive decline and dementia in South Africa.

The HAALSI Dementia sample includes 635 individuals, 50 years and older, of whom 99 also participated in an ancillary magnetic resonance imaging (MRI) sub-study.
The HAALSI Dementia study encompasses a comprehensive, culturally sensitive cognitive battery with multidomain psychometric scales, informant interviews and neurological evaluations, and has sufficient overlap with international Harmonized Cognitive Assessment Protocol (HCAP) and HRS studies to enable cross-calibration.

Fred J Barker, Justine I Davies, Xavier F Gomez-Olive, Kathleen Kahn, Fiona E Matthews, Collin F Payne, Joshua A. Salomon, Stephen M Tollman, Alisha N Wade, Richard W Walker, and Miles D Witham. 11/2021. “Developing and evaluating a frailty index for older South Africans—findings from the HAALSI study.” Age and Ageing, 50, 6, Pp. 2167-2173. Publisher's VersionAbstract
despite rapid population ageing, few studies have investigated frailty in older people in sub-Saharan Africa. We tested a cumulative deficit frailty index in a population of older people from rural South Africa.analysis of cross-sectional data from the Health and Ageing in Africa: Longitudinal Studies of an INDEPTH Community (HAALSI) study. We used self-reported diagnoses, symptoms, activities of daily living, objective physiological indices and blood tests to calculate a 32-variable cumulative deficit frailty index. We fitted Cox proportional hazards models to test associations between frailty category and all-cause mortality. We tested the discriminant ability of the frailty index to predict one-year mortality alone and in addition to age and sex.in total 3,989 participants were included in the analysis, mean age 61 years (standard deviation 13); 2,175 (54.5\%) were women. The median frailty index was 0.13 (interquartile range 0.09–0.19); Using population-specific cutoffs, 557 (14.0\%) had moderate frailty and 263 (6.6\%) had severe frailty. All-cause mortality risk was related to frailty severity independent of age and sex (hazard ratio per 0.01 increase in frailty index: 1.06 [95\% confidence interval 1.04–1.07]). The frailty index alone showed moderate discrimination for one-year mortality: c-statistic 0.68–0.76; combining the frailty index with age and sex improved performance (c-statistic 0.77–0.81).frailty measured by cumulative deficits is common and predicts mortality in a rural population of older South Africans. The number of measures needed may limit utility in resource-poor settings.
Cassandra C Soo, Meagan T Farrell, Stephen M Tollman, Lisa F Berkman, Almut Nebel, and Michele Ramsay. 10/14/2021. “Apolipoprotein E Genetic Variation and Its Association With Cognitive Function in Rural-Dwelling Older South Africans.” Frontiers in Genetics. Publisher's Version
Eva van Empel, Rebecca A de Vlieg, Livia Montana, F. Xavier Gómez-Olivé, Kathleen Kahn, Stephan Tollman, Lisa Berkman, Till W. Bärnighausen, and Jennifer Manne-Goehler. 10/1/2021. “Older Adults Vastly Overestimate Both HIV Acquisition Risk and HIV Prevalence in Rural South Africa.” Archives of Sexual Behavior, online. Publisher's VersionAbstract
Perceptions of HIV acquisition risk and prevalence shape sexual behavior in sub-Saharan Africa (SSA). We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa baseline survey. Data were collected through home-based interviews of 5059 people ≥ 40 years old. We elicited information on perceived risk of HIV acquisition and HIV prevalence among adults ≥ 15 and ≥ 50 years old. We first describe these perceptions in key subgroups and then compared them to actual estimates for this cohort. We then evaluated the relationship between sociodemographic characteristics and accurate perceptions of prevalence in regression models. Finally, we explored differences in behavioral characteristics among those who overestimated risk compared to those who underestimated or accurately estimated risk. Compared to the actual HIV acquisition risk of < 1%, respondents vastly overestimated this risk: 35% (95% CI: 32–37) and 34% (95% CI: 32–36) for men and women, respectively. Respondents overestimated HIV prevalence at 53% (95% CI: 52–53) for those ≥ 15 years old and 48% (95% CI: 48–49) for those ≥ 50 years old. True values were less than half of these estimates. There were few significant associations between demographic characteristics and accuracy. Finally, high overestimators of HIV prevalence tested themselves less for HIV compared to mild overestimators and accurate reporters. More than 30 years into the HIV epidemic, older people in a community with hyperendemic HIV in SSA vastly overestimate both HIV acquisition risk and prevalence. These misperceptions may lead to fatalism and reduced motivation for prevention efforts, possibly explaining the continued high HIV incidence in this community.
