Development of a brief screening method for identification of depression in older adults in Sub-Saharan Africa.

OBJECTIVES: To develop a brief, culturally appropriate screening tool for identifying late life depression (LLD), for use by non-specialist clinicians in primary and out-patient care settings in sub-Saharan Africa (SSA). BACKGROUND: Depressive disorders are a leading contributor to the global health burden. LLD is common and cases will increase as populations' age, particularly in low- and middle-income countries (LMICs), such as those in SSA. A chronic mental health workforce shortage and the absence of culturally adapted LLD screening tools to aid non-specialist clinicians have contributed to a significant diagnostic gap. DESIGN: A systematic random sample of older people attending general medical clinics were interviewed using a 30-item LLD questionnaire, developed utilizing a Delphi consensus analysis of items from the Geriatric Depression Scale, Patient Health Questionnaire-2 and questions developed from a study of lay conceptualisations of depression in Tanzania. The items were assessed for validity against blinded DSM 5 diagnosis of depression by a research doctor. Factor and item analysis were then used to refine the questionnaire. RESULTS: The 12-item Maddison Old-age Scale for Identifying Depression (MOSHI-D) was developed. It has good internal consistency (Cronbach's α = 0.820) and construct and criterion validity (AUROC = 0.880). CONCLUSIONS: On initial evaluation, the MOSHI-D showed good internal validity. It should be easy for non-specialists to administer. External validation and further refinement will be conducted. A culturally-appropriate LLD screen may improve mental health care integration into existing healthcare settings within SSA and facilitate greater patient access to care, in accordance with current WHO strategy.

Effectiveness of App-Based Cognitive Screening for Dementia by Lay Health Workers in Low Resource Settings. A Validation and Feasibility Study in Rural Tanzania.

BACKGROUND: The majority of people with dementia live in low-and middle-income countries (LMICs). In sub-Saharan Africa (SSA) human-resource shortages in mental health and geriatric medicine are well recognized. Use of technological solutions may improve access to diagnosis. We aimed to assess the diagnostic accuracy of a brief dementia screening mobile application (app) for non-specialist workers in rural Tanzania against blinded gold-standard diagnosis of DSM-5 dementia. The app includes 2 previously-validated culturally appropriate low-literacy screening tools for cognitive (IDEA cognitive screen) and functional impairment (abbreviated IDEA-IADL questionnaire). METHODS: This was a 2-stage community-based door-to-door study. In Stage1, rural primary health workers approached all individuals aged ≥60 years for app-based dementia screening in 12 villages in Hai district, Kilimanjaro Tanzania.In Stage 2, a stratified sub-sample were clinically-assessed for dementia blind to app screening score. Assessment included clinical history, neurological and bedside cognitive assessment and collateral history. RESULTS: 3011 (of 3122 eligible) older people consented to screening. Of these, 610 were evaluated in Stage 2. For the IDEA cognitive screen, the area under the receiver operating characteristic (AUROC) curve was 0.79 (95% CI 0.74-0.83) for DSM-5 dementia diagnosis (sensitivity 84.8%, specificity 58.4%). For those 358 (44%) completing the full app, AUROC was 0.78 for combined cognitive and informant-reported functional assessment. CONCLUSIONS: The pilot dementia screening app had good sensitivity but lacked specificity for dementia when administered by non-specialist rural community workers. This technological approach may be a promising way forward in low-resource settings, specialist onward referral may be prioritized.

Prevalence estimates of dementia in older adults in rural Kilimanjaro 2009-2010 and 2018-2019: is there evidence of changing prevalence?

