Cognition, Health, and Well-Being in a Rural Sub-Saharan African Population

  • Collin F. Payne
  • Iliana V. Kohler
  • Chiwoza Bandawe
  • Kathy Lawler
  • Hans-Peter Kohler
Article
  • 49 Downloads

Abstract

Cognitive health is an important dimension of well-being in older ages, but few studies have investigated the demography of cognitive health in sub-Saharan Africa’s growing population of mature adults (= persons aged 45+). We use data from the Malawi Longitudinal Study of Families and Health to document the age and gender patterns of cognitive health, the contextual and life-course correlates of poor cognitive health, and the understudied linkages between cognitive and physical/mental well-being. Surprisingly, the age pattern of decline in cognitive health is broadly similar to that observed in the USA. We also find that women have substantially worse cognitive health than men and experience a steeper age gradient in cognitive ability. Strong social ties and exposure to socially complex environments are associated with higher cognitive health, as is higher socioeconomic status. Poor cognitive health is associated with adverse social and economic well-being outcomes such as less nutrition intake, lower income, and reduced work efforts even in this subsistence agriculture context. Lower levels of cognitive health are also strongly associated with increased levels of depression and anxiety and are associated with worse physical health measured through both self-reports and physical performance. Our findings suggest that cognition plays a key—but understudied—role in shaping late-life well-being in low-income populations.

Keywords

Cognitive health Aging Sub-Saharan Africa Mental health Physical health 

Notes

Acknowledgements

The first wave of the MLSFH was funded by the Rockefeller Foundation. Subsequent funding has been provided by the NICHD (Grants R01 HD053781, R01 HD/MH041713, R01 HD37276, R01 HD044228, R21 HD050652, R03 HD058976, R21 HD050652, R21 HD071471) and has been supported by pilot grants from the Population Studies Center (PSC), Population Aging Research Center (PARC), the Boettner Center for Pensions and Retirement Security, the Institute on Aging and the Center for AIDS Research (CFAR), all at the University of Pennsylvania, supported by among other sources NIH Grants NICHD R24 HD044964, NIA P30 AG12836, NIAID AI 045008. The project also received funding from the University of Pennsylvania Research Foundation. We are also grateful for pilot funding received through the Penn Center for AIDS Research (CFAR), supported by NIAID AI 045008, and the Penn Institute on Aging. Part of this research was also supported by the Swiss Agency for Development and Cooperation (SDC) and the Swiss National Science Foundation through the Swiss Programme for Research on Global Issues for Development (SFF R4d Programme, Grant Number: 400640_160374). NICHD R01HD053781 is the only grant that provided direct support for the writing of this manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare no competing interests, and the funders had no role in the design of the study, the analysis of the data, or the decision to present the results.

Ethical Approval

The data collection and research conducted by MLSFH was approved by the Institutional Review Board (IRB) at the University of Pennsylvania and, in Malawi, by the College of Medicine Research Ethics Committee (COMREC) or the National Health Sciences Research Committee (NHSRC).

Supplementary material

10680_2017_9445_MOESM1_ESM.pdf (1.3 mb)
Supplementary material 1 (PDF 1332 kb)

