Understanding psychosocial determinants of malaria behaviours in low-transmission settings: a scoping review.

BACKGROUND: Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings. METHODS: A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000-2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours. RESULTS: Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour. CONCLUSIONS: The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex.

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

External resilience in the context of drug use and socio-structural vulnerabilities: a qualitative exploration among women who use drugs and sell sex in Baltimore, Maryland.

BACKGROUND: Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one's environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience. METHODS: WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response. RESULTS: Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and "self-medication" through substance use was common absent other perceived options for help. CONCLUSIONS: External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS' ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society's stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities.

"We have this, with my husband, we live in harmony": exploring the gendered decision-making matrix for malaria prevention and treatment in Nampula Province, Mozambique.

BACKGROUND: Conceptualizing gender dynamics and ways of bridging entrenched gender roles will contribute to better health promotion, policy and planning. Such processes are explored in relation to malaria in Mozambique. METHODS: A multi-method, qualitative study using focus group discussions (FGDs) and in-depth interviews (IDIs) explored the perspectives of community members, leaders and stakeholders on malaria. The study was conducted in Nampula Province, in an intervention district for the Tchova Tchova Stop Malaria (TTSM) gender-sensitive community dialogues, and in a non-intervention district. RESULTS: Participants (n = 106) took part in six FGDs and five IDIs in each district. Those exposed to TTSM commonly stated that the programme influenced more equalitarian gender roles, attitudes and uptake of protective malaria-related practices. These positive changes occurred within the context of an observed, gendered decision-making matrix, which aligns inward- or outward-facing decisions with malaria prevention or treatment. Decisions more dependent on male or elder sanctioning at community level are outward-facing decisions, while decisions falling within women's domain at household level are inward-facing decisions. Related to prevention, using bed nets was largely an inward-facing prevention decision for women, who were generally tasked with hanging, washing and making nets usable. Net purchase and appropriation for malaria prevention (rather than for instance for fishing) was men's prerogative. Regular net use was associated with sleeping together more regularly, bringing couples closer. Attending antenatal care to access intermittent preventive treatment during pregnancy was often an outward-facing prevention decision, under the purview of older, influential women and ultimately needing sanctioning by men. With respect to seeking care for malaria symptoms, women typically sought help from traditional healers first. This inward-facing treatment decision was within their control, in contrast to the frequently transport-dependent, outward-facing decision to attend a health facility. Sharing decisions was described as a feature of a "harmonious household," something that was said to be encouraged by the TTSM intervention and that was both lived and aspirational. CONCLUSIONS: TTSM community dialogues helped communication on both interpersonal (couple) and community levels, ultimately encouraging malaria-related behaviours. Leveraging ways of bringing men and women together to share decision making will improve malaria intervention success.

The (re)productive work of labour migration: the reproductive lives of women with an absent spouse in the central hill region of Nepal.

Limited attention has been given to the effects of labour migration on the reproductive lives of women 'left behind' as their partners travel for work. Drawing on two rounds of qualitative interviews with 20 women in the central hill region of Nepal, this paper examines how global economic processes that lead Nepali men to travel for work also affect women's reproductive work, including childrearing and reproductive decision-making. Women understood their husband's migration to engage in the wage economy as a response to both immediate and long-term goals for their children and family. As a result, such productive work was intrinsically linked to reproductive work. Men's migration patterns played a pivotal role in reinforcing women's immediate childrearing roles and affecting whether and when women used a contraceptive method and what methods they considered. During periods of spousal migration, women's reproductive lives became targets of gossip and rumours as their intimate and reproductive practices and use of remittances were socially monitored. This complex understanding of women's lived experiences at the nexus of (re)productive work and labour migration can be practically applied to address the reproductive health needs of women with migrant spouses in Nepal.

Urbanicity of residence and depression among adults 50 years and older in Ghana and South Africa: an analysis of the WHO Study on Global AGEing and Adult Health (SAGE).

