Surprising Gendered Age Differences in Rural Malawians' Early COVID-19 Pandemic Prevention Efforts

OBJECTIVES

We assess how age, the presence of mature adults aged 45+ years, and recent deaths in rural households are associated with coronavirus disease 2019 (COVID-19) preventative actions and the likelihood of getting vaccinated against the virus in Malawi during early stages of the pandemic.

METHODS

We draw upon data from 2,187 rural Malawians who participated in a 2020 COVID-19 Phone Survey. We estimate the log odds of engaging in "low-cost" and "high-cost" COVID-19 preventative actions based on age, gender, household composition, and recent household deaths. Low-cost prevention efforts were washing hands with soap and water frequently, avoiding close contact with people when going out, and avoiding shaking hands. High-cost actions included staying at home and decreasing time spent close to people not living in their household. We also estimate the chances of acquiring the COVID-19 vaccine in early stages of its availability.

RESULTS

Mature women (45+ years) in general and younger men (<45 years)-living with at least one mature adult in the household-were less likely than others to comply with low-cost actions. Mature men were more likely than younger men (<45 years) to take on high-cost actions. To some extent, individuals who experienced a recent family death were more likely to engage in high-cost COVID-19 preventative actions as well as getting vaccinated.

DISCUSSION

Gendered age differences in preventing the transmission of COVID-19 offer hints of larger social norms affecting protective efforts. The analyses also inform future COVID-19 public health outreach efforts in Malawi and other rural SSA contexts.

MORTALITY RISK INFORMATION, SURVIVAL EXPECTATIONS AND SEXUAL BEHAVIOURS

We investigate the impact of a randomised information intervention about population-level mortality on health investment and subjective health expectations. Our focus is on risky sex in a high-HIV-prevalence environment. Treated individuals are less likely to engage in risky sexual practices one year after the intervention, with, for example, an 8% increase in abstinence. We collected detailed data on individuals' subjective expectations about their own and population survival, as well as other important health outcomes. Our findings emphasise the significance of integrating subjective expectation data in field experiments to identify the pathways that lead to behavioural change.

Oral Health Policy and Research Capacity: Perspectives From Dental Schools in Africa

INTRODUCTION AND AIMS

The prioritisation of oral health in all health policies in the WHO African region is gaining momentum. Dental schools in this region are key stakeholders in informing the development and subsequent downstream implementation and monitoring of these policies. The objectives of our study are to determine how dental schools contribute to oral health policies (OHPs) in this region, to identify the barriers to and facilitators for engaging with other local stakeholders, and to understand their capacity to respond to population and public health needs.

METHODS

We developed a needs assessment survey, including quantitative and qualitative questions. The survey was developed electronically in Qualtrics and distributed by email in February 2023 to the deans or other designees at dental schools in the WHO African region. Data were analysed in SAS version 9.4 and ATLAS.ti.

RESULTS

The capacity for dental schools to respond to population and public health needs varied. Most schools have postgraduate programs to train the next generation of researchers. However, these programs have limitations that may hinder the students from achieving the necessary skills and training. A majority (75%) of respondents were aware of the existence of national OHPs and encountered a myriad of challenges when engaging with them, including a lack of coordination with other stakeholders, resources, and oral health professionals, and the low priority given to oral health. Their strengths as technical experts and researchers was a common facilitator for engaging with OHPs.

CONCLUSION

Dental schools in the region face common challenges and facilitators in engaging in the OHP process. There were several school-specific research and training capacities that enabled them to respond to population and public health needs. Overall, shared challenges and facilitators can inform stakeholder dialogues at a national and subnational level and help develop tailored solutions for enhancing the oral health policy pipeline.

Barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of oral health policies in the WHO Africa region: A scoping review protocol

Background

Evidence-informed oral health policies (OHP) can be instrumental in ending the neglect of oral health globally. When appropriately developed and implemented, OHP can improve the efficiency of healthcare systems and the quality of health outcomes. However, more than half of the countries in the World Health Organization (WHO) African region do not have an oral health policy or even the existence of a policy in need of additional and more national-specific OHP as part of non-communicable diseases and universal health coverage agendas. The objective of this protocol's study is to determine the barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in the WHO Africa region.