References

  1. Alfaro-Acha, A., Snih, S. A., Raji, M. A., Kuo, Y.-F., Markides, K. S., & Ottenbacher, K. J. (2006). Handgrip strength and cognitive decline in older Mexican Americans. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 61, 859–865. doi:10.1093/gerona/61.8.859.CrossRefGoogle Scholar
  2. Antinori, A., Arendt, G., Becker, J. T., Brew, B. J., Byrd, D. A., Cherner, M., et al. (2007). Updated research nosology for HIV-associated neurocognitive disorders. Neurology, 69, 1789–1799. doi:10.1212/01.WNL.0000287431.88658.8b.CrossRefGoogle Scholar
  3. Banda, K. N. (1982). A brief history of education in Malaŵi. Lilongwe: Dzuka Publishing Company.Google Scholar
  4. Blankevoort, C. G., Scherder, E. J. A., Wieling, M. B., Hortobágyi, T., Brouwer, W. H., Geuze, R. H., et al. (2013). Physical predictors of cognitive performance in healthy older adults: A cross-sectional analysis. PLoS ONE, 8, e70799. doi:10.1371/journal.pone.0070799.CrossRefGoogle Scholar
  5. Blazer, D. G., Yaffe, K., & Liverman, C. T. (Eds.). (2015). Cognitive aging: Progress in understanding and opportunities for action. Washington, DC: National Academy Press.Google Scholar
  6. Burbidge, J. B., Magee, L., & Robb, A. L. (1988). Alternative transformations to handle extreme values of the dependent variable. Journal of the American Statistical Association, 83, 123–127. doi:10.2307/2288929.CrossRefGoogle Scholar
  7. Busch, R. M., Chelune, G. J., & Suchy, Y. (2006). Using norms in neuropsychological assessment of the elderly. In D. K. Attix & K. A. Welsh-Bohmer (Eds.), Geriatric neuropsychology: Assessment and intervention. New York: Guilford Publications.Google Scholar
  8. Chandra, V., Ganguli, M., Ratcliff, G., Pandav, R., Sharma, S., Belle, S., et al. (2014). Practical issues in cognitive screening of elderly illiterate populations in developing countries. The Indo-US Cross-National Dementia Epidemiology Study. Aging Clinical and Experimental Research, 10, 349–357. doi:10.1007/BF03339881.CrossRefGoogle Scholar
  9. Cook, C. J., & Fletcher, J. M. (2015). Can education rescue genetic liability for cognitive decline? Special Issue: Educational Attainment and Adult Health: Contextualizing Causality, 127, 159–170.Google Scholar
  10. Ellwardt, L., Aartsen, M., Deeg, D., & Steverink, N. (2013). Does loneliness mediate the relation between social support and cognitive functioning in later life? Social Science and Medicine, 98, 116–124. doi:10.1016/j.socscimed.2013.09.002.CrossRefGoogle Scholar
  11. Fitzpatrick, A. L., Buchanan, C. K., Nahin, R. L., DeKosky, S. T., Atkinson, H. H., Carlson, M. C., et al. (2007). Associations of gait speed and other measures of physical function with cognition in a healthy cohort of elderly persons. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 62, 1244–1251.CrossRefGoogle Scholar
  12. Freeman, E. (2016). Understanding HIV-related stigma in older age in rural Malawi. Social Science and Medicine, 164, 35–43. doi:10.1016/j.socscimed.2016.07.006.CrossRefGoogle Scholar
  13. Freeman, E., & Anglewicz, P. (2012). HIV prevalence and sexual behaviour at older ages in rural Malawi. International Journal of STD and AIDS, 23, 490–496. doi:10.1258/ijsa.2011.011340.CrossRefGoogle Scholar
  14. Frost, L., Navarro, A. L., Lynch, M., Campbell, M., Orcutt, M., Trelfa, A., et al. (2015). Care of the elderly: Survey of teaching in an aging sub-Saharan Africa. Gerontology and Geriatrics Education, 36, 14–29. doi:10.1080/02701960.2014.925886.CrossRefGoogle Scholar
  15. Gandek, B., Ware, J. E., Aaronson, N. K., Apolone, G., Bjorner, J. B., Brazier, J. E., et al. (1998). Cross-validation of item selection and scoring for the SF-12 health survey in nine countries: Results from the IQOLA project. Journal of Clinical Epidemiology, 51, 1171–1178. doi:10.1016/S0895-4356(98)00109-7.CrossRefGoogle Scholar
  16. Guerchet, M., Mbelesso, P., Ndamba-Bandzouzi, B., Pilleron, S., Desormais, I., Lacroix, P., et al. (2014). Epidemiology of dementia in Central Africa (EPIDEMCA): Protocol for a multicentre population-based study in rural and urban areas of the Central African Republic and the Republic of Congo. SpringerPlus, 3, 338. doi:10.1186/2193-1801-3-338.CrossRefGoogle Scholar