INTRODUCTION: Although limited, existing epidemiological data on dementia in sub-Saharan Africa indicate that prevalence may be increasing; contrasting with recent decreases observed in high-income countries. We have previously reported the age-adjusted prevalence of dementia in rural Tanzania in 2009-2010 as 6.4% (95% confidence interval [CI] 4.9-7.9) in individuals aged ≥70 years. We aimed to repeat a community-based dementia prevalence study in the same setting to assess whether prevalence has changed. METHODS: This was a two-phase door-to-door community-based cross-sectional survey in Kilimanjaro, Tanzania. In Phase I, trained primary health workers screened all consenting individuals aged ≥60 years from 12 villages using previously validated, locally developed, tools (IDEA cognitive screen and IDEA-Instrumental Activities of Daily Living questionnaire). Screening was conducted using a mobile digital application (app) on a hand-held tablet. In Phase II, a stratified sample of those identified in Phase I were clinically assessed using the DSM-5 criteria and diagnoses subsequently confirmed by consensus panel. RESULTS: Of 3011 people who consented, 424 screened positive for probable dementia and 227 for possible dementia. During clinical assessment in Phase II, 105 individuals met DSM-5 dementia criteria. The age-adjusted prevalence of dementia was 4.6% (95% CI 2.9-6.4) in those aged ≥60 years and 8.9% (95% CI 6.1-11.8) in those aged ≥70 years. Prevalence rates increased significantly with age. CONCLUSIONS: The prevalence of dementia in this rural Tanzanian population appears to have increased since 2010, although not significantly. Dementia is likely to become a significant health burden in this population as demographic transition continues.

Feasibility and acceptability of a nutritional intervention testing the effects of nitrate-rich beetroot juice and folic acid on blood pressure in Tanzanian adults with elevated blood pressure.

Sub-Saharan African countries are experiencing an alarming increase in hypertension prevalence. This study evaluated the feasibility and acceptability of nitrate-rich beetroot and folate supplementation, alone or combined, for the reduction of blood pressure (BP) in Tanzanian adults with elevated BP. This was a three-arm double-blind, placebo-controlled, parallel randomised clinical trial. Forty-eight participants were randomised to one of three groups to follow a specific 60-day intervention which included a: (1) combined intervention (beetroot juice + folate), (2) single intervention (beetroot juice + placebo), and (3) control group (nitrate-depleted beetroot juice + placebo). Forty-seven participants (age: 50-70 years) completed the study. The acceptability of the interventions was high. Self-reported compliance to the interventions was more than 90% which was confirmed by the significant increase in nitrate and folate concentrations in plasma and saliva samples in the treatment arms. This study provides important information for the design of high-nitrate interventions to reduce BP in Sub-Saharan African countries.

Nitrate-Rich Beetroot Juice Reduces Blood Pressure in Tanzanian Adults with Elevated Blood Pressure: A Double-Blind Randomized Controlled Feasibility Trial.

BACKGROUND: In Sub-Saharan Africa, current strategies are struggling to control the burgeoning hypertension epidemic. Dietary interventions such as inorganic nitrate or folic acid supplementation could represent promising strategies for reducing blood pressure (BP) in this setting. OBJECTIVES: This feasibility study explores the effects of dietary inorganic nitrate supplementation, alone or in combination with folic acid, on BP in Tanzanian adults with elevated BP in Tanzania. METHODS: A placebo-controlled, double-blind, randomized controlled feasibility trial was conducted. Forty-seven middle-aged and older participants (age: 50-70 y, BMI: 26.3-29.1 kg/m2) were randomly assigned to 3 conditions for a period of 60 d: 1) high-nitrate beetroot juice (∼400 mg nitrate) and folic acid (∼5 mg folic acid) (N + F), 2) high-nitrate beetroot juice and placebo (N + P), or 3) nitrate-depleted beetroot juice and placebo (P + P). Clinic and 24-h ambulatory BP and measurements of compliance in plasma (nitrate and folate concentrations) and saliva (nitrate and nitrite) were obtained at baseline, 30 d, and 60 d. RESULTS: Baseline resting systolic and diastolic BP (mean ± SD) was 151.0 ± 19.4 mm Hg and 91.8 ± 11.7 mm Hg, respectively. Compliance to the interventions was high (>90%) in all groups which was confirmed by the significant increase in nitrate and folic acid concentrations in plasma and saliva samples in the treatment arms. After 60 d, 24-h systolic BP dropped by -10.8 ± 9.8 mm Hg (P < 0.001), -6.1 ± 13.2 mm Hg (P = 0.03), and -0.3 ± 9.7 mm Hg (P = 0.83) in the N + P, N + F, and P + P groups, respectively. There was a significant decrease in 24-h diastolic BP in the N + P group (-5.4 ± 5.0 mm Hg, P = 0.004), whereas changes were not significant in the N + F (-1.8 ± 8.1 mm Hg, P = 0.32) and P + P (1.6 ± 8.3 mm Hg, P = 0.43) groups. CONCLUSIONS: Dietary inorganic nitrate represents a potential nutritional strategy to lessen the hypertension epidemic in Sub-Saharan Africa. These findings support the rationale for future long-term investigations exploring the efficacy of dietary nitrate for lowering BP and attenuating cardiovascular disease risk in this setting.This trial was registered at isrctn.com as ISRCTN67978523.