Methods

We will conduct a systematic search in Global Health, Embase, PubMed, PAIS, ABI/Inform, Web of Science, Academic Search Complete, Scopus, databases that index gray literature, and the WHO policy repositories. We will include qualitative, quantitative, or mixed-methods research studies and OHP documents published since January 1, 2002, which address stakeholders' perceptions and experiences regarding barriers to and facilitators for the creation, dissemination, implementation, monitoring, and evaluation of OHP in countries part of the WHO African region. We will produce descriptive statistics (frequencies and proportions) for quantitative data and conduct descriptive content analysis for qualitative data.

Discussion

To effectively establish evidence-based OHP in the WHO African region, it is crucial to recognize existing challenges and opportunities for progress. The findings of this review will be relevant for Chief Dental Officers at ministries of health, administrators of dental schools, or academic institutions in the WHO African region and will inform a stakeholder dialogue meeting in Kenya in November of 2023.

Registration

Open Science Framework: https://doi.org/10.17605/OSF.IO/9KMWR.

Barker's Hypothesis Among the Global Poor: Positive Long-Term Cardiovascular Effects of in Utero Famine Exposure

An influential literature on the Developmental Origins of Health and Disease (DOHaD) has documented that poor conditions in utero lead to higher risk of cardiovascular disease at older ages. Evidence from low-income countries (LICs) has hitherto been missing, despite the fact that adverse in utero conditions are far more common in LICs. We find that Malawians exposed in utero to the 1949 Nyasaland famine have better cardiovascular health 70 years later. These findings highlight the potential context specificity of the DOHaD hypothesis, with in utero adversity having different health implications among aging LIC individuals who were exposed to persistent poverty.

Resilience, Accelerated Aging and Persistently Poor Health: Diverse Trajectories of Health in Malawi

Individuals age at vastly different rates resulting in significant within-population heterogeneity in health and aging outcomes. This diversity in health and aging trajectories has rarely been investigated among low-income aging populations that have experienced substantial hardships throughout their lifecourses. Utilizing 2006-2018 data from the Malawi Longitudinal Study of Families and Health (MLSFH) and estimating group-based trajectory models (GBTM), our analyses identified three distinct lifecourse health trajectories: (1) comparatively good initial mental and physical health that persisted throughout the lifecourse ("resilient aging"); (2) relatively good initial mental and physical health that started to deteriorate during mid-adulthood ("accelerated aging"); and (3) poor initial mental and physical health that further declined over the lifecourse ("aging with persistently poor health"). For both physical and mental health, men were more likely to enjoy resilient aging than women. Predictors other than gender of trajectory membership sometimes confirmed, and sometimes contradicted, hypotheses derived from high-income country studies. Our analyses highlight the long arm of early life conditions and gender in determining aging trajectories and show that a non-trivial sub-population is characterized by aging with persistently poor health. The study uncovers widening gaps in health outcomes between those who age with resilience and those who experience accelerated aging.

Cognition and Cognitive Changes in a Low-Income Sub-Saharan African Aging Population

BACKGROUND

Cognition and its age-related changes remain vastly understudied in low-income countries (LICs), despite evidence suggesting that cognitive decline among aging low-income populations is a rapidly increasing disease burden often occurring at younger ages as compared to high-income countries (HICs).

OBJECTIVE

We examine patterns of cognition among men and women, 45 + years old, living in rural Malawi. We analyze how key socioeconomic characteristics predict levels of cognition and its changes as individuals get older.

METHODS

Utilizing the Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) collected during 2012-2017, we estimate standard regression models to analyze predictors of the age- and sex-specific levels and longitudinal changes in cognition. Cognition is assessed with a screening instrument that is adapted to this low-literacy context and measures different domains such as language, attention, or executive functioning.

RESULTS

Women have lower levels of cognition than men, a pattern in stark contrast to findings in HICs. Schooling and socioeconomic status increase the probability of having consistently high performance during the cognitive assessment. Cognitive decline accelerates with age and is detectable already at mid-adult ages (45-55 years). Despite lower levels of cognitive function observed among women, the pace of decline with age is similar for both genders.

