Kohler, Iliana V.

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  • Publication
    Resilience, Accelerated Aging and Persistently Poor Health: Diverse Trajectories of Health among the Global Poor
    (2022-08-01) Kohler, Iliana V; Hoang, Cung Truong; Amin, Vikesh; Behrman, Jere R; Kohler, Hans-Peter
    Objectives: This study is among the first to document lifecourse trajectories of physical and mental health across adult and older ages (20-70 years) for a poor sub-Saharan African population having faced frequent and sustained adversities. Methods: The 2006-19 waves of the Malawi Longitudinal Study of Families and Health (MLSFH) were analyzed using group-based trajectory models (GBTM) to identify trajectories of heath (SF12 mental/physical health and BMI) across the lifecourse. Predictors of trajectory membership were estimated using fractional multinomial logits. Results: Analyses identified three distinct trajectories: (1) good initial mental/physical health that persisted throughout the lifecourse ("resilient aging"); (2) good initial mental and physical health that deteriorated with age ("accelerated aging"); or (3) poor initial mental and physical health with possibly further declines over the lifecourse ("aging with persistently poor health"). Predictors of trajectory group membership included gender, childhood poverty, and schooling. Discussion: Despite lifecourses being characterized by poverty and frequent adversities in this poor population, our analyses identified a sizable group (30%) of resilient individuals who experienced successful aging with good initial health that persisted across the lifecourse and into old age. Accelerated aging was the most common trajectory for SF12 physical and mental health in this poor population, while for BMI, persistently poor health was most common. Men were more likely to enjoy resilient aging than women in terms of physical/mental health, contrary to previous findings from high-income contexts. Other predictors of trajectory membership sometimes confirmed, and sometimes contradicted, hypotheses derived from high-income country studies.
  • 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
    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-Peter
    Cohort 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
    Heterogenous Trajectories in Physical, Mental and Cognitive Health among Older Americans: Roles of Genetics and Earlier SES
    (2021-09-12) Hoang, Cung Truong; Amin, Vikesh; Behrman, Jere R.; Kohler, Hans-Peter; Kohler, Iliana V.
    We investigate the roles of genetic predispositions, childhood SES and adult schooling attainment in shaping trajectories for three important components of the overall health and wellbeing of older adults -- BMI, depressive symptoms and cognition. We use the Health & Retirement Study (HRS) and group-based trajectory modelling (GBTM) to identify subgroups of people who share the same underlying trajectories over ages 50-94 years. After identifying common underlying trajectories, we use fractional multinomial logit models to estimate associations of (1) polygenic scores for BMI, depression, ever-smoked, education, cognition and subjective wellbeing, (2) childhood SES and (3) schooling attainment on the probabilities of trajectory group membership. While genetic predispositions do play a part in predicting trajectory group membership, our results highlight the long arm of socioeconomic factors. Schooling attainment is the most robust predictor—it predicts increased probabilities of belonging to trajectories with BMI in the normal rage, low depressive symptoms and high initial cognition. Childhood circumstances are manifested in trajectories to a lesser extent, with childhood SES only predicting the likelihood of being on the low depressive symptoms trajectory. We also find suggestive evidence that associations of schooling attainment on the probabilities of being on trajectories with BMI in the normal rage, low depressive symptoms and high initial cognition vary with genetic predispositions.
  • 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-Peter
    While 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
    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.
  • 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-Peter
    Background: 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
    Childhood Predictors of Late-Life Diabetes: The Case of Mexico
    (2005-09-01) Kohler, Iliana V; Soldo, Beth J
    We 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
    Barker’s Hypothesis Among the Global Poor: Positive Long-term Cardiovascular Effects of In-utero Famine Exposure
    (2022-01-10) Ciancio, Alberto; Behrman, Jere R.; Kämpfen, Fabrice; Kohler, Iliana V.; Maurer, Jürgen; Kohler, Hans-Peter; Mwapasa, Victor
    An influential literature on the Barker's hypothesis (or the Developmental Origins of Health and Disease, DOHaD) has documented that poor conditions in utero lead to higher risk of hypertension, diabetes, stroke and heart disease in middle age in middle- and high-income contexts. One of the main explanations is that periods of high calorie intake after birth are inconsistent with the adaptations that the fetus makes to prepare for a poor resources environment (thrifty phenotype hypothesis). Using data from a persistently low-income country, Malawi, we find that individuals exposed in utero to a substantial famine in 1949, have lower levels of blood pressure and blood sugar and less symptoms associated with stroke over half a century later. These findings may be explained by a prolonged period of malnutrition following the famine in contrast to most of the contexts studied in the previous literature.
  • Publication
    Evaluating Health and Disease in Sub-Saharan Africa: Minimally Invasive Collection of Plasma in the Malawi Longitudinal Study of Families and Health (MLSFH)
    (2012-07-30) Kohler, Iliana V.; Anglewicz, Philip; Kohler, Hans-Peter; McCabe, John F.; Chilima, Ben; Soldo, Beth J.
    Background: The collection of biomarker-based indicators of adult health and fitness is an important addition to socioeconomic surveys since these indicators provide valuable insights into the biological functions, and the complex causal pathways between socioeconomic environments and health of adult individuals. Other than select Demographic and Health Surveys (DHS), there are almost no population-based sources of biomarker-based indicators of adult health in sub-Saharan Africa (SSA), where most population-based biologic data are focused on HIV, other STDs, malaria, or nutritional status. While infectious diseases---such as HIV and malaria---attract the majority of research and NGOs attention in sub-Saharan Africa, there is an important need to understand the general determinants of adult health in SSA since the region will rapidly age in the next decades in ways that are significantly different from the aging patterns in other developing regions due to the AIDS epidemic, and chronic diseases will increasingly become relevant for understanding the health of sub-Saharan populations. Methods and Design: We document our protocol for the collection of biomarker-based health indicators as a pilot project within the Malawi Longitudinal Study of Families and Health (MLSFH), and we provide basic descriptive information about the study population and the collected biomarker-based indicators of adult health obtained from respondents in rural Malawi. LabAnywhere kits were used to obtain blood plasma from 980 adult men and women living in Balaka, the southern-most region in rural Malawi. The procedure allows for the non-invasive collection of blood plasma, but has not been been previously used in the context of a developing country. We collected biomarkers for inflammation and immunity, lipids, organ function, and metabolic processes. We specifically collected wide-range CRP, total cholesterol, LDL, HDL, total protein, urea, albumin, blood urea nitrogen, creatinine, random blood glucose and HbA1c assays. Overall, the mean values of the biomarkers are below the lower limits of clinical guidelines for adult populations in the U.S. and other developed countries, and only small proportions of the sample are above the upper limits of the normal clinical ranges as defined by U.S. standards. The correlationional patterns of the collected biomarkers are consistent with observations from developed countries, and the comparison with other low-income populations such as the Tsimane in Bolivia or the Yakuts in Siberia show remarkably similar age-specific patterns of the biomarkers despite differences in the mode of blood sampling. Discussion: The MLSFH biomarker sample makes a potentially important contribution to understanding the health of the adult populations in low income environments. The present study confirms that the collection of such biomarkers using the LabAnywhere system is feasible in rural sub-Saharan contexts: the refusal rate was very low in the MLSFH and following the procedures described above, only a small fraction of the biomarker samples could not be analyzed by LabAnywhere. The system therefore provides an attractive alternative to the collection of dried blood spots (DBS) and venous blood samples, providing a broader range of potential biomarkers than DBS and being logistically easier than the collection of venous blood.