Mortality risk information and health-seeking behavior during an epidemic.

In a context where pessimistic survival perceptions have been widespread as a result of the HIV/AIDS epidemic (Fig. 1 A), we study vaccine uptake and other health behaviors during the recent COVID-19 pandemic. Leveraging a longitudinal cohort study in rural Malawi that has been followed for up to 25 y, we document that a 2017 mortality risk information intervention designed to reduce pessimistic mortality perceptions (Fig. 1 B) resulted in improved health behavior, including COVID-19 vaccine uptake (Fig. 1 C). We also report indirect effects for siblings and household members. This was likely the result of a reinforcing process where the intervention triggered engagement with the healthcare system and stronger beliefs in the efficacy of modern biomedical treatments, which led to the adoption of health risk reduction behavior, including vaccine uptake. Our findings suggest that health information interventions focused on survival perceptions can be useful in promoting health behavior and participation in the formal healthcare system, even during health crises-such as the COVID-19 pandemic-that are unanticipated at the time of the intervention. We also note the importance of the intervention design, where establishing rapport, tailoring the content to the local context, and spending time with respondents to convey the information contributed to the salience of the message.

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.

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.

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.

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.

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

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 (SSA) growing population of mature adults (= persons age 45+). We use data from the Malawi Longitudinal Study of Families and Health (MLSFH) 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 U.S. 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.

The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context.

Very few studies have investigated mental health in sub-Saharan Africa (SSA). Using data from Malawi, this article provides a first picture of the demography of depression and anxiety (DA) among mature adults (aged 45 or older) in a low-income country with high HIV prevalence. DA are more frequent among women than men, and individuals affected by one are often affected by the other. DA are associated with adverse outcomes, such as poorer nutrition intake and reduced work efforts. DA also increase substantially with age, and mature adults can expect to spend a substantial fraction of their remaining lifetime-for instance, 52 % for a 55-year-old woman-affected by DA. The positive age gradients of DA are not due to cohort effects, and they are in sharp contrast to the age pattern of mental health that has been shown in high-income contexts, where older individuals often experience lower levels of DA. Although socioeconomic and risk- or uncertainty-related stressors are strongly associated with DA, they do not explain the positive age gradients and gender gap in DA. Stressors related to physical health, however, do. Hence, our analyses suggest that the general decline of physical health with age is the key driver of the rise of DA with age in this low-income SSA context.

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.

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.

Barriers to and facilitators for creating, disseminating, implementing, monitoring and evaluating oral health policies in the WHO African region: A scoping review.

OBJECTIVE: To advance oral health policies (OHPs) in the World Health Organization (WHO) African region, barriers to and facilitators for creating, disseminating, implementing, monitoring and evaluating OHPs in the region were examined. METHODS: Global Health, Embase, PubMed, Public Affairs Information Service Index, ABI/Inform, Web of Science, Academic Search Complete, Scopus, Dissertations Global, Google Scholar, WHO's Institutional Repository for Information Sharing (IRIS), the WHO Noncommunicable Diseases Document Repository and the Regional African Index Medicus and African Journals Online were searched. Technical officers at the WHO Regional Office for Africa were contacted. Research studies and policy documents reporting barriers to and facilitators for OHP in the 47 Member States in the WHO African region published between January 2002 and March 2024 in English, French or Portuguese were included. Frequencies were used to summarize quantitative data, and descriptive content analysis was used to code and classify barrier and facilitator statements. RESULTS: Eighty-eight reports, including 55 research articles and 33 policy documents, were included. The vast majority of the research articles and policy documents were country-specific, but they were lacking for most countries. Frequently mentioned barriers across policy at all stages included financial constraints, a limited and poorly organized workforce, deprioritization of oral health, the absence of health information systems, inadequate integration of oral health services within the overarching health system and limited oral health literacy. Facilitators included a renewed commitment to establishing national OHPs, recognition of a need to diversify the oral health workforce, and an increased understanding of the influence of social determinants of health among oral health care providers. CONCLUSIONS: Most countries lack a country-specific body of evidence to assist policymakers in anticipating barriers to and facilitators for OHPs. The barriers and facilitators relevant to disparate subnational, national, and regional conditions and circumstances must be considered to advance the creation, dissemination, implementation, monitoring and evaluation of OHPs in the WHO African region.

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.

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.

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.

Is experience of the HIV/AIDS epidemic associated with responses to COVID-19? Evidence from the Rural Malawi.

INTRODUCTION: Starting in late 2019, the coronavirus "SARS-CoV-2", which causes the disease Covid-19, spread rapidly and extensively. Although many have speculated that prior experience with infectious diseases like HIV/AIDS, Ebola, or SARS would better prepare populations in sub-Saharan Africa for COVID-19, this has not been formally tested, primarily due to data limitations. METHODS: We use longitudinal panel data from the Malawi Longitudinal Study of Families and Health (MLSFH, waves 2006, 2008, and 2020) to examine the association between exposure to the HIV/AIDS epidemic and perceptions of, and behavioral response to, the COVID-19 pandemic. We measured exposure to HIV infection through perceived prevalence of HIV/AIDS in the community, worry about HIV infection, perceived likelihood of HIV infection, and actual HIV status; and the experience of HIV/AIDS-related mortality through self-reports of knowing members of the community and extended family who died from AIDS (measured in 2006 or 2008). Our outcome measures were perceptions of COVID-19 presence in the community, perceptions of individual vulnerability to COVID-19, and prevention strategies to avoid COVID-19 collected through phone-interviews in 2020. RESULTS: Based on our data analysis using multivariable regression models, we found that the experience of HIV-related mortality was positively associated with perceptions of COVID-19 prevalence in the community and preventive behaviors for COVID-19. However, perceived vulnerability to HIV-AIDS infection and actual HIV positive status 10-years prior to the COVID-19 pandemic are generally not associated with COVID-19 perceptions and behaviors. CONCLUSIONS: Our results suggest that COVID-19-related behaviors are impacted more by experience of AIDS mortality instead of HIV/AIDS risk perceptions, and that individuals may be correctly viewing HIV/AIDS and COVID-19 transmission as distinct disease processes.

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.

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.

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.

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.

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.

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.