CONCLUSION

Women are particularly affected by poor cognition in this context. The study emphasizes the importance of prioritizing cognitive health and research on cognition among older individuals in sub-Saharan Africa LICs, to which relatively little health care resources continue to be allocated.

Mental health and life-course shocks in a low-income country: Evidence from Malawi

Economic insecurity has been widely hypothesized to be an important determinant of mental health, but this relationship has not been well-documented in low-income countries. Using data from the Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC), we investigate the association of negative economic shocks with mental health outcomes such as depression and anxiety among adults aged 45+ years living in a low-income country. Using fixed effects estimates that control for time-invariant unobserved individual heterogeneity, we find that increased economic instability caused by events such as death of a family member, yield loss, or income loss is positively associated with worse mental health outcomes as measured by the PHQ-9 and GAD-7 instruments. Our results suggest that costly economic events are a key component to worsening mental health in settings characterized by pervasive poverty and underscore the importance of mental health as a public health and development target.

Aging and hypertension among the global poor-Panel data evidence from Malawi

Hypertension is a rapidly growing disease burden among older persons in low-income countries (LICs) that is often inadequately diagnosed and treated. Yet, most LIC research on hypertension is based on cross-sectional data that does not allow inferences about the onset or persistence of hypertension, its correlates, and changes in hypertension as individuals become older. The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) is used to provide among the first panel analyses of hypertension for older individuals in a sub-Saharan LIC using blood pressure measurements obtained in 2013 and 2017. We find that high blood pressure is very common among mature adults aged 45+, and hypertension is more prevalent among older as compared to middle-aged respondents. Yet, in panel analyses for 2013-17, we find no increase in the prevalence of hypertension as individuals become older. Hypertension often persists over time, and the onset of hypertension is predicted by factors such as being overweight/obese, or being in poor physical health. Otherwise, however, hypertension has few socioeconomic predictors. There is also no gender differences in the level, onset or persistence in hypertension. While hypertension is associated with several negative health or socioeconomic consequences in longitudinal analyses, cascade-of-care analyses document significant gaps in the diagnosis and treatment of hypertension. Overall, our findings indicate that hypertension and related high cardiovascular risks are widespread, persistent, and often not diagnosed or treated in this rural sub-Saharan population of older individuals. Prevalence, onset and persistence of hypertension are common across all subgroups-including, importantly, both women and men. While age is an important predictor of hypertension risk, even in middle ages 45-55 years, hypertension is already widespread. Hypertension among adults aged 45+ in Malawi is thus more similar to a "generalized epidemic" than in high-income countries where cardiovascular risk has strong socioeconomic gradients.

Pain Is Widespread and Predicts Poor Mental Health Among Older Adults in Rural Malawi

Background and Objectives

Pain is common among older persons and has been documented as an important predictor of disability, health, and economic outcomes. Evidence about its prevalence and relationship to well-being is scarce in rural sub-Saharan Africa (SSA), where work is frequently physically demanding, and pain prevention or treatment options are limited. We investigate the prevalence of pain and its association with mental health and subjective well-being in a population-based study of older adults in rural Malawi.

Research Design and Methods

We estimate the prevalence, severity, and duration of pain along with its sociodemographic distribution in a sample of 1,577 individuals aged 45 and older. We assess the association of pain with clinically validated measures of mental health, including depression and anxiety, and subjective well-being.

Results

Pain is widespread in this mature population with an average age of 60 years: 62% of respondents report the experience of at least minor pain during the last year, and half of these cases report severe or disabling pain. Women are more likely to report pain than men. Pain is a strong predictor of mental health and subjective well-being for both genders. More severe or longer pain episodes are associated with worse mental states. Individuals reporting pain are more likely to suffer from depression or express suicidal thoughts.

Discussion and Implications

Our study identifies key subpopulations such as older women in a SSA low-income context who are particularly affected by the experience of pain in daily life and calls for interventions targeting pain and its consequences for mental health and subjective well-being.

