Publications

2021
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.
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. 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.
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. 
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
Leslie B. Adams, Meagan Farrell, Sumaya Mall, Nomsa Mahlalela, and Lisa Berkman. 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, 277, Pp. 850 - 856. 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 5059 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.
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.

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