Association of multidimensional poverty with dementia in adults aged 50 years or older in South Africa
Original author: Trani J, Moodley J et al. (2022) (DOI: 10.1001/jamanetworkopen.2022.4160)
Jr. Economist intern
September 28, 2022
Dementia has become a global health challenge. It is well documented that poor social determinants of health are directly associated with the disease. Hence a multidimensional approach to poverty (which encompasses various components of well-being measured in terms of individuals functioning and capabilities instead of resources or utility) offers not only a more precise account of risk factors that eventually trigger multiple conditions including dementia but also offers insight into how to improve care and policy.
In this study, final samples from a cross-sectional study of 227 adults aged 50 years or older living in Soweto, Johannesburg, South Africa were collected. The 8-item interview to differentiate Aging and Dementia (Assessing Dementia 8 [AD8]) and the Rowland Universal Dementia Assessment Scale (RUDAS) were used to assess dementia.
Multidimensional poverty measures: 7 dimensions were considered. Each dimension contained indicators identified in the literature as crucial to human development.
Education: Education is associated with one’s ability to gain employment and earn an income. Study participants were considered deprived if they had access only to primary education.
Health: Any severe activity limitation or functioning difficulty was considered as the cut-off for deprivation of health.
Economic activity: Unemployment was considered an indicator of deprivation. The cut-off was used if an adult was unemployed, looking for a job, or not looking for a job because the participant was discouraged or could not afford the cost of seeking work or the wages offered were too low.
Living standards: Household living standards were composed of 3 indicators (waterpipe, electricity, and flush toilet), for which deprivation within the compound was the cut-off.
Social participation and fair treatment: Study participants who were not involved in any group were considered deprived. Discrimination and stigma were measured using the validated 22-item Unfair Treatment subscale of the Discrimination and Stigma Scale. Content and face validity tests were conducted. Moderate discrimination was the cut-off.
Psychological well-being: Measures of depression and self-esteem represented deprivation of psychological well-being. Depression was measured using the 10-item Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10). A score of 10 or higher was the established cut-off. Self-esteem was measured using the 10-item Rosenberg Self-Esteem Scale, with a score below 15 as the established cut-off.
Dimensions of deprivation were independently assessed. Then these multidimensional poverty measures were aggregated which consisted of 2 cut-offs –
Older adults were considered deprived if they fell below the cut-off on a given dimension.
The number of dimensions in which an older adult had to be deprived to be deemed multidimensionally poor.
Further, a correlation analysis was performed to assess the overlap of dimensions of deprivation.
Later, 3 indicators were measured: –
The poverty headcount indicates the number of older adults who lived below the poverty line.
The mean deprivation share is the mean number of dimensions of deprivation experienced by each older adult who lived below the poverty line.
The adjusted headcount ratio is the product of the poverty headcount and the mean deprivation share. The adjusted headcount ratio denotes the intensity of poverty.
The study calculated unadjusted and adjusted logistic regression models to identify the association between dementia and multidimensional poverty. A person deprived of 4 or more dimensions was considered multidimensionally poor. Missing values (n=10) were treated as random.
Results & discussion
The study found that exposure to multidimensional poverty was strongly associated with dementia. Men with dementia were poorer and deprived in a higher number of dimensions than women with dementia. In addition, deprivation of education, health, and employment was identified as major contributors to multidimensional poverty, which constitutes an important indicator that social and environmental determinants of health are associated with dementia.
Impact of the research
This study provides evidence for physicians, allied health professionals, and policymakers to consider daily stressors associated with multidimensional poverty and aging. It offers some valuable insight into LMICs (low-and-middle-income countries) and what public policies (access to quality education, a strong workforce, and quality and free universal healthcare) could be prioritized that may be associated with dementia prevention and may reduce its effect on families and communities.