Curtailing Covid-19 on a dollar-a-day in Malawi: Role of community leadership for shaping public health and economic responses to the pandemic

Utilizing population-based data from the Covid-19 phone survey ( N = 2 , 262 ) of the Malawi Longitudinal Study of Families and Health (MLSFH) collected during June 2nd-August 17th, 2020, we focus on the crucial role that community leadership and trust in institutions played in shaping behavioral, economic and social responses to Covid-19 in this low-income sub-Saharan African context. We argue that the effective response of Malawi to limit the spread of the virus was facilitated by the engagement of local leadership to mobilize communities to adapt and adhere to Covid-19 prevention strategies. Using linear and ordered probit models and controlling for time fixed effects, we show that village heads (VHs) played pivotal role in shaping individuals' knowledge about the pandemic and the adoption of preventive health behaviors and were crucial for mitigating the negative economic and health consequences of the pandemic. We further show that trust in institutions is of particular importance in shaping individuals' behavior during the pandemic, and these findings highlight the pivotal role of community leadership in fostering better compliance and adoption of public health measures essential to contain the virus. Overall, our findings point to distinctive patterns of pandemic response in a low-income sub-Saharan African rural population that emphasized local leadership as mediators of public health messages and policies. These lessons from the first pandemic wave remain relevant as in many low-income countries behavioral responses to Covid-19 will remain the primary prevention strategy for a foreseeable future.

Impairment in Activities of Daily Living and Unmet Need for Care Among Older Adults: A Population-Based Study From Burkina Faso

Objectives

The importance of impairment in performing activities of daily living (ADL) is likely to increase in sub-Saharan Africa because few care options for affected people exist. This study investigated the prevalence of ADL impairment, the extent to which care need was met, and described characteristics of people with ADL impairment and unmet need in Burkina Faso.

Methods

This study used data from the Centre de Recherche en Santé de Nouna Heidelberg Aging Study, a population-based study among 3,026 adults aged older than 40 years conducted in rural Burkina Faso. Information on 6 basic ADL items was sought, with a follow-up question asking whether care need was not met, partially met, or met. Bivariable correlations and multivariable logistic regression were used to determine sociodemographic and health characteristics associated with ADL impairment and unmet need.

Results

ADL impairment of any kind was reported by 1,202 (39.7%) respondents and was associated with older age (adjusted odds ratio: 1.05 [95% CI: 1.04–1.06]), being a woman (1.33 [1.06–1.60]), and reporting depressive symptoms (1.90 [1.65–2.18]). Among those with ADL impairment, 67.8% had at least one unmet need. Severe ADL impairment was found in 202 (6.7%) respondents, who reported a lower prevalence of unmet need (43.1%). Severe ADL impairment was associated with depressive symptoms (2.55 [2.11–3.07]) to a stronger degree than any ADL impairment.

Discussion

Prevalence of ADL impairment and unmet need was high in this setting. Variation in impairment across the population highlighted key groups for future interventions. Unmet need for care was highest in middle-aged adults, indicating a gap in care provision.

Marital dissolutions and changes in mental health: Evidence from rural Malawi

BACKGROUND

Advancing efforts to unpack the complex relationship between marital dissolutions and health outcomes increasingly requires assessing the marital histories and health of individuals who have lived long enough to experience divorce or widowhood ‒ or even multiples of each ‒ and measurable changes in health.

OBJECTIVE

To explore this line of inquiry, we chose a sample from rural Malawi where a high prevalence of marital dissolutions and remarrying exists, as an ideal theoretical foil to the predominant literature found in high-income countries (HICs). We examine if changes in having experienced a marital dissolution, one's total number of dissolutions, and the percentage of one's life spent outside of marriage since first becoming married are associated with changes in mental health.

METHODS

Our analyses focus on 1,266 respondents aged 45 years and older who participated in the 2012 Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC), linked back to cohort information from 2008 and 2010 available through the MLSFH. Fixed-effects regressions guide our inferences over the 2008, 2010, and 2012 waves of data.

RESULTS

For men, spending more life outside of marriage is associated with worse mental health, while more marital dissolutions are surprisingly associated with better mental health for women.

CONCLUSIONS

These results could suggest that larger portions of one's life spent unmarried are associated with a type of role strain for men or simply that men are burdened with taking up tasks that their spouses had previously done in order to survive. For women, many may have gotten out of 'bad' marriages that otherwise would have been detrimental to their mental health and/or those in good mental health are the ones able to remarry.