Conceptualization of depression amongst older adults in rural Tanzania: a qualitative study.

BACKGROUND: Depression in older people is likely to become a growing global health problem with aging populations. Significant cultural variation exists in beliefs about depression (terminology, symptomatology, and treatments) but data from sub-Saharan Africa are minimal. Low-resource interventions for depression have been effective in low-income settings but cannot be utilized without accurate diagnosis. This study aimed to achieve a shared understanding of depression in Tanzania in older people. METHODS: Using a qualitative design, focus groups were conducted with participants aged 60 and over. Participants from rural villages of Kilimanjaro, Tanzania, were selected via randomized sampling using census data. Topic guides were developed including locally developed case vignettes. Transcripts were translated into English from Swahili and thematic analysis conducted. FINDINGS: Ten focus groups were held with 81 participants. Three main themes were developed: a) conceptualization of depression by older people and differentiation from other related conditions ("too many thoughts," cognitive symptoms, affective and biological symptoms, wish to die, somatic symptoms, and its difference to other concepts); b) the causes of depression (inability to work, loss of physical strength and independence, lack of resources, family difficulties, chronic disease); c) management of depression (love and comfort, advice, spiritual support, providing help, medical help). CONCLUSIONS: This research expands our understanding of how depression presents in older Tanzanians and provides information about lay beliefs regarding causes and management options. This may allow development of culturally specific screening tools for depression that, in turn, increase diagnosis rates, support accurate diagnosis, improve service use, and reduce stigma.

Factors Associated with the Uptake of Human Papilloma Virus Vaccine Among Adolescent Girls Aged 14 Old in Hai District of Kilimanjaro Region in Northern Tanzania.

Background: Human Papilloma Virus (HPV) vaccination is a key primary prevention method against cervical cancer which is given to young girls before onset of sexual activity. In Tanzania, cervical cancer is the most frequent occurring cancer among women and is the leading cause of cancer mortality. The HPV Vaccination programme was rolled-out in Tanzania in 2018 for adolescent girls aged 9-14 years to receive two doses at a six-months interval, with an annual vaccine uptake of 46.1%. In 2019, the uptake of the HPV vaccine was only 64%, whereas the national coverage target is 75%. This study aimed at assessing the determinants of HPV vaccination among adolescent girls in Hai district, Kilimanjaro region, northern Tanzania. Methodology: A cross-sectional study was conducted from July 2020 to August 2020 among 14-year-old adolescent girls in four selected secondary schools, including two government-owned and two private-owned, within Hai district. Close-ended questionnaire interviews were conducted with the adolescent girls in the study and data analysis was done using IBM SPSS Statistics for Windows version 20.0 (IBM Corp, Armonk, NY, USA). Odds ratio was used to assess the association between several factors and HPV vaccination. Results: A total of 301 adolescent girls aged 14 years consented to the study. HPV vaccination uptake was 65%. More than three-fifths (n=119, 60.7%) reported having received the two required doses. Knowledge of HPV (OR 5.68; 95% CI, 0.72 to 44.96; P=.01) and HPV vaccine (OR 20.11; 95% CI, 10.88 to 37.99); P =.01) contributed significantly to HPV vaccine uptake among the adolescent girls in the study. More than one-third (n=105, 34.9%,) of the participants, were not vaccinated, the main reasons adduced for not being vaccinated include lack of proper information about the HPV vaccine (60.0%), fear of side effects (14%) and parental refusal (11%). Conclusion: HPV vaccination uptake was 65%. Lack of proper information to both the children and parents about the safety of the vaccine hinders its uptake. More effort should be made for clear and comprehensible dissemination of information especially to the community stakeholders mainly parents, community and religious leaders, about cervical cancer and HPV vaccine in order to considerably increase vaccination coverage among adolescent girls. Likewise, involvement of healthcare workers and policymakers in educating people about cervical cancer prevention measures can ensure successful implementation of HPV vaccination. There is need to conduct an indepth qualitative study to explore further people's perceptions and attitudes towards HPV.

