The differential impact of mortality of American troops in the Iraq War: The non-metropolitan dimension

This study investigates the disproportionate impact of mortality among United States troops in Iraq on rural communities. We advance scholarly research and popular accounts that suggest a non-metropolitan disadvantage by disaggregating the risk of mortality according to the metropolitan status of their home county and by examining potential sources of variation, including enlistment, rank and race or ethnicity. Results show that troops from non-metropolitan areas have higher mortality after accounting for the disproportionate enlistment of non-metropolitan youth, and the non-metropolitan disadvantage generally persists across military branch and rank. Moreover, most of the differential is due to higher risks of mortality for non-metropolitan African American and Hispanic military personnel, compared to metropolitan enlistees of the same race or ethnicity.ethnicity, Iraq War, military, military mortality, mortality, non-metropolitan impact, race/ethnicity

Health and Aging in Low-Resource Contexts: Three Essays on Healthy Life Expectancy in the Developing World

The population of the world is getting older. In 2010, worldwide, there were about 524 million people over the age of 65; by 2050, over 1.5 billion people will be in this age group. This shift in population will not affect only developed countries, however—much of this increase in the elderly population will occur in low- and middle-income countries. As populations age, low-income countries will need to invest in health care for older adults and in disease prevention programs to prevent or delay the onset of non-communicable diseases (such as heart disease, stroke, and cancer). Past research on population-level health in the developing world has been widely hindered by a lack of high-quality longitudinal data. My dissertation uses recently-collected longitudinal data to gain insight into overall trends in health in low- and middle-income contexts. My first chapter uses a multi-state life table approach to investigate the overall level of health and functional ability (the ability to carry out tasks of daily life) among the rural population in Malawi. I find that this population experiences a substantial burden of disability in later life, and that these high levels of disability greatly limit work efforts among older individuals. In my second chapter, I conduct a cross-national comparison of health and disability-free life expectancy using data from recent longitudinal surveys in Costa Rica, Mexico, Puerto Rico, and the US. I find that current disability-free life expectancy at age 65 is comparable across these populations, though future trends are uncertain. My third chapter investigates how Malawi’s 2008 rollout of Anti-Retroviral Therapy (ART) to rural clinics affected overall population health and mortality. I find that the introduction of ART led to substantial declines in mortality and an increase in adult life expectancy, and that population morbidity also decreased after the introduction of ART

When snacks become meals: How hunger and environmental cues bias food intake

<p>Abstract</p> <p>Background</p> <p>While environmental and situational cues influence food intake, it is not always clear how they do so. We examine whether participants consume more when an eating occasion is associated with meal cues than with snack cues. We expect their perception of the type of eating occasion to mediate the amount of food they eat. In addition, we expect the effect of those cues on food intake to be strongest among those who are hungry.</p> <p>Methods</p> <p>One-hundred and twenty-two undergraduates (75 men, 47 women; mean BMI = 22.8, <it>SD </it>= 3.38) were randomly assigned to two experimental conditions in which they were offered foods such as quesadillas and chicken wings in an environment that was associated with either meal cues (ceramic plates, glasses, silverware, and cloth napkins at a table), or snack cues (paper plates and napkins, plastic cups, and no utensils). After participants finished eating, they were asked to complete a questionnaire that assessed their hunger, satiety, perception of the foods, and included demographic and anthropometric questions. In addition, participants' total food intake was recorded.</p> <p>Results</p> <p>Participants who were in the presence of meal-related cues ate 27.9% more calories than those surrounded with snack cues (416 versus 532 calories). The amount participants ate was partially mediated by whether they perceived the eating occasion to be a meal or a snack. In addition, the effect of the environmental cues on intake was most pronounced among participants who were hungry.</p> <p>Conclusions</p> <p>The present study demonstrated that environmental and situational cues associated with an eating occasion could influence overall food intake. People were more likely to eat foods when they were associated with meal cues. Importantly, the present study reveals that the effect of these cues is uniquely intertwined with cognition and motivation. First, people were more likely to eat ambiguous foods when they perceived them as a meal rather than a snack. Second, the effect of the environmental cues on intake was only observed among those who were hungry.</p

Up, Down and Reciprocal: The Dynamics of Intergenerational Transfers, Family Structure and Health in a Low-Income Context