CONTRIBUTIONS

Our research from rural Malawi provides a type of litmus test for many HICs where marriage, remarriage, and dissolution rates are lower but quite consequential for mental health outcomes. Measuring time outside of marriage should be more strongly considered in such settings. These results also inform increasingly important research on the relationship between marital dissolutions and mental health in other African nations as noncommunicable diseases play a continually more important role in people's lives.

Health screening for emerging non-communicable disease burdens among the global poor: Evidence from sub-Saharan Africa

Evidence for the effectiveness of population health screenings to reduce the burden of non-communicable diseases in low-income countries remains very limited. We investigate the sustained effects of a health screening in Malawi where individuals received a referral letter if they had elevated blood pressure. Using a regression discontinuity design and a matching estimator, we find that receiving a referral letter reduced blood pressure and the probability of being hypertensive by about 22 percentage points four years later. These lasting effects are explained by a 20 percentage points increase in the probability of being diagnosed with hypertension. There is also evidence of an increase in the uptake of medication, while we do not identify improvements in hypertension-related knowledge or risk behaviors. On the contrary, we find an increase in sugar intake and a decrease in physical activity both of which are considered risky behaviors in Western contexts. The health screening had some positive effects on mental health. Overall, this study suggests that population-based hypertension screening interventions are an effective tool to improve health in low-income contexts.

Cohort profile: the mature adults cohort of the Malawi longitudinal study of families and health (MLSFH-MAC)

PURPOSE

The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global ageing studies by providing a rare opportunity to study the processes of individual and population ageing, the public health and social challenges associated with ageing and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context.

PARTICIPANTS

The MLSFH-MAC is an open population-based cohort study of mature adults aged 45+ years living in rural communities in three districts in Malawi. Enrolment at baseline is 1266 individuals in 2012. Follow-ups were in 2013, 2017 and 2018 when the cohort size reached 1626 participants in 2018.

FINDINGS TO DATE

Survey instruments cover ageing-related topics such as cognitive and mental health, non-communicable diseases (NCDs) and related health literacy, subjective survival expectations, measured biomarkers including HIV, grip strength, hypertension, fasting glucose, body mass index (BMI), broad individual-level and household-level social and economic information, a 2018 qualitative survey of mature adults and community officials, 2019 surveys of village heads, healthcare facilities and healthcare providers in the MLSFH-MAC study areas. Across many domains, MLSFH-MAC allows for comparative research with global ageing studies through harmonised measures and instruments. Key findings to date include a high prevalence of depression and anxiety among older adults, evidence for rapid declines in cognitive health with age, a low incidence of HIV among mature adults, rising prevalence of HIV due to increased survival of HIV-positive individuals and poor physical health with high NCD prevalence.

FUTURE PLANS

An additional wave of MLSFH-MAC is forthcoming in 2021, and future expansions of the cohort are planned. MLSFH-MAC data will also be publicly released and will provide a wealth of information unprecedented for ageing studies in a low-income SSA context that broadly represents the socioeconomic environment of millions of individuals in south-eastern Africa.

Know your epidemic, know your response: Early perceptions of COVID-19 and self-reported social distancing in the United States

As COVID-19 is rapidly unfolding in the United States, it is important to understand how individuals perceive the health and economic risks of the pandemic. In the absence of a readily available medical treatment, any strategy to contain the virus in the US will depend on the behavioral response of US residents. In this paper, we study individual's perceptions on COVID-19 and social distancing during the week of March 10-16, 2020, a week when COVID-19 was officially declared to be a pandemic by WHO and when new infections in the US were more than doubling every three days. Using a nationally representative sample of 5,414 respondents 18+ years of age from the Understanding America Study (UAS), we find that perceptions about COVID-19 health risks and economic consequences in the US population were largely pessimistic and highly variable by age and education. US residents who are young and do not have a college degree perceived a lower risk of getting infected but a higher probability of running out of money than others. Most individuals reported taking some steps to distance themselves from others but important differences emerge by gender and by source of information on COVID-19. Using state and day fixed-effect regressions, we show that perceptions of the health risks closely followed the number of COVID-19 cases in the country, and perceptions of the economic consequences and the prevalence of social distancing were driven upwards by both national and state-level cases. Unless addressed by effective health communication that reaches individuals across all social strata, variations in perceptions about COVID-19 epidemic raise concerns about the ability of the US to implement and sustain the widespread and restrictive policies that are required to curtail the pandemic.

