Kohler, Iliana V.
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Publication Cohort Profile: The Malawi Longitudinal Study of Families and Health (MLSFH)(2013-07-31) KOHLER, HANS-PETER; Watkins, Susan C.; Behrman, Jere R; Kohler, Iliana V.; Anglewicz, Philip; Fleming, Peter; Thornton, Rebecca L.; Mkandawire, James; Kalilani-Phiri, Linda; Honde, Hastings; Hawara, Augustine; Chilima, Ben; Bandawe, Chiwoza; Mwapasa, Victor; MLSFH Study Team,The Malawi Longitudinal Study of Families and Health (MLSFH) is one of very few long-standing publicly-available longitudinal cohort studies in a sub-Saharan African (SSA) context. It provides a rare record of more than a decade of demographic, socioeconomic and health conditions in one of the world's poorest countries. With data collection rounds in 1998, 2001, 2004, 2006, 2008, 2010 and 2012 for up to 4,000 individuals, the MLSFH permits researchers to investigate the multiple influences that contribute to HIV risks in sexual partnerships, the variety of ways that people manage risk within and outside of marriage, the possible effects of HIV prevention policies and programs, and the mechanisms through which poor rural individuals, families, households, and communities cope with the impacts of high morbidity and mortality that are often---but not always---related to HIV/AIDS. The MLSFH been used to document (i) the influence of social networks on HIV-related behaviors and perceptions, (ii) the HIV prevention strategies employed by individuals in rural high-HIV prevalence contexts, (iii) the relationship between life-course transitions and HIV infection risks, (iv) the acceptability of HIV testing and counseling (HTC) and the consequences of HTC on subsequent behaviors, and (v) the health and well-being across the life-course of individuals facing multiple challenges resulting from high disease burdens and widespread poverty.Publication Cognitive Health among Older Adults: Evidence from Rural Sub-Saharan Africa(2016-07-26) Payne, Collin F.; Kohler, Iliana V.; Bandawe, Chiwoza; Lawler, Kathy A.; Kohler, Hans-PeterCognitive health is an important dimension of well-being in older ages, but few studies have investigated 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 for both men and women is similar to that observed in the U.S. We also find that women have substantially worse cognitive health than men, and experience a steeper decline of cognitive ability with age. 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.Publication The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC)(2020-01-28) Kohler, Iliana V.; Bandawe, Chiwoza; Ciancio, Alberto; Kämpfen, Fabrice; Payne, Collin F.; Mwera, James; Mkandawire, James; Kohler, Hans-PeterCohort purpose: The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global aging studies by providing a rare opportunity to study the processes of individual and population aging, the public health and social challenges associated with aging and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context. Design and Measures: The MLSFH-MAC is a population-based cohort study of mature adults aged 45 years and older living in rural communities in three districts in Malawi (Mchinji, Balaka and Rumphi). Initial enrollment at baseline is 1,266 individuals in 2012. MLSFH-MAC follow-ups were in 2013, 2017, and 2018. Survey instruments cover aging-related topics such as cognitive and mental health, NCDs and related health literacy, subjective survival expectations, measured biomarkers including HIV, grip strength, hypertension, fasting glucose, BMI, a broad range of individual- and household-level social and economic information, a 2018 qualitative survey of mature adults and community officials, 2019 surveys of village heads, health care facilities and health care providers in the MLSFH-MAC study areas. Unique features: MLSFH-MAC is a data resource that covers 20 years of the life course of cohort members and provides a wealth of information unprecedented for aging studies in a low-income SSA context that broadly represents the socioeconomic environment of millions of individuals in south-eastern Africa. Among these are the longitudinal population-based data on depression and anxiety using clinically-validated instruments. MLSFH-MAC is also vanguard in measuring longitudinal changes in cognitive health among older individuals in SSA. Complemented by contextual and qualitative information, the extensive MLSFH-MAC data facilitate a life-course perspective on aging that reflects the dynamic and distinct settings in which people reach older ages in SSA LICs. Across many domains, MLSFH-MAC also allows for comparative research with global aging studies through harmonized measures and instruments. Collaboration and data access: Public-use version of the 2012 (baseline) MLSFH-MAC data can be requested at http://www.malawi.pop.upenn.edu. Sharing of additional MLSFH-MAC data is currently possible as part of collaborative research projects (if not overlapping with ongoing research projects, and subject to a Data Use Agreement).Publication Aging and Hypertension among the Global Poor—Panel Data Evidence from Malawi(2022-02-10) Kohler, Iliana V.; Sudharsanan, Nikkil; Bandawe, Chiwoza; Kohler, Hans-PeterBackground: Hypertension has 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. Data and methods: 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. Findings: High blood pressure is very common among mature adults aged 45+ in rural Malawi, 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. Conclusions: 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 and untreated hypertension particularly prevalent in vulnerable subsets of older persons.Publication The Demography of Mental Health Among Mature Adults in a Low-Income High HIV-Prevalence Context(2015-04-21) Kohler, Iliana V; Payne, Collin F.; Bandawe, Chiwoza; Kohler, Hans-PeterWhile