A Door-to-Door Prevalence Survey of Dental Fluorosis in Tindigani, a Village in the Hai District of Northern Tanzania.

Fluoride in excess of the World Health Organisation limit of 1.5mg/L in drinking water can cause dental fluorosis (DF) in developing teeth. DF is a significant problem in the Hai District of Northern Tanzania, where there is limited access to safe piped water and groundwater is high in fluoride. A door-to-door prevalence survey of residents of Tindigani village was undertaken to assess current prevalence and severity of DF in the Hai District, and the effectiveness of previous interventions to promote low-fluoride drinking water, following a prevalence survey in 2009. DF was graded by trained assessors, utilising dental photography, and drinking water sources were sampled for chemical analysis. DF was endemic in the 563 people assessed, with a prevalence of 79.4% (CI=76.1-82.7%). Prevalence and severity were found to be higher in permanent teeth than deciduous teeth. Fluoride concentrations in non-piped water sources ranged from 2.5-38.6mg/L. Despite more households reporting the use of low-fluoride, piped water sources, compared to 2009 (82.8% versus 62%), DF remains a significant problem in Tindigani and other such communities where low-fluoride drinking water is not easily and reliably accessible. Policy makers must prioritise reliable access to low-fluoride water, especially for children as their permanent dentition develops.

Prevalence of Skeletal Fluorosis in Northern Tanzania: A Follow-Up Study.

OBJECTIVES: Skeletal fluorosis is a metabolic bone disease caused by excessive exposure to fluoride, predominantly through contamination of drinking water. This study aimed to identify all cases of skeletal fluorosis in Tindigani village situated in Northern Tanzania. This was done following changes in drinking water sources after a previous prevalence study in 2009 in this population. METHODS: In a door-to-door cross-sectional study of Tindigani village, a sample of residents was assessed for skeletal fluorosis and dental fluorosis. Diagnosis of skeletal fluorosis was based on pre-defined angles of deformity of the lower limbs. Dental fluorosis was diagnosed and graded using the Thylstrup and Fejerskov Index. Samples from current drinking water sources underwent fluoride analysis. RESULTS: Tindigani village had a population of 1,944 individuals. Of the 1,532 individuals who were screened, 45 had skeletal fluorosis, giving a prevalence of 3.3% (95% CI=2.4, 4.3). Dental fluorosis was present in 82.5% of those examined (95% CI=79.8, 85.3). Dental fluorosis was present in all individuals with skeletal fluorosis and at higher grades than in the rest of the population. Drinking water samples were collected from 28 sources. These included piped, surface, well, and borehole water sources. Fluoride concentrations ranged from 0.45-38.59 mg/L of fluoride. CONCLUSIONS: Skeletal fluorosis is an ongoing but preventable health problem in the current population. The delivery of sustainable low fluoride piped water to this community would be of clear health benefit. This has been addressed at a local level.