Using grip strength to compute physical health-adjusted old age dependency ratios

The standard approach for comparing the potential challenges of population aging across countries based on conventional old-age dependency ratios (OADR) does not account for cross-population differences in health, functional capacity or disability, despite their importance for labor force participation and dependency more broadly. We investigate how OADRs observed across selected low-, middle-, and high-income countries change if population differences in physical health measured by hand-grip strength are accounted for. Specifically, we propose and calculate an adjusted measure of the OADR based on hand-grip strength, which serves as an objective indicator of muscle function and has been shown to predict future morbidity, disability and mortality. We show that adjusting the OADR for differences in hand-grip strength results in substantial changes in country rankings by OADR compared to a ranking based on the conventional OADR definition. Accounting for cross-population differences in hand-grip strength, the estimated OADRs for low- and middle-income countries tend to increase compared to the conventional OADR approach based on age only, whereas the estimated OADRs in high-income countries decline substantially relative to the standard approach. Since hand-grip strength is an important prerequisite for maintaining functional capacity and productivity and preventing disability -especially in economies in low-income settings- our grip-strength-adjusted OADRs clearly show that population aging is not just a challenge in high-income countries but also an important concern for economies in the developing world.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

A Single-Item Visual Analogue Scale (VAS) Measure for Assessing Depression Among College Students

There is an increased need for efficient, low-cost methods to collect information on a range of widely prevalent mental health outcomes in the general population that can be administered outside of clinical settings. We evaluate the validity of a single-item Visual Analogue Scale (VAS) for assessing the presence and severity of depression and compare its performance with the Patient Health Questionnaire (PHQ-9) depression scale using a large non-clinical sample (N = 1816) of college students from Switzerland. The VAS scale is strongly correlated with the PHQ-9 total score (0.61) and its 9 individual items (ranging from 0.19 to 0.67). ROC analysis shows that the VAS scale has high accuracy for detecting the presence and different levels (mild to severe) of depression corresponding to PHQ-9 cutoffs. The VAS depression scale represents a simple, easily implementable instrument that is suitable for mental health research in common settings and larger population-based studies.

The association between advanced maternal and paternal ages and increased adult mortality is explained by early parental loss

The association between advanced maternal and paternal ages at birth and increased mortality among adult offspring is often attributed to parental reproductive aging, e.g., declining oocyte or sperm quality. Less attention has been paid to alternative mechanisms, including parental socio-demographic characteristics or the timing of parental death. Moreover, it is not known if the parental age-adult mortality association is mediated by socioeconomic attainment of the children, or if it varies over the lifecourse of the adult children. We used register-based data drawn from the Finnish 1950 census (sample size 89,737; mortality follow-up 1971-2008) and discrete-time survival regression with logit link to analyze these alternative mechanisms in the parental age-offspring mortality association when the children were aged 35-49 and 50-72. Consistent with prior literature, we found that adult children of older parents had increased mortality relative to adults whose parents were aged 25-29 at the time of birth. For example, maternal and paternal ages 40-49 were associated with mortality odds ratios (ORs) of 1.31 (p<.001) and 1.22 (p<.01), respectively, for offspring mortality at ages 35-49. At ages 50-72 advanced parental age also predicted higher mortality, though not as strongly. Adjustment for parental socio-demographic characteristics (education, occupation, family size, household crowding, language) weakened the associations only slightly. Adjustment for parental survival, measured by whether the parents were alive when the child reached age 35, reduced the advanced parental age coefficients substantially and to statistically insignificant levels. These results indicate that the mechanism behind the advanced parental age-adult offspring mortality association is mainly social, reflecting early parental loss and parental characteristics, rather than physiological mechanisms reflecting reproductive aging.