a nascent body of research investigates the shift in sub-Saharan Africa's (SSA's) disease burden towards non-communicable diseases (NCDs), very few studies have investigated mental health, specifically depression and anxiety (DA), in SSA. Using the 2012--13 Malawi Longitudinal Study of Families and Health (MLSFH), this paper provides a first picture of the demography of DA among mature adults (= persons aged 45+) in a low-income high HIV-prevalence context. DA are more frequent among women than men, and individuals are often affected by both. DA are associated with adverse outcomes, such as less nutrition intake and reduced work efforts. DA also increase substantially with age for both females and males, and mature adults can expect to spend a substantial fraction of their remaining life time---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 have been shown in high-income contexts where older individuals often experience lower levels of DA and better subjective well-being than middle-aged individuals. While socioeconomic and risk/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 strength and health with age, as is indicated by hand grip strength, and the interference of poor physical health with daily activities, are key drivers of the rise of DA with age among mature adults.Publication Curtailing COVID-19 on a Dollar-a-Day in Malawi: Implications for the Ongoing Pandemic(2021-03-15) Kohler, Iliana V.; Kämpfen, Fabrice; Ciancio, Alberto; Mwera, James; Kohler, Hans-Peter; Mwapasa, VictorUtilizing 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 investigate behavioral, economic and social responses COVID-19 and focus on the crucial role that community leadership and trust in institutions play towards shaping these responses. We argue that the effective response of Malawi to limit the spread of the virus was facilitated by the engagement of local leaders to mobilize communities to adapt and adhere to COVID-19 prevention strategies. Village heads (VHs) played pivotal role in shaping individual's knowledge about the pandemic and the adaption 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.Publication Mortality Risk Information, Survival Expectations and Sexual Behaviors(2020-01-29) Ciancio, Alberto; Delavande, Adeline; Kohler, Hans-Peter; Kohler, Iliana V.Individuals in low-income settings are often overly pessimistic about their own survival, suggesting that better knowledge about survival risks might encourage investments in health. This paper provides evidence from a randomized experiment that provided mature adults aged 45+ in Malawi with information about mortality risks. Treated individuals are less likely to engage in risky sexual practices one year after the intervention, and they increase other forward-looking behaviors such as investments in agriculture. Expectations of HIV+ people living longer, which makes the pool of potential partners riskier, are a primary driver of reduced sexual risk taking in response to the intervention.Publication Health Screening for Emerging and Non-Communicable Disease Burdens Among the Global Poor(2021-01-26) Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Hans-Peter; Kohler, Iliana V.Among adults in rural Malawi, population health screening for high blood pressure (BP) led to a 22-percentage point drop in the likelihood of being hypertensive four years later. Individuals with elevated BP received a referral letter upon initial screening; at follow-up, they had lower BP and higher self-reported mental health than individuals with similar BP who were just below the threshold for referral. Population health screenings can reduce the burden of non-communicable diseases in low-income countries.Publication Childhood Predictors of Late-Life Diabetes: The Case of Mexico(2005-09-01) Kohler, Iliana V; Soldo, Beth JWe investigated the interplay between characteristics of early childhood circumstances and current socioeconomic conditions and health, focusing specifically on diabetes in mid and late life in Mexico. The analysis used data from the 2001 Mexican Health and Aging Study (MHAS), a large nationally representative study of Mexicans born before 1950. We analyzed the extent to which childhood conditions, such as exposure to infectious diseases, a poor socioeconomic environment, and parental education, affect the risk of diabetes in later life. Our results indicate that individuals age 50 and older who experienced serious health problems before age 10 have a higher risk of having late-life diabetes. There is a significant inverse relationship between maternal education and diabetes in late life of adult offspring. Individuals with better educated mothers have a lower risk of being diabetic after age 50. This relationship remains after controlling for other childhood and adult risk factors.Publication Educational differences in all-cause mortality Evidence from Bulgaria, Finland and the United States(2008-12-10) Kohler, Iliana; Martikainen, Pekka; Smith, Kirsten P; Elo, Irma T.Using life table measures, we compare educational differentials in all-cause mortality at ages 40 to 70 in Bulgaria to those in Finland and the United States. Specifically, we assess whether the relationship between education and mortality is modified by marital status. Although high education and being married are associated with lower mortality in all three countries, absolute educational differences tend to be smaller among married than unmarried individuals. Absolute differentials by education are largest for Bulgarian men, but in relative terms educational differences are smaller among Bulgarian men than in Finland and the U.S. Among women, Americans experience the largest education-mortality gradients in both relative and absolute terms. Our results indicate a particular need to tackle health hazards among poorly educated men in countries in transition.