Abstract
Short, reliable, easily administered executive function (EF) assessment tools are needed to measure EF in low- and middle-income countries, particularly in sub-Saharan Africa given the prevalence of human immunodeficiency virus (HIV)-associated neurocognitive disorder. We administered Oxford Cognitive Screen-Executive Function (OCS-EF) to 932 rural South African females (mean age 19.7 years). OCS-EF includes seven tasks: two hot inhibition tasks (a modified Iowa Gambling Task, emotional go/no-go) and five cool EF tasks, two switching tasks (visuospatial rule-finding, geometric trails) and three working memory tasks (digit recall, selection and figure drawing). We performed confirmatory factor analysis testing whether a three-factor, two-factor hot-cool, two-factor working memory and inhibition/switching, or one-factor EF model fitted the data better. The three-factor (switching, inhibition and working memory) model had the best local and global fit (χ2 (11) 24.21, p=0.012; RMSEA 0.036; CFI 0.920; CD 0.617). We demonstrated the feasibility of OCS-EF administration by trained laypeople, the tripartite structure of EF amongst adolescent females and the factorial validity of OCS-EF in this population and context. OCS-EF tablet-based cognitive assessment tool can be administered by trained laypeople and is a valid tool for assessing cognition at scale amongst adolescents in rural South Africa and similar environments.
Highlights
We demonstrated the feasibility of large-scale fieldworker-administered adolescent cognitive testing with the OCS-EF in rural SA
All tasks had > 90% valid data; there were two tasks, trails and selection, where invalidation was more common, due to tablets freezing during these tasks in hot weather, resulting in fieldworkers sometimes double-clicking and accidentally skipping task sections. This problem was likely due to a combination of technical, climate and fieldworker factors; the solution would primarily be technical as described in the recommendations section below
The feasibility of large-scale cognitive testing and research in these rural, underdeveloped villages was likely facilitated by the existing HDSS platform of the MRC/Wits Agincourt Research Unit with its skills development ethos, experience with training fieldworkers, experience with electronic tablet-based data collection with the support of a skilled data team, existing quality control standard operating procedures, and well-established relationships with community leaders and members
Summary
This validation study utilised cross-sectional data collected during HPTN 068, a longitudinal cohort post-randomised controlled trial in the MRC/Wits Rural (Agincourt) Research Unit in SA. This region has high youth unemployment (∼ 75%), poverty and lacks quality education and work opportunities. Eligibility criteria for trial participation included: 13–20-year-old females in grades 8–11 at government schools; not married or pregnant; able to complete tablet-based questionnaires alone; having documentation to open a bank account (to receive cash transfers safely); having a parent/guardian at home with similar documentation; currently living and intending to reside in the region until study completion. Eligibility criteria for this study (which occurred 5-year post-trial enrolment) included: 17–25-year-old females; confirmed HIV-negative status; a complete, single cognitive dataset
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