Cohort Profile: The Malawi Longitudinal Study of Families and Health (MLSFH)

The Malawi Longitudinal Study of Families and Health (MLSFH) is one of very few long-standing, publicly available longitudinal cohort studies in a sub-Saharan African (SSA) context. It provides a rare record of more than a decade of demographic, socioeconomic and health conditions in one of the world's poorest countries. The MLSFH was initially established in 1998 to study social network influences on fertility behaviours and HIV risk perceptions, and over time the focus of the study expanded to include health, sexual behaviours, intergenerational relations and family/household dynamics. The currently available data include MLSFH rounds collected in 1998, 2001, 2004, 2006, 2008, 2010 and 2012 for up to 4000 individuals, providing information about socioeconomic and demographic characteristics, sexual behaviours, marriage, household/family structure, risk perceptions, social networks and social capital, intergenerational relations, HIV/AIDS and other dimensions of health. The MLSFH public use data can be requested on the project website: http://www.malawi.pop.upenn.edu/.

Association of blood lipids, creatinine, albumin, and CRP with socioeconomic status in Malawi

BACKGROUND

The objective of these analyses is to document the relationship between biomarker-based indicators of health and socioeconomic status (SES) in a low-income African population where the cumulative effects of exposure to multiple stressors on physiological functions and health in general are expected to be highly detrimental for the well-being of individuals.

METHODS

Biomarkers were collected subsequent to the 2008 round of the Malawi Longitudinal Study of Families and Health (MLSFH), a population-based study in rural Malawi, including blood lipids (total cholesterol, LDL, HDL, ratio of total cholesterol to HDL), biomarkers of renal and liver organ function (albumin and creatinine) and wide-range C-reactive protein (CRP) as a non-specific biomarker for inflammation. These biomarkers represent widely used indicators of health that are individually or cumulatively recognized as risk factors for age-related diseases among prime-aged and elderly individuals. Quantile regressions are used to estimate the age-gradient and the within-day variation of each biomarker distribution. Differences in biomarker levels by socioeconomic status are investigated using descriptive and multivariate statistics.

RESULTS

Overall, the number of significant associations between the biomarkers and socioeconomic measures is very modest. None of the biomarkers significantly varies with schooling. Except for CRP where being married is weakly associated with lower risk of having an elevated CRP level, marriage is not associated with the biomarkers measured in the MLSFH. Similarly, being Muslim is associated with a lower risk of having elevated CRP but otherwise religion does not predict being in the high-risk quartiles of any of the MLSFH biomarkers. Wealth does not predict being in the high-risk quartile of any of the MLSFH biomarkers, with the exception of a weak effect on creatinine. Being overweight or obese is associated with increased likelihood of being in the high-risk quartile for cholesterol, Chol/HDL ratio, and LDL.

CONCLUSIONS

The results provide only weak evidence for variation of the biomarkers by socioeconomic indicators in a poor Malawian context. Our findings underscore the need for further research to understand the determinants of health outcomes in a poor low-income context such as rural Malawi.

Intergenerational transfers in the era of HIV/AIDS: Evidence from rural Malawi

BACKGROUND

Intergenerational transfer patterns in sub-Saharan Africa are poorly understood, despite the alleged importance of support networks to ameliorate the complex implications of the HIV/AIDS epidemic for families.

OBJECTIVE

There is a considerable need for research on intergenerational support networks and transfers to better understand the mechanisms through which extended families cope with the HIV/AIDS epidemic and potentially alleviate some of its consequences in sub-Saharan Africa, and to comprehend how transfers respond-or not-to perceptions about own and other family members' health.

METHODS

Using the 2008 round of the Malawi Longitudinal Study of Families and Health (MLSFH), we estimate the age patterns and the multiple directions of financial and non-financial transfer flows in rural Malawi-from prime-aged respondents to their elderly parents and adult children age 15 and up. We also estimate the social, demographic and economic correlates of financial and non-financial transfers of financial intergenerational transfers in this context.

RESULTS AND CONCLUSIONS

Our findings are that: (1) intergenerational financial and non-financial transfers are widespread and a key characteristic of family relationships in rural Malawi; (2) downward and upward transfers are importantly constrained and determined by the availability of transfer partners (parents or adult children); (3) financial net transfers are strongly age-patterned and the middle generations are net-providers of transfers; (4) non-financial transfers are based on mutual assistance rather than reallocation of resources; and (5) intergenerational transfers are generally not related to health status, including HIV positive status.