Population normative data for three cognitive screening tools for older adults in sub-Saharan Africa.

In sub-Saharan Africa (SSA),cognitive screening is complicated by both cultural and educational factors, and the existing normative values may not be applicable. The Identification of Dementia in Elderly Africans (IDEA) cognitive screen is a low-literacy measure with good diagnostic accuracy for dementia. OBJECTIVE: The aim of this study is to report normative values for IDEA and other simple measures [i.e., categorical verbal fluency, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) 10-word list] in representative community-dwelling older adults in SSA. METHODS: Individuals aged ≥60 years resident in 12 representative villages in Kilimanjaro, Tanzania and individuals aged ≥65 years resident within three communities in Akinyele Local Government Area, Oyo State, Nigeria underwent cognitive screening. The normative data were generated by the categories of age, sex, and education. RESULTS: A total of 3,011 people in Tanzania (i.e., 57.3% females and 26.4% uneducated) and 1,117 in Nigeria (i.e., 60.3% females and 64.5% uneducated) were screened. Individuals with higher age, lower education, and female gender obtained lower scores. The 50th decile values for IDEA were 13 (60-64 years) vs. 8/9 (above 85 years), 10-11 uneducated vs. 13 primary educated, and 11/12 in females vs. 13 in males. The normative values for 10-word list delayed recall and categorical verbal fluency varied with education [i.e., delayed recall mean 2.8 [standard deviation (SD) 1.7] uneducated vs. 4.2 (SD 1.2) secondary educated; verbal fluency mean 9.2 (SD 4.8) uneducated vs. 12.2 (SD 4.3) secondary educated], substantially lower than published high-income country values. CONCLUSIONS: The cut-off values for commonly used cognitive screening items should be adjusted to suit local normative values, particularly where there are lower levels of education.

Na África Subsaariana (ASS), a triagem cognitiva é complicada por fatores culturais e educacionais, além dos valores normativos existentes poderem não ser aplicáveis. O rastreio cognitivo Identification of Dementia in Elderly Africans (IDEA) é uma medida para níveis baixos de alfabetização com boa acurácia diagnóstica para demência. OBJETIVO: Relatar os valores normativos para a IDEA e outras medidas simples (fluência verbal categórica, a lista de 10 palavras do Consortium to Establish a Registry for Alzheimer's Disease (CERAD) em idosos residentes na comunidade, representativos da ASS. Métodos: Indivíduos com idade ≥60 residentes em 12 comunidades representativas em Kilimanjaro, Tanzânia e indivíduos com idade ≥65 anos residentes em três comunidades na área governamental de Akinyele, Estado de Oyo, Nigéria, foram submetidos à triagem cognitiva. Os dados normativos foram gerados por faixas etárias, sexo e escolaridade. RESULTADOS: Um total de 3.011 pessoas na Tanzânia (57,3% mulheres, 26,4% sem educação) e 1.117 na Nigéria (60,3% mulheres, 64,5% sem educação) foram examinadas. Os indivíduos com idade mais alta, menor escolaridade e mulheres obtiveram escores mais baixos. Os valores do percentil 50 para a IDEA foram 13 (60­64 anos) vs. 8/9 (85+ anos), 10­11 para analfabetos vs. 13 com educação primária e 11/12 em mulheres vs. 13 em homens. Os valores normativos para a evocação tardia da lista de 10 palavras e a fluência verbal categórica variaram com a educação (evocação tardia 2,8 (SD 1,7) para os sem educação, vs. 4,2 (SD 1,2) para com educação secundária; fluência verbal 9,2 (DP 4,8) para os sem educação vs. 12,2 (SD 4.3) para os com ensino médio, substancialmente inferior aos valores publicados em países de alta renda. CONCLUSÕES: Os valores de corte para testes de triagem cognitiva comumente usados devem ser ajustados para se adequar aos valores normativos locais, particularmente em níveis baixos de educação.

