Publications

2021
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.
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.
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.

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