OBJECTIVES: As the primary cause of disability worldwide, depression is a significant contributor to global morbidity and mortality and often disproportionately affects older adults. Several studies have demonstrated a link between urban residence and depression, but few studies have examined this association among older adult populations, and even fewer have studied it within an African context. Given that African societies are aging and urbanizing at rapid rates, this study aimed to assess the relationship between urbanicity and depression within older adult populations in two African countries. METHOD: Data were drawn from the Ghana and South Africa samples of the World Health Organization Study on Global AGEing and Adult Health (SAGE) wave 1 (2007-2008). Depression over the past 12 months was measured using self-reported treatment and depressive symptoms based on ICD-10 criteria in 4209 Ghanaian and 3148 South African adults aged 50 years and older residing in their current location for over one year. RESULTS: The 12-month prevalence of depression was 7.5% and 4.0% in Ghana and South Africa, respectively; 41.1% and 65.6%, respectively, lived in urban areas. Comparing urban to rural residents, the adjusted odds ratio (OR) for depression in multivariable analysis was 1.13 (95% CI: 0.71-1.79) in South Africa and 0.85 (95% CI: 0.55-1.31) in Ghana. CONCLUSION: Results do not support a significant urban-rural difference in 12-month depression among Ghanaian or South African SAGE participants. Mental health resources in rural areas should therefore be enhanced in these countries for more equitable distributions between the two settings given similar need.

Adapting the Risk Environment Framework to Understand Substance Use, Gender-Based Violence, and HIV Risk Behaviors Among Female Sex Workers in Tanzania.

Female sex workers (FSWs) in sub-Saharan Africa are disproportionately affected by HIV and gender-based violence (GBV). Substance use overlaps with these co-occurring epidemics to further increase FSWs' risk for negative health outcomes. We explored the relationship between substance use, GBV, and consistent condom use utilizing baseline data from a cohort of 496 FSWs in Tanzania. Results demonstrate high levels of alcohol use and GBV, and low levels of consistent condom use. Frequent intoxication during sex work was associated with increased odds of recent GBV (aOR 1.64, 95% CI 1.07, 2.49; p value 0.02) and reduced odds of consistent condom use with clients (aOR 0.58, 95% CI 0.37, 0.92; p-value 0.02). We adapt the risk environment framework to contextualize our findings in the social and structural context and to gain insight into intervention approaches to address the intersecting challenges of substance use, GBV, and HIV among FSWs in Tanzania and similar settings.

Sexual motivations during the menopausal transition among Iranian women: a qualitative inquiry.

BACKGROUND: Women's sexuality may be adversely affected during the menopausal transition. This exploratory qualitative study was conducted to explore how women assign meaning to and process sexual motivation during the menopausal transition. METHODS: We purposefully approached 22 married women ages 44-59 (52.81 ± 3.6 years) in urban health care centers and workplaces in Tabriz city, located in northwest Iran. Individual face-to-face interviews were performed at a place and time convenient to the women. All interviews were audio recorded and then transcribed to create verbatim written accounts. Inspiring Graneheim and Lundman approach, we employed conventional content analysis to derive coding categories directly from our row data. FINDINGS: Four main themes emerged from data analysis: "Diminished sexual capacity" (effect of menopause, Illnesses associated with mid-life, desire discrepancy); "intimate coupling" (lack of physical and/or emotional intimacy, couple communication and romance); "sociocultural scripts" (sexual script, parental responsibilities); and "sense of youthfulness" (having an active and happy life, maintaining physically attractiveness). CONCLUSION: The qualitative findings suggest that providing sexual health education and counseling, to encourage critical discussions regarding current sociocultural scripts and to create an environment that would enable men and women alike to adopt a healthy and happy lifestyle for eliminating barriers and preserving and enhancing motivational factors associated with sexuality.

'You already drank my beer, I can decide anything': using structuration theory to explore the dynamics of alcohol use, gender-based violence and HIV risk among female sex workers in Tanzania.

Female sex workers experience high rates of gender-based violence and HIV. Alcohol has been shown to facilitate women's risk of both gender-based violence and HIV; however, little research has explored how aspects of the sex work environment shape this risk. Drawing on structuration theory, this study explored how social conduct is patterned across time and space within the sex work environment to influence alcohol consumption, gender-based violence and HIV risk among female sex workers. Qualitative in-depth interviews were conducted with 24 female sex workers enrolled in an ongoing community randomised controlled trial of a combination HIV prevention intervention in Iringa, Tanzania. Data were analysed using both inductive and deductive approaches. Findings reveal how routine interactions between female sex workers and their clients occur at three moments of time and space during the sex exchange process to facilitate alcohol consumption and increase women's risk of gender-based violence and HIV. Findings also highlight how sex workers utilise collective agency to address aspects of the sex work environment that place them at risk of alcohol abuse, gender-based violence and HIV. Implications for future interventions to prevent gender-based violence and HIV among female sex workers in Tanzania and similar contexts are discussed.