  17. Haan, M. N., Al-Hazzouri, A. Z., & Aiello, A. E. (2011). Life-span socioeconomic trajectory, nativity, and cognitive aging in Mexican Americans: The Sacramento Area Latino Study on Aging. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 66B, i102–i110. doi:10.1093/geronb/gbq071.CrossRefGoogle Scholar
  18. Hanushek, E. A., & Woessmann, L. (2008). The role of cognitive skills in economic development. Journal of Economic Literature, 46, 607–668. doi:10.1257/jel.46.3.607.CrossRefGoogle Scholar
  19. Haslam, C., Cruwys, T., & Haslam, S. A. (2014). “The we’s have it”: Evidence for the distinctive benefits of group engagement in enhancing cognitive health in aging. Social Science and Medicine, 120, 57–66. doi:10.1016/j.socscimed.2014.08.037.CrossRefGoogle Scholar
  20. Heaton, R. K., Clifford, D. B., Franklin, D. R., Woods, S. P., Ake, C., Vaida, F., et al. (2010). HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy CHARTER Study. Neurology, 75, 2087–2096. doi:10.1212/WNL.0b013e318200d727.CrossRefGoogle Scholar
  21. Herd, P. (2010). Education and health in late-life among high school graduates cognitive versus psychological aspects of human capital. Journal of Health and Social Behavior, 51, 478–496. doi:10.1177/0022146510386796.CrossRefGoogle Scholar
  22. Hsu, H. C. (2007). Does social participation by the elderly reduce mortality and cognitive impairment? Aging and Mental Health, 11, 699–707. doi:10.1080/13607860701366335.CrossRefGoogle Scholar
  23. Huang, W., & Zhou, Y. (2013). Effects of education on cognition at older ages: Evidence from China’s great famine. Social Science and Medicine, 98, 54–62.CrossRefGoogle Scholar
  24. Hurst, L., Stafford, M., Cooper, R., Hardy, R., Richards, M., & Kuh, D. (2013). Lifetime socioeconomic inequalities in physical and cognitive aging. American Journal of Public Health, 103, 1641–1648. doi:10.2105/AJPH.2013.301240.CrossRefGoogle Scholar
  25. Jones, R. N. (2015). Practice and retest effects in longitudinal studies of cognitive functioning. Alzheimer’s and Dementia (Amsterdam), 1, 101–102. doi:10.1016/j.dadm.2015.02.002.Google Scholar
  26. Kohler, I. V., Kohler, H.-P., Anglewicz, P., & Behrman, J. R. (2012). Intergenerational transfers in the era of HIV/AIDS: Evidence from rural Malawi. Demographic Research, 27, 775–834.CrossRefGoogle Scholar
  27. Kohler, I. V., Payne, C. F., Bandawe, C., & Kohler, H.-P. (2017). The demography of mental health among mature adults in a low-income, high-HIV-prevalence context. Demography. doi:10.1007/s13524-017-0596-9.Google Scholar
  28. Kohler, H.-P., Watkins, S. C., Behrman, J. R., Anglewicz, P., Kohler, I. V., Thornton, R. L., et al. (2015). Cohort profile: The Malawi Longitudinal Study of Families and Health (MLSFH). International Journal of Epidemiology, 44, 394–404. doi:10.1093/ije/dyu049.CrossRefGoogle Scholar
  29. Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Löwe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 32, 345–359. doi:10.1016/j.genhosppsych.2010.03.006.CrossRefGoogle Scholar
  30. Lawler, K., Jeremiah, K., Mosepele, M., Ratcliffe, S. J., Cherry, C., Seloilwe, E., et al. (2011). Neurobehavioral effects in HIV-positive individuals receiving highly active antiretroviral therapy (HAART) in Gaborone, Botswana. PLoS ONE, 6, 1156–1162. doi:10.1371/journal.pone.0017233.CrossRefGoogle Scholar
  31. Lawler, K., Mosepele, M., Ratcliffe, S., Seloilwe, E., Steele, K., Nthobatsang, R., et al. (2010). Neurocognitive impairment among HIV-positive individuals in Botswana: A pilot study. Journal of the International AIDS Society. doi:10.1186/1758-2652-13-15.Google Scholar
  32. Lee, R. D., & Mason, A. (2011). Generational economics in a changing world. Population and Development Review, 37, 115–142. doi:10.1111/j.1728-4457.2011.00380.x.CrossRefGoogle Scholar
  33. Lee, J., Shih, R. A., Feeney, K. C., & Langa, K. M. (2011). Cognitive health of older Indians [WWW Document]. http://www.rand.org/pubs/working_papers/WR889.html. Accessed 6.6.16.
  34. Lee, J., Shih, R., Feeney, K., & Langa, K. M. (2014). Gender disparity in late-life cognitive functioning in India: Findings from the longitudinal aging study in India. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 69, 603–611. doi:10.1093/geronb/gbu017.CrossRefGoogle Scholar
  35. Lei, X., Smith, J. P., Sun, X., & Zhao, Y. (2014). Gender differences in cognition in China and reasons for change over time: Evidence from CHARLS. The Journal of the Economics of Ageing, 4, 46–55. doi:10.1016/j.jeoa.2013.11.001.CrossRefGoogle Scholar