Margaret Ralston, Elyse Jennings, and Enid Schatz. 8/5/2021. “Who is at Risk? Social Support, Relationship Dissolution, and Illness in a Rural Context*.” Sociological Inquiry, n/a, n/a. Publisher's VersionAbstract
Abstract This study focuses on a cohort of adults (40-plus) in rural South Africa to unpack associations between physical health and receipt of social support, and the extent to which these associations were moderated by marital status. We use logistic regression to estimate the odds of having received emotional, physical, or financial support separately for men (N = 2247) and women (N = 2609). Our results suggest having an Activity of Daily Living (ADL) limitation or having at least one chronic condition was not significantly associated with social support receipt for women, but having an ADL limitation was associated with reduced odds of receiving financial support among men. Although marital status was strongly and significantly associated with receipt of social support for both men and women, marital status moderated the relationship between health indicators and social support receipt only for men. Our findings suggest that when men, but not women, experience a marital dissolution and are suffering from a disability or a chronic condition, their networks respond by providing needed social support.
Elyse A. Jennings, Meagan T. Farrell, and Lindsay C. Kobayashi. 3/31/2021. “Grandchild Caregiving and Cognitive Health Among Grandparents in Rural South Africa.” Journal of Aging and Health, Pp. 08982643211006592. Publisher's VersionAbstract
Objectives: We investigate how caregiving for grandchildren is associated with cognitive function among rural South Africans, and whether the association differs by gender. We further investigate whether measures of physical activity or social engagement mediate this association. Methods: Data were from interviews with 3668 Black, South African grandparents in the “Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa” study, conducted between 2014 and 2015. Results: We find that caregiving grandparents have better cognitive function than non-caregiving grandparents, and this association does not differ by grandparent gender. Although grandchild caregiving is associated with physical activity and social engagement measures, and some of these measures are associated with cognitive function, we do not find conclusive evidence of mediation. Discussion: Providing care for grandchildren may stimulate cognitive function for both grandmothers and grandfathers. Neither physical activity nor social engagement explains the association between caregiving and cognitive function.
Kobayashi Lindsay, Farrell Meagan, Langa K, Mahlalela N, Wagner RG, and Lisa F Berkman. 3/3/2021. “Incidence of Cognitive Impairment during Aging in Rural South Africa: Evidence from HAALSI, 2014 to 2019.” Neuroepidemiology, online. Publisher's VersionAbstract
Introduction: Despite rapid population aging, there are currently limited data on the incidence of aging-related cognitive impairment in sub-Saharan Africa. We aimed to determine the incidence of cognitive impairment and its distribution across key demographic, social, and health-related factors among older adults in rural South Africa. Methods: Data were from in-person interviews with 3,856 adults aged ≥40 who were free from cognitive impairment at baseline in the population-representative cohort, “Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa” (HAALSI), in Agincourt sub-district, Mpumalanga province, South Africa (2014–19). Cognitive impairment was defined as scoring <1.5 standard deviations below the mean of the baseline distribution of orientation and episodic memory scores. Incidence rates and rate ratios for cognitive impairment were estimated according to key demographic, social, and health-related factors, adjusted for age, sex/gender, and country of birth. Results: The incidence of cognitive impairment was 25.7/1,000 person-years (PY; 95% confidence interval [CI]: 23.0–28.8), weighted for mortality (12%) and attrition (6%) over the 3.5-year mean follow-up (range: 1.5–4.8 years). Incidence increased with age, from 8.9/1,000 PY (95% CI: 5.2–16.8) among those aged 40–44 to 93.5/1,000 PY (95% CI: 75.9–116.3) among those aged 80+, and age-specific risks were similar by sex/gender. Incidence was strongly associated with formal education and literacy, as well as marital status, household assets, employment, and alcohol consumption but not with history of smoking, hypertension, stroke, angina, heart attack, diabetes, or prevalent HIV. Conclusions: This study presents some of the first incidence rate estimates for aging-related cognitive impairment in rural South Africa. Social disparities in incident cognitive impairment rates were apparent in patterns similar to those observed in many high-income countries.