Talking about reproduction with a migrating spouse: Women's experiences in Dhading, Nepal.

Communication between Nepali women and their migrating spouses affects the transregional or transnational social fields of women "left behind" and may have implications for their reproductive health. We explored women's interactions with their absent spouses using data gathered from qualitative interviews. Conversations with migrant husbands were frequent, organized around husbands' schedules, and focused on children's needs and expenses. Couple power dynamics were challenged and reinforced in such conversations. Communication about family planning and childbearing was often delayed until the husband's return. In an increasingly mobile world, encouraging partner communication should be integral to reproductive health programs working with migrant couples.

Community Theater Participation and Nutrition-Related Practices: Evidence from Nepal.

Suaahara, a nutrition-enhancement program in Nepal, conducted participatory community theater (CT) dramas with the goal of improving nutrition-related practices. To evaluate CT, a pre/posttest with randomized intervention and matched control sites was used. Dramas were conducted in Nawalparasi, Bajhang, and Sindhupalchowk Districts to represent the mountain, hill, and terai/plains regions. Within each study district, two intervention sites were randomly selected and two matched comparison sites were identified for inclusion in the study. At both baseline and endline, 600 individuals aged 18-59 (100 men and 100 women/district × 3 districts) were interviewed in the control sites and 600 in the intervention sites (1200 total respondents). Multivariate logistic analysis controlling for background characteristics found that CT attendance was significantly and positively associated with improved nutrition-related knowledge (adjusted odds ratio ratio [aORR] 10.2, p < 0.001) and communication (aORR 2.4, p < 0.001), hand washing after cleaning a defecating child (aORR 1.49, p < 0.05), feeding children eggs (aORR 1.83, p < 0.01), and feeding children meat and/or fish (aORR 2.10, p < 0.01). This is the first study to rely on a pre/post matched intervention-control design to assess CT effects in a low-income setting. By testing the "difference-in-differences"-or the difference between intervention groups at baseline and endline minus that between controls at baseline and endline-the argument that the effects can be causally attributed to the intervention itself is strengthened. These findings support the continued and expanded use of CT to improve nutrition-related knowledge, communication, efficacy, and feeding practices as a valuable community-based, public health approach.

Suaahara in Nepal: An at-scale, multi-sectoral nutrition program influences knowledge and practices while enhancing equity.

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non-health determinants of undernutrition. In Nepal, one large-scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000-day period, while simultaneously addressing inequities. In this study, we use household-level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non-disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child-, maternal-, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non-Suaahara areas and sometimes even than non-DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non-DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large-scale integrated interventions can influence nutrition-related knowledge and practices, while simultaneously reducing inequities.

A meta-review of school-based disaster interventions for child and adolescent survivors.

BACKGROUND: Children and adolescents are among the most vulnerable groups affected by natural and man-made disaster. To better understand research and practice concerning mental health and psychosocial support efforts in humanitarian settings, the authors conducted a comprehensive review of all intervention programmes within the past decade that universally targeted children and adolescents who were exposed to a natural and/or man-made disaster. METHODS: We searched PubMed, PsychINFO, Cochrane Library and CINAHL for mental health and psychosocial interventions (MHPSS) involving children and adolescents. A total of 11 studies, 4 from natural disasters and 7 from conflict-affected areas met the inclusion criteria. Effect sizes were calculated using a random effects model for studies in post-natural disaster and war/terrorist-affected settings separately. RESULTS: The weighted mean effect sizes for interventions in both settings were statistically significant: -0.308, 95% CI=-0.54- -0.07, z=-2.58, p=0.010 after a natural disaster, and -0.514, 95% CI=-0.80 to -0.23, z=-3.57, p<0.001 in conflict areas. This indicates that MHPSS interventions in both disaster settings resulted in a reduction in PTSD symptoms compared to the control. CONCLUSIONS: This review suggests that school-based, universal programmes that are conducted by teachers or local paraprofessionals are effective in reducing PTSD symptoms in children and adolescents. The few studies meeting the inclusion criteria of this study demonstrate the need for further expansion of statistical methods and study designs to test for the effects of interventions in challenging humanitarian settings.