  36. Lekoubou, A., Echouffo-Tcheugui, J. B., & Kengne, A. P. (2014). Epidemiology of neurodegenerative diseases in sub-Saharan Africa: A systematic review. BMC Public Health, 14, 653. doi:10.1186/1471-2458-14-653.CrossRefGoogle Scholar
  37. Lynch, J. W., Kaplan, G. A., & Shema, S. J. (1997). Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. New England Journal of Medicine, 337, 1889–1895. doi:10.1056/NEJM199712253372606.CrossRefGoogle Scholar
  38. Lyu, J., & Burr, J. A. (2016). Socioeconomic status across the life course and cognitive function among older adults: An examination of the latency, pathways, and accumulation hypotheses. Journal of Aging and Health, 28, 40–67. doi:10.1177/0898264315585504.CrossRefGoogle Scholar
  39. Madsen, J. B. (2016). Barriers to prosperity: Parasitic and infectious diseases, IQ, and economic development. World Development, 78, 172–187. doi:10.1016/j.worlddev.2015.10.032.CrossRefGoogle Scholar
  40. Malawi DHS. (2011). Malawi demographic and health survey 2010 (final report). National Statistical Office (NSO) and ICF Macro., Zomba, Malawi, and Calverton, Maryland, USA.Google Scholar
  41. Maurer, J. (2010). Height, education and later-life cognition in Latin America and the Caribbean. Economics and Human Biology, 8, 168–176. doi:10.1016/j.ehb.2010.05.013.CrossRefGoogle Scholar
  42. Maurer, J. (2011). Education and male–female differences in later-life cognition: International evidence from Latin America and the Caribbean. Demography, 48, 915–930. doi:10.1007/s13524-011-0048-x.CrossRefGoogle Scholar
  43. McArdle, J., Rodgers, W., & Willis, R. (2015). Cognition and aging in the USA (CogUSA) 2007–2009. Inter-university Consortium for Political and Social Research. doi:10.3886/ICPSR36053.v1.
  44. Moritz, D. J., Kasl, S. V., & Berkman, L. F. (1995). Cognitive functioning and the incidence of limitations in activities of daily living in an elderly community sample. American Journal of Epidemiology, 141, 41–49.CrossRefGoogle Scholar
  45. Msyamboza, K. P., Ngwira, B., Dzowela, T., Mvula, C., Kathyola, D., Harries, A. D., et al. (2011). The burden of selected chronic non-communicable diseases and their risk factors in Malawi: Nationwide STEPS survey. PLoS ONE, 6, e20316.CrossRefGoogle Scholar
  46. Murray, C. J. L., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, C., et al. (2012). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2197–2223. doi:10.1016/S0140-6736(12)61689-4.CrossRefGoogle Scholar
  47. National Institute on Aging (2012). Global health and aging (NIH Publication no. 11-7737). Bethesda: National Institute on Aging. Retrieved from https://www.nia.nih.gov/sites/default/files/2017-06/global_health_aging.pdf.
  48. Organization, International Labour (Ed.). (2016). World employment and social outlook: Trends 2016, world employment and social outlook. Geneva: International Labour Department.Google Scholar
  49. Paddick, S.-M., Gray, W. K., Ogunjimi, L., Lwezuala, B., Olakehinde, O., Kisoli, A., et al. (2015). Validation of the identification and intervention for dementia in elderly Africans (IDEA) cognitive screen in Nigeria and Tanzania. BMC Geriatrics, 15, 53. doi:10.1186/s12877-015-0040-1.CrossRefGoogle Scholar
  50. Payne, C., & Kohler, H.-P. (2017). The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi. Demographic Research, 36, 1081–1108. doi:10.4054/DemRes.2017.36.37.CrossRefGoogle Scholar
  51. Payne, C. F., Mkandawire, J., & Kohler, H.-P. (2013). Disability transitions and health expectancies among adults 45 years and older in Malawi: A cohort-based model. PLoS Medicine, 10, e1001435. doi:10.1371/journal.pmed.1001435.CrossRefGoogle Scholar
  52. Prince, M., Acosta, D., Ferri, C. P., Guerra, M., Huang, Y., Jacob, K. S., et al. (2011). A brief dementia screener suitable for use by non-specialists in resource poor settings—The cross-cultural derivation and validation of the brief Community Screening Instrument for Dementia. International Journal of Geriatric Psychiatry, 26, 899–907. doi:10.1002/gps.2622.CrossRefGoogle Scholar
  53. Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematic review and metaanalysis. Alzheimer’s and Dementia, 9(63–75), e2. doi:10.1016/j.jalz.2012.11.007.Google Scholar