Population normative data for three cognitive screening tools for older adults in sub-Saharan Africa / Dados normativos populacionais para três instrumentos de triagem cognitiva para idosos na áfrica subsaariana

ABSTRACT In sub-Saharan Africa (SSA),cognitive screening is complicated by both cultural and educational factors, and the existing normative values may not be applicable. The Identification of Dementia in Elderly Africans (IDEA) cognitive screen is a low-literacy measure with good diagnostic accuracy for dementia. Objective: The aim of this study is to report normative values for IDEA and other simple measures [i.e., categorical verbal fluency, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) 10-word list] in representative community-dwelling older adults in SSA. Methods: Individuals aged ≥60 years resident in 12 representative villages in Kilimanjaro, Tanzania and individuals aged ≥65 years resident within three communities in Akinyele Local Government Area, Oyo State, Nigeria underwent cognitive screening. The normative data were generated by the categories of age, sex, and education. Results: A total of 3,011 people in Tanzania (i.e., 57.3% females and 26.4% uneducated) and 1,117 in Nigeria (i.e., 60.3% females and 64.5% uneducated) were screened. Individuals with higher age, lower education, and female gender obtained lower scores. The 50th decile values for IDEA were 13 (60-64 years) vs. 8/9 (above 85 years), 10-11 uneducated vs. 13 primary educated, and 11/12 in females vs. 13 in males. The normative values for 10-word list delayed recall and categorical verbal fluency varied with education [i.e., delayed recall mean 2.8 [standard deviation (SD) 1.7] uneducated vs. 4.2 (SD 1.2) secondary educated; verbal fluency mean 9.2 (SD 4.8) uneducated vs. 12.2 (SD 4.3) secondary educated], substantially lower than published high-income country values. Conclusions: The cut-off values for commonly used cognitive screening items should be adjusted to suit local normative values, particularly where there are lower levels of education.

RESUMO Na África Subsaariana (ASS), a triagem cognitiva é complicada por fatores culturais e educacionais, além dos valores normativos existentes poderem não ser aplicáveis. O rastreio cognitivo Identification of Dementia in Elderly Africans (IDEA) é uma medida para níveis baixos de alfabetização com boa acurácia diagnóstica para demência. Objetivo: Relatar os valores normativos para a IDEA e outras medidas simples (fluência verbal categórica, a lista de 10 palavras do Consortium to Establish a Registry for Alzheimer's Disease (CERAD) em idosos residentes na comunidade, representativos da ASS. Métodos: Indivíduos com idade ≥60 residentes em 12 comunidades representativas em Kilimanjaro, Tanzânia e indivíduos com idade ≥65 anos residentes em três comunidades na área governamental de Akinyele, Estado de Oyo, Nigéria, foram submetidos à triagem cognitiva. Os dados normativos foram gerados por faixas etárias, sexo e escolaridade. Resultados: Um total de 3.011 pessoas na Tanzânia (57,3% mulheres, 26,4% sem educação) e 1.117 na Nigéria (60,3% mulheres, 64,5% sem educação) foram examinadas. Os indivíduos com idade mais alta, menor escolaridade e mulheres obtiveram escores mais baixos. Os valores do percentil 50 para a IDEA foram 13 (60-64 anos) vs. 8/9 (85+ anos), 10-11 para analfabetos vs. 13 com educação primária e 11/12 em mulheres vs. 13 em homens. Os valores normativos para a evocação tardia da lista de 10 palavras e a fluência verbal categórica variaram com a educação (evocação tardia 2,8 (SD 1,7) para os sem educação, vs. 4,2 (SD 1,2) para com educação secundária; fluência verbal 9,2 (DP 4,8) para os sem educação vs. 12,2 (SD 4.3) para os com ensino médio, substancialmente inferior aos valores publicados em países de alta renda. Conclusões: Os valores de corte para testes de triagem cognitiva comumente usados devem ser ajustados para se adequar aos valores normativos locais, particularmente em níveis baixos de educação.