RA de Vlieg, E van Empel, L Montana, F Xavier Gómez-Olivé, K Kahn, S Tollman, L Berkman, TW Bärnighausen, and J Manne-Goehler. 1/2/2021. “Alcohol Consumption and Sexual Risk Behavior in an Aging Population in Rural South Africa.” AIDS Behav. . Publisher's VersionAbstract
We sought to characterize the relationship between alcohol consumption and sexual risk-taking in an aging population in rural South Africa. A cross-sectional analysis was conducted using baseline data from the Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community (HAALSI) cohort. We elicited information on sexual risk behavior and self-reported frequency of alcohol consumption among 5059 adults ≥ 40 years old. Multivariable models showed that more frequent alcohol consumption is associated with a higher number of sexual partners (β: 1.38, p < .001) and greater odds of having sex for money (OR: 42.58, p < .001) in older adults in South Africa. Additionally, daily drinkers were more likely to have sex without a condom (OR: 2.67, p = .01). Older adults who drank more alcohol were more likely to engage in sexual risk-taking. Behavioral interventions to reduce alcohol intake should be considered to reduce STI and HIV transmission.
Alisha N Wade, Collin F Payne, Lisa Berkman, Angela Chang, Xavier F Gómez-Olivé, Chodziwadziwa Kabudula, Kathleen Kahn, Joshua A Salomon, Stephen Tollman, Miles Witham, and Justine Davies. 2021. “Multimorbidity and mortality in an older, rural black South African population cohort with high prevalence of HIV findings from the HAALSI Study.” BMJ Open, 11, 9. Publisher's VersionAbstract
Objectives Multimorbidity is associated with mortality in high-income countries. Our objective was to investigate the relationship between multimorbidity (>=2 of the following chronic medical conditions: hypertension, diabetes, dyslipidaemia, anaemia, HIV, angina, depression, post-traumatic stress disorder, alcohol dependence) and all-cause mortality in an older, rural black South African population. We further investigated the relationship between HIV multimorbidity (HIV as part of the multimorbidity cluster) and mortality, while testing for the effect of frailty in all models.Design Population cohort study.Setting Agincourt subdistrict of Mpumalanga province, South Africa.Participants 4455 individuals (54.7% female), aged >=40 years (median age 61 years, IQR 52–71) and resident in the study area.Primary and secondary outcome measures The primary outcome measure was time to death and the secondary outcome measure was likelihood of death within 2 years of the initial study visit. Mortality was determined during annual population surveillance updates.Results 3157 individuals (70.9%) had multimorbidity; 29% of these had HIV. In models adjusted for age and sociodemographic factors, multimorbidity was associated with greater risk of death (women: HR 1.72; 95% CI: 1.18 to 2.50; men: HR 1.46; 95% CI: 1.09 to 1.95) and greater odds of dying within 2 years (women: OR 2.34; 95% CI: 1.32 to 4.16; men: OR 1.51; 95% CI: 1.02 to 2.24). HIV multimorbidity was associated with increased risk of death compared with non-HIV multimorbidity in men (HR 1.93; 95% CI: 1.05 to 3.54), but was not statistically significant in women (HR 1.85; 95% CI: 0.85 to 4.04); when detectable, HIV viral loads were higher in men (p=0.021). Further adjustment for frailty slightly attenuated the associations between multimorbidity and mortality risk (women: HR 1.55; 95% CI: 1.06 to 2.26; men: HR 1.36; 95% CI: 1.01 to 1.82), but slightly increased associations between HIV multimorbidity and mortality risk.Conclusions Multimorbidity is associated with mortality in this older black South African population. Health systems which currently focus on HIV should be reorganised to optimise identification and management of other prevalent chronic diseases.Data are available in a public, open access repository. Data are available upon reasonable request. The HAALSI baseline data are publicly available at the Harvard Centre for Population and Development Studies (HCPDS) programme website [www.haalsi.org]. Data are also accessible through the Inter-university Consortium for Political and Social Research (ICPSR) at the University of Michigan [www.icpsr.umich.edu] and the INDEPTH Data Repository [http://www.indepth-ishare.org/index.php/catalog/113]. Mortality data are available upon request.