  54. RAND. (2015). RAND HRS around-the-world harmonization meeting. Bethesda, MD: RAND Corporation.Google Scholar
  55. Ryff, C. D., & Lachman, M. E. (2009). Midlife in the United States (MIDUS 2): Cognitive Project, 2004–2006. Inter-university Consortium for Political and Social Research. doi:10.3886/ICPSR25281.v5.
  56. Salthouse, T. A. (1991). Theoretical perspectives on cognitive aging (Revised ed.). Hillsdale, NJ: Psychology Press.Google Scholar
  57. Seeman, T. E., Lusignolo, T. M., Albert, M., & Berkman, L. (2001). Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging. Health Psychology, 20, 243–255.CrossRefGoogle Scholar
  58. Sosa, A. L., Albanese, E., Stephan, B. C. M., Dewey, M., Acosta, D., Ferri, C. P., et al. (2012). Prevalence, distribution, and impact of mild cognitive impairment in Latin America, China, and India: A 10/66 population-based study. PLoS Medicine, 9, e1001170. doi:10.1371/journal.pmed.1001170.CrossRefGoogle Scholar
  59. Staff, R. T., Chapko, D., Hogan, M. J., & Whalley, L. J. (2016). Life course socioeconomic status and the decline in information processing speed in late life. Social Science and Medicine, 151, 130–138. doi:10.1016/j.socscimed.2016.01.019.CrossRefGoogle Scholar
  60. Stern, Y. (2009). Cognitive reserve. Neuropsychologia, 47, 2015–2028. doi:10.1016/j.neuropsychologia.2009.03.004.CrossRefGoogle Scholar
  61. Sternäng, O., Reynolds, C. A., Finkel, D., Ernsth-Bravell, M., Pedersen, N. L., & Aslan, D. K. A. (2016). Grip strength and cognitive abilities: Associations in old age. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 71, 841–848. doi:10.1093/geronb/gbv017.CrossRefGoogle Scholar
  62. Thomas, P. A. (2011). Trajectories of social engagement and limitations in late life. Journal of Health and Social Behavior, 52, 430–443. doi:10.1177/0022146511411922.CrossRefGoogle Scholar
  63. UNDP. (2014). Human development report 2014: Sustaining human progress-reducing vulnerabilities and building resilience. New York, NY: United Nations Development Programme.CrossRefGoogle Scholar
  64. United Nations Population Division. (2015). World population prospects (No. ESA/P/WP.241).Google Scholar
  65. Watson, N. L., Rosano, C., Boudreau, R. M., Simonsick, E. M., Ferrucci, L., Sutton-Tyrrell, K., et al. (2010). Executive function, memory, and gait speed decline in well-functioning older adults. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. doi:10.1093/gerona/glq111.Google Scholar
  66. Weir, D., Lay, M., & Langa, K. (2014). Economic development and gender inequality in cognition: A comparison of China and India, and of SAGE and the HRS sister studies. The Journal of the Economics of Ageing, 4, 114–125. doi:10.1016/j.jeoa.2014.08.002.CrossRefGoogle Scholar
  67. World Health Orginazation (WHO). (2014). Noncommunicable diseases country profiles 2014. Malawi. Retrieved from http://www.who.int/countries/mwi/en/.
  68. Zagheni, E. (2011). The impact of the HIV/AIDS epidemic on kinship resources for orphans in Zimbabwe. Population and Development Review, 37, 761–783.CrossRefGoogle Scholar
  69. Zhang, Z. (2006). Gender differentials in cognitive impairment and decline of the oldest old in China. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 61, S107–S115.CrossRefGoogle Scholar
  70. Zhang, Z., Hayward, M. D., & Yu, Y.-L. (2016). Life course pathways to racial disparities in cognitive impairment among older Americans. Journal of Health and Social Behavior, 57, 184–199. doi:10.1177/0022146516645925.CrossRefGoogle Scholar
  71. Zimmer, Z., & Teachman, J. (2009). Household composition among elders in sub-Saharan Africa in the context of HIV/AIDS. Journal of Marriage and Family, 71, 1086–1099.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2017

Authors and Affiliations

  • Collin F. Payne
    • 1
  • Iliana V. Kohler
    • 2
  • Chiwoza Bandawe
    • 3
  • Kathy Lawler
    • 4
  • Hans-Peter Kohler
    • 5
  1. 1.Center for Population and Development StudiesHarvard UniversityCambridgeUSA
  2. 2.Population Studies CenterUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of Mental HealthCollege of MedicineBlantyreMalawi
  4. 4.Department of NeurologyPerelman School of Medicine University of PennsylvaniaPhiladelphiaUSA
  5. 5.Department of SociologyUniversity of PennsylvaniaPhiladelphiaUSA

Personalised recommendations