Transitions to adulthood: examining the influence of initiation rites on the HIV risk of adolescent girls in Mangochi and Thyolo districts of Malawi.

Although some cultural practices have been identified as a determinant of HIV transmission, research investigating how specific practices affect HIV risk is lacking. In Malawi, initiation rites, in which young people attend ceremonies around the time of puberty, have received little attention. In this qualitative study, we explored whether communities in southern Malawi perceive initiation rites to be an HIV risk factor for girls. Twelve focus group discussions were held with adolescents and adults in a rural community of Thyolo district and a peri-urban community of Mangochi district. Community members observed that certain aspects of traditional initiation rites propel girls into sexual roles expected of adulthood, without facilitating their adaption to the emerging landscape of HIV, thereby increasing HIV risk. HIV prevention programming needs to address the role of initiation rites in adolescent girls' vulnerability to HIV and help young girls navigate the conflicting messages they receive from a wide range of channels about expected sexual behavior.

Moderating effects of a postdisaster intervention on risk and resilience factors associated with posttraumatic stress disorder in Chinese children.

This study is an evaluation of a psychosocial intervention involving child and adolescent survivors of the 2008 Sichuan China earthquake. Sociodemographics, earthquake-related risk exposure, resilience using the Connor-Davidson Resilience Scale, and posttraumatic stress disorder (PTSD) using the UCLA-PTSD Index were collected from 1,988 intervention participants and 2,132 controls. Mean resilience scores and the odds of PTSD did not vary between groups. The independent factors for risk and resilience and the dependent variable, PTSD, in the measurement models between control and intervention groups were equivalent. The structural model of risk and 2 resilience factors on PTSD was examined and found to be unequivalent between groups. In contrast to controls, risk exposure (B = −0.32, p <.001) in the intervention group was negatively associated with PTSD. Rational thinking (B = −0.48, p < .001), a resilience factor, was more negatively associated with PTSD in the intervention group. The second resilience factor explored, self-awareness, was positively associated with PTSD in both groups (B = 0.46 for controls, p < .001, and B = 0.69 for intervention, p < .001). Results highlight the need for more cross-cultural research in resilience theory to develop culturally appropriate interventions and evaluation measures.

Making a difference in adult-child relationships: evidence from an adult-child communication intervention in Botswana, Malawi, and Mozambique.

Girls are vulnerable to HIV in part because the social systems in which they live have failed to protect them. This study evaluates a program aimed at strengthening adult-child relationships to reduce girls' vulnerability to HIV in Botswana, Malawi, and Mozambique. In addition to an extensive process evaluation, a cross-sectional post-intervention survey was conducted in the three countries. The total sample size was 1418 adolescent girls (ages 11-18). Bivariate and multilevel, multivariate analyses were conducted to assess the association between adult program exposure and adult-child relationship improvement. In Botswana, Malawi, and Mozambique, girls whose mothers and fathers participated in the program, as compared to those whose parents did not participate in the program, were significantly more likely to report that their relationships with their parents had improved. Research has shown the important role that adults can play in the mitigation of youth risk taking behavior.

Gender norms, contraceptive use, and intimate partner violence: A six-country analysis.

BACKGROUND: While considerable research has explored associations between gender norms and various sexual and reproductive health behaviors (SRH) with the aim of informing programs, no studies have examined whether couple concordance on specific gender norms is associated with both contraceptive use and reduced intimate partner violence (IPV) experience. METHODS: This study relies on analysis of Demographic and Health Survey (DHS) couples' datasets from Mali, Nigeria, Nepal, Pakistan, Tanzania, and Zambia that were collected in/after 2015 and include the DHS Domestic Violence Module for female respondents. To examine the associations between couple concordance regarding household decision-making or justification of violence (wife beating) and women's use of modern contraceptives or experience of violence, bivariate and multivariate logistic regression models were fit using Stata15. RESULTS: Joint decision-making about large household purchases was significantly positively associated with modern contraceptive use in all study countries as well as with reduced odds of IPV experience in adjusted models in Tanzania and Zambia. In Nigeria, women's justification for violence was negatively associated with contraceptive use. Across settings, women in couples where both justified violence had significantly increased odds of reporting IPV experience. CONCLUSIONS: The evidence suggests that family planning programs should support joint decision-making as it was positively associated with contraceptive use across the six countries and is a proxy for shared economic power within the household. IPV reduction and prevention programs should also consider encouraging joint decision-making given the correlations found in two settings. Programs should enable participants to interrogate attitudes regarding justifying violence against female partners and propose approaches to avoid IPV. Finally, husbands' alcohol consumption, a strong predictor of IPV experience, has too long been overlooked.