Lindsay C Kobayashi, Emily P Morris, Guy Harling, Meagan T Farrell, Mohammed U Kabeto, Ryan G Wagner, and Lisa F Berkman. 2021. “Subjective social position and cognitive function in a longitudinal cohort of older, rural South African adults, 2014–2019.” Journal of Epidemiology & Community Health. Publisher's VersionAbstract
Background The relationship between subjective social position (SSP) and cognitive ageing unclear, especially in low-income settings. We aimed to investigate the relationship between SSP and cognitive function over time among older adults in rural South Africa.Methods Data were from 3771 adults aged >=40 in the population-representative ‘Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa’ from 2014/2015 (baseline) to 2018/2019 (follow-up). SSP was assessed at baseline with the 10-rung MacArthur Network social position ladder. Outcomes were composite orientation and episodic memory scores at baseline and follow-up (range: 0–24). Mortality- and attrition-weighted linear regression estimated the associations between baseline SSP with cognitive scores at each of the baseline and follow-up. Models were adjusted for age, age2, sex, country of birth, father’s occupation, education, employment, household assets, literacy, marital status and health-related covariates.Results SSP responses ranged from 0 (bottom ladder rung/lowest social position) to 10 (top ladder rung/highest social position), with a mean of 6.6 (SD: 2.3). SSP was positively associated with baseline cognitive score (adjusted β=0.198 points per ladder rung increase; 95% CI 0.145 to 0.253) and follow-up cognitive score (adjusted β=0.078 points per ladder rung increase; 95% CI 0.021 to 0.136).Conclusion Independent of objective socioeconomic position measures, SSP is associated with orientation and episodic memory scores over two time points approximately 3 years apart among older rural South Africans. Future research is needed to establish the causality of the observed relationships, whether they persist over longer follow-up periods and their consistency in other populations.Data are available in a public, open access repository.
2020
Elyse A. Jennings, Margaret Ralston, and Enid Schatz. 12/2020. “Support in times of need: How depressive symptoms can impact receipt of social support among aging adults in rural South Africa.” SSM - Population Health, 12, Pp. 100666. Publisher's VersionAbstract
The relationship between mental health and receipt of social support is not well understood in low- and middle-income countries. In this paper, we focus on a cohort of older adults (40-plus) in rural South Africa to unpack associations between mental health and receipt of social support, and the extent to which marital status modifies these associations. We use baseline data from a population-based study, Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), conducted between 2014 and 2015. Our results suggest that men and women who report depressive symptoms are less likely to receive social support: women are less likely to receive emotional and financial support, and men are less likely to receive physical and financial support. Both men and women who are married or partnered are more likely to receive social support than their non-married counterparts. The association between depressive symptomology and receipt of social support differs for women who are separated/divorced and for men who are widowed. Specifically, the association between having depressive symptoms and receiving physical or financial support is more positive for separated/divorced women than their married/cohabiting counterparts; for men, the association between having depressive symptoms and receiving physical support is more positive for widowed men than their married/cohabiting counterparts. Our findings speak to the complicated associations between social support, marriage and mental health in later life and the different experiences that men and women may have.