In the absence of well-functioning public transfer systems and safety nets, the family acts as the key provider of income and support through the intergenerational redistribution of resources. In this paper we use micro-level longitudinal data and a mix of methodologies to document the lifecycle patterns of financial transfers in a rural, sub-Saharan African population. Underneath a well-established age-pattern of intergenerational transfers in which transfer patterns change according to broad stages of the economic life cycle, our analyses document significant heterogeneity and fluidity: Intergenerational transfers are variable and reverse their direction, with individuals moving between the provider and recipient states repeatedly across their life course and within each major stage of the life-cycle. Contrary to common perceptions about family transfers ameliorating short-term shocks, transfers in our analyses are driven primarily by demographic factors such as changes in health, household size, and household composition, rather than short-term events. Overall our analyses suggest that the role of transfers in this rural sub-Saharan context is significantly more complex than suggested by theories and evidence on aggregate transfer patterns, and at the micro-level, intergenerational transfers encapsulate multiple functions ranging from direct exchange to old-age support in the absence of a public pension system

The Demography of Mental Health Among Mature Adults in a Low-Income High HIV-Prevalence Context

While a nascent body of research investigates the shift in sub-Saharan Africa\u27s (SSA\u27s) 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

The role of reductions in old-age mortality in old-age population growth

Background: The variable-r model provides demographers with a way to explore the contributions of demographic components (fertility, mortality, migration) to changes in populations’ age structures. However, traditional variable-r methods require extremely long mortality series to explore growth at oldest-old ages. Objective: Our goal is to disentangle the old-age growth rate into two main components: the growth rate at some younger age, and reductions in mortality between the younger and older ages. Methods: We focus on an adaptation of the variable-r model that can use shorter mortality series to explore population growth between two ages. Results: Using data from the Human Mortality Database, we explore how these two components are driving the growth rate of 100-year-olds. Observed growth of those reaching age 100 results primarily from the high growth rates when those cohorts were 80-year-olds, and from time reductions in cohort mortality between ages 80 and 100. However, the latter component behaves differently across populations, with some countries experiencing recent slowdowns in cohort mortality declines or increases in mortality between ages 80 and 100. Conclusions: We find great diversity in the level of old-age mortality improvements across populations, and heterogeneity in the drivers of these improvements. Our findings highlight the need to closely monitor the underlying reasons for the changes in old-age mortality across populations and time. Contribution: We present illustrations of the use of the variable-r method to monitor demographic change in an online interactive application, estimated even when only short historical series of demographic data are available

Cognitive Health among Older Adults: Evidence from Rural Sub-Saharan Africa

Cognitive 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

Education and adult mortality in middle-income countries: Surprising gradients in six nationally-representative longitudinal surveys

Background: There are large differences in adult mortality across schooling groups in many high-income countries (HICs). An important open question is whether there are similar gradients in adult mortality in middle-income countries (MICs), where schooling and healthcare quality tends to be lower and health-related behaviors are often not strongly patterned by schooling. Methods: We present one of the first international-comparative studies on schooling differences in adult mortality across MICs using harmonizedlongitudinal data on adults ages 50+from China, Costa Rica, Indonesia, Mexico, South Africa, and South Korea. We use Cox proportional hazards models to estimate differences in the hazard of mortality across schooling groups overall and separately by sex and broad age groups. We also estimate schooling gradients in smoking and body mass index to determine whether risk factor gradients potentially explain mor-tality patterns. Results: Only adults with tertiary schooling have a consistent adult mortality advantage compared to those with no schooling. We do not find evidence that individuals with primary schooling have a lower hazard of mortality compared to individuals with no schooling in five of the six countries. The mortality advantage for individuals with secondary schooling is mixed, with evidence of lower mortality relative to those with no schooling in Mexico, South Africa, and South Korea. Gradients in BMI and smoking are inconsistent across countries and unlikely to explain mortality differences. Conclusions: We find that adult mortality and risk factor gradients in MICs can be much different than the established patterns seen in modern HICs. Our results highlight that adult mortality gradients are not an inev-itability and are not found in all populations. Understanding what factors give rise to inequalities in adult mortality and what can be done to minimize gradients while still ensuring continued mortality improvements in MICs is a crucial focus for research and policy

The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC)

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)