Effects of women's economic empowerment interventions on antenatal care outcomes: a systematic review.

OBJECTIVES: Early and adequate antenatal care (ANC) has been shown to reduce maternal morbidity and mortality globally. Increasing evidence suggests that women's economic empowerment (WEE) is a critical factor that may influence uptake of ANC during pregnancy. However, existing literature lacks a comprehensive synthesis of studies on WEE interventions and their effects on ANC outcomes. This systematic review analyses WEE interventions at the household, community and national levels and their effects on ANC outcomes in low-income and middle-income countries, where the majority of maternal deaths occur. METHODS: Six electronic databases were systematically searched as well as 19 websites of relevant organisations. Studies published in English and after 2010 were included. RESULTS: Following abstract and full-text review, 37 studies were included in this review. Seven studies used an experimental study design, 26 studies used a quasi-experimental study design, 1 study used an observational design and 1 study was a systematic review with meta-analysis. Thirty-one included studies evaluated a household-level intervention, and six studies evaluated a community-level intervention. No included studies examined a national-level intervention. CONCLUSION: Most included studies on household-level and community-level interventions found a positive association between the intervention and the number of ANC visits women received. This review emphasises the need for more WEE interventions that empower women at the national level, for the expansion of the definition of WEE to be more inclusive of the multidimensionality of WEE interventions and the social determinants of health, and the standardisation of ANC outcome measurement globally.

Residence in urban and rural areas over the life course and depression among Ghanaian and South African older adults.

This study assessed associations between depression and urban/rural residence from a life-course perspective within African settings. Data on Ghanaian and South African adults aged 50 years and older were taken from wave 1 of the World Health Organization Study on Global Ageing and Adult Health (SAGE). Neither urbanicity of childhood nor adulthood residence was associated with later-life depression in either country. Significant differences were also not observed for residence changes over the life course, but there were trends in the data suggestive of higher depression prevalence in Ghanaian recent rural-urban migrants and lower prevalence among South African recent urban-rural migrants.

Assessing urban-rural differences in the relationship between social capital and depression among Ghanaian and South African older adults.

INTRODUCTION: Research has demonstrated benefits of social capital on depression, but variations in this relationship by geographic characteristics such as urbanicity have rarely been investigated. METHODS: Using survey data on 4,209 Ghanaian and 3,148 South African adults aged 50 and above from the World Health Organization (WHO) Study on Global AGEing and Adult Health (SAGE), exploratory and confirmatory factor analyses were conducted to extract dimensions of social capital from survey items. Structural equation models with the extracted factors were then used to estimate the associations between social capital and depression in each sample and assess differences between urban and rural settings with measurement and structural invariance tests. RESULTS: Factor analyses suggested three dimensions of social capital representing community engagement, sociability, and trust. Urbanicity did not substantially modify the effects of social capital on depression in either setting, but urban-rural differences in the measurement and level of social capital were observed. Urban Ghanaian older adults were less socially integrated and trusting than older rural residents (standardized mean difference: -0.28, -0.24, and -0.38 for community engagement, sociability, and trust, respectively) while urban South African older adults appeared less engaged in community activities but significantly more trusting and socially active informally than older rural residents (standardized mean difference: -0.33, 0.30, and 0.17 for community engagement, sociability, and trust, respectively). Moreover, while trust was associated with a lower risk of depression in South Africa overall, sociability and trust were associated with an increased risk of depression in Ghana. CONCLUSIONS: Results indicate that the composition and average levels of social capital differ between urban and rural older adult residents in Ghana and South Africa although urban-rural differences in the strength of the association between social capital and depression were not substantial. Furthermore, the associations between social capital and depression are context-specific and are not uniformly beneficial.