Stephen B Asiimwe, Meagan Farrell, Lindsay C Kobayashi, Jen Manne-Goehler, Kathleen Kahn, Stephen M Tollman, W Kabudula, Chodziwadziwa, Gómez-Olivé FX, Wagner RG, Montana L, Lisa F Berkman, MM Glymour, and Till W. Bärnighausen. 10/6/2020. “Cognitive differences associated with HIV serostatus and antiretroviral therapy use in a population-based sample of older adults in South Africa.” Scientific Reports, 10, 16625. Publisher's VersionAbstract
Previous clinical studies have reported adverse cognitive outcomes for people living with HIV (PLWH), but there are no population-based studies comparing cognitive function between older PLWH and comparators without HIV in sub-Saharan Africa. We analyzed baseline data of 40 + years-old participants in “Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa” (HAALSI) cohort. We measured cognition using a battery of conventional instruments assessing orientation, immediate- and delayed-recall, and numeracy (N = 4560), and the Oxford Cognitive Screen [OCS]-Plus, a novel instrument for low-literacy populations, assessing memory, language, visual-spatial ability, and executive functioning (N = 1997). Linear regression models comparing cognitive scores between participants with and without HIV were adjusted for sex, education, age, country of birth, father’s occupation, ever-consumed alcohol, and asset index. PLWH scored on average 0.06 (95% CI 0.01–0.12) standard deviation (SD) units higher on the conventional cognitive function measure and 0.02 (95% CI − 0.07 to 0.04) SD units lower on the OCS-Plus measure than HIV-negative participants. We found higher cognitive function scores for PLWH compared to people without HIV when using a conventional measure of cognitive function but not when using a novel instrument for low-literacy settings.
Leslie B Adams, Meagan Farrell, Sumaya Mall, Nomsa Mahlalela, and Lisa Berkman. 9/2/2020. “Dimensionality and differential item endorsement of depressive symptoms among aging Black populations in South Africa: Findings from the HAALSI study.” Journal of Affective Disorders. Publisher's VersionAbstract
Background : The Center for Epidemiologic Studies-Depression (CES-D) scale is a widely used measure of depressive symptoms, but its construct validity has not been adequately assessed in sub-Saharan Africa. This study validates the CES-D among an aging Shangaan-speaking and predominantly Black African sample in rural South Africa, with a special emphasis on gender differences. Methods : An 8-item CES-D scale was administered in Shangaan to 5,059 respondents, aged 40+ years, residing in Agincourt, South Africa. We used Cronbach's alpha and exploratory and confirmatory factor analysis to examine and confirm dimensionality of the CES-D scale. Differential endorsement of CES-D items by gender were assessed using the Mantel-Haenszel (MH) odds ratio test. Results : Reliability of the CES-D scale differed by gender with women reporting higher internal consistency on items than men. A two-factor solution was retained and confirmed representing two latent factors: (1) Negative Affect (six items) and (2) Diminished Positive Affect (two items). MH results showed that men exhibited significantly higher odds of putting an effort in everything that they did (OR: 1.33, 95% CI: 1.15-1.54) and lower odds of feeling depressed (OR: 0.71, 95% CI: 0.56-0.89) and having restless sleep (OR: 0.67, 95% CI:0.58-0.77) than women. Limitations : Analyses were limited to a dichotomous, short form of the CES-D, a self-reported population-based measure. Conclusion : Aging Black Africans differ in endorsing affective and somatic items on the CES-D scale by gender, which may lead to skewed population-level estimates of depression in key subpopulations. These findings highlight the importance of continued research disentangling cross-cultural and gendered nuances of depression measurements.
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. 

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