Ethnic and religious differentials in Bulgarian mortality, 1993-98

We investigated ethnic/religious mortality differentials in Bulgaria during the 1990s. The analyses employed a unique longitudinal data-set covering the entire population of Bulgaria from the census of 1992 until 1998. The mortality of Roma is very high compared to all other ethnic/religious groups. The excess applies to nearly every cause of death examined and is not entirely explained by the adverse location of Roma on social and economic variables. For young men, Muslim mortality is substantially lower than that of non-Muslims when socio-economic differences are controlled. An analysis of causes of death suggests that lower consumption of alcohol may contribute to this 'Muslim paradox'. For older Turkish women, a significant mortality disadvantage remains after controls are imposed. Suicide mortality is lower for Muslims than for Christian groups of the same ethnicity. Consistent with deteriorating economic conditions over the study period, mortality was rising, particularly for women.

Educational differences in all-cause mortality by marital status - Evidence from Bulgaria, Finland and the United States

Using life table measures, we compare educational differentials in all-cause mortality at ages 40 to 70 in Bulgaria to those in Finland and the United States. Specifically, we assess whether the relationship between education and mortality is modified by marital status. Although high education and being married are associated with lower mortality in all three countries, absolute educational differences tend to be smaller among married than unmarried individuals. Absolute differentials by education are largest for Bulgarian men, but in relative terms educational differences are smaller among Bulgarian men than in Finland and the U.S. Among women, Americans experience the largest education-mortality gradients in both relative and absolute terms. Our results indicate a particular need to tackle health hazards among poorly educated men in countries in transition.

Survival of parents and siblings of supercentenarians

BACKGROUND

Given previous evidence of familial predisposition for longevity, we hypothesized that siblings and parents of supercentenarians (age >or= 110 years) were predisposed to survival to very old age and that, relative to their birth cohorts, their relative survival probabilities (RSPs) are even higher than what has been observed for the siblings of centenarians.

METHODS

Mean age at death conditional upon survival to ages 20 and 50 and survival probabilities from ages 20 and 50 to higher ages were determined for 50 male and 56 female siblings and 54 parents of 29 supercentenarians. These estimates were contrasted with comparable estimates based on birth cohort-specific mortality experience for the United States and Sweden.

RESULTS

Conditional on survival to age 20 years, mean age at death of supercentenarians' siblings was approximately 81 years for men and women. Compared with respective Swedish and U.S. birth cohorts, these estimates were 17%-20% (12-14 years) higher for the brothers and 11%-14% (8-10 years) higher for the sisters. Sisters had a 2.9 times greater probability and brothers had a 4.3 times greater probability of survival from age 20 to age 90. Mothers of supercentenarians had a 5.8 times greater probability of surviving from age 50 to age 90. Fathers also experienced an increased survival probability from age 50 to age 90 of 2.7, but it failed to attain statistical significance.

CONCLUSIONS

The RSPs of siblings and mothers of supercentenarians revealed a substantial survival advantage and were most pronounced at the oldest ages. The RSP to age 90 for siblings of supercentenarians was approximately the same as that reported for siblings of centenarians. It is possible that greater RSPs are observed for reaching even higher ages such as 100 years, but a larger sample of supercentenarians and their siblings and parents is needed to investigate this possibility.

Childhood predictors of late-life diabetes: the case of Mexico

We investigated the interplay between characteristics of early childhood circumstances and current socioeconomic conditions and health, focusing specifically on diabetes in mid and late life in Mexico. The analysis used data from the 2001 Mexican Health and Aging Study (MHAS), a large nationally representative study of Mexicans born before 1950. We analyzed the extent to which childhood conditions, such as exposure to infectious diseases, a poor socioeconomic environment, and parental education, affect the risk of diabetes in later life. Our results indicate that individuals age 50 and older who experienced serious health problems before age 10 have a higher risk of having late-life diabetes. There is a significant inverse relationship between maternal education and diabetes in late life of adult offspring. Individuals with better educated mothers have a lower risk of being diabetic after age 50. This relationship remains after controlling for other childhood and adult risk factors.