Karine Scheuermaier

Sleep health in adolescence is a global public health concern. However, limited studies on adolescent sleep health in Africa exist, and the extent of the available literature on the African continent has not been previously mapped. This review aimed to map the studies on adolescent sleep health in Africa with a focus on the geographical distribution, publication trends, pattern of sleep health measures, prevalence of sleep disorders, the barriers and facilitators to good sleep health, rural-urban disparities, as well as the associations of sleep health with mental health, school schedule and cardio-metabolic risk among the adolescents. All published articles on adolescent sleep health in Africa in English, French, Spanish, Portuguese, and Italian languages were to be included. We conducted a scoping review by searching five databases: MEDLINE (via PubMed), CINAHL (via EBSCOHost), PsycINFO (via EBSCOHost), Scopus, and the African Journal Online (AJOL), from the inception of the databases to January 2025. As previously highlighted in our published protocol, we used the JBI methodology for the scoping review. After screening 921 titles and abstracts and 78 full-text articles, we included 43 articles. There has been an increasing number of studies on adolescent sleep in Africa in the past 25 years. Cross-sectional studies were the most frequent design (67.4%). Most studies focused on sleep quantity and quality, with small sample sizes and scanty evidence on other aspects of sleep health. Inadequate weekday sleep duration was common among adolescents, often compensated by longer weekend sleep durations. Screen use at bedtime, sleeping environment, school schedules, and chronic medical conditions were the major risk factors for sleep disturbances. Poor sleep was associated with poor academic performance, depression, anxiety, and adverse cardiometabolic risk. This review shows a lack of studies on the multidimensional aspects of sleep health and the need for more objective sleep measures to better characterise the sleep health of adolescents in Africa. Larger studies with longitudinal and mixed-method designs are needed to drive the planning and execution of interventions to improve sleep health among African adolescents.

Purpose: We examined the psychometric properties of the Pittsburgh Sleep Quality Index (PSQI) in a large sample of young women in Soweto, South Africa, to assess its reliability and structural validity in this context. Methods: Data were collected from 7182 women enrolled in the Bukhali randomized controlled trial, part of the Healthy Life Trajectories Initiative (HeLTI). Sociodemographic information and PSQI data were collected through interviewer-administered surveys. Internal consistency was assessed using Cronbach’s alpha, McDonald’s omega and item-level correlations. Confirmatory factor analysis (CFA) evaluated the original one-factor and established two- and three-factor multidimensional models. Model fit was examined using Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), and Tucker–Lewis Index (TLI). Results: Most women (57.4%) reported good sleep quality (PSQI ≤ 5). Poor sleep quality was associated with higher household socioeconomic status (assets score), higher education, and single relationship status. Average sleep was 7.8 hours, characterized by prolonged onset latency and high fragmentation, suggesting that continuity disruptions rather than opportunity shortage drove poor sleep. The PSQI had modest internal consistency (α = .57; ω = .57; item–total r = .33 – .65). The one-factor model demonstrated poor fit (χ ² (14) = 1677.70; CFI = .65; TLI = .48; RMSEA = .13) whereas fit was good for the two-factor (χ ² (13) = 291.46; CFI = .94; TLI = .91; RMSEA = .05) and three-factor models (χ ² (11) = 285.21; CFI = .94; TLI = .89; RMSEA = .06). Conclusion: The PSQI showed a multidimensional structure in this population. While both multidimensional models performed well, the two-factor model showed slightly better fit and is recommended for use in this population. Interpreting PSQI components rather than the global score offers more meaningful insight into sleep quality and highlights the need for context-specific psychometric validation in diverse settings. Brief Summary: Current Knowledge/Study Rationale: The Pittsburgh Sleep Quality Index is widely used, but prior evidence shows its reliability and factor structure vary across populations, settings, and sex. Young women in under-resourced urban South African settings may experience sleep disruption shaped by psychosocial stress, safety concerns, caregiving demands, and environmental factors, yet the PSQI had not been evaluated in this population. Study Impact: In this large Soweto cohort, sleep problems appeared driven more by fragmented sleep and continuity disruptions than by insufficient sleep opportunity. The PSQI performed better as a multidimensional measure, particularly a parsimonious two-factor structure, than as a single global score. The findings support using component- or factor-informed PSQI interpretation and highlight the need for context-specific validation of sleep measures in diverse populations.

Introduction: HIV/AIDS continues to be a significant health issue in sub-Saharan Africa, with stigma likely affecting ART adherence, and subsequently viremia, inflammation, and cardiovascular disease (CVD). We investigated the association between stigma, ART adherence, and CVD risk among people living with HIV (PLWH). Setting: A longitudinal study was conducted among 325 PLWH from the Ndlovu Cohort Study, South Africa. Methods: Stigma was assessed using a 12-item questionnaire (range: 0–44; higher scores indicate greater stigma). Pulse wave velocity (PWV, CVD surrogate marker) and viral load (VL) were assessed at 12 and 36 months. VL was considered a surrogate marker of ART adherence: VL > 1000 copies indicating poor/no adherence, VL 50–1000 copies suboptimal, and VL < 50 copies good adherence. The relationship between stigma, VL, and PWV was assessed by linear regression and changes in PWV overtime by mixed linear models. Results: At baseline, PLWH (n = 325, mean age (SD) = 41.1 (10.2) years, 67% female) had mean PWV of 7.3 min/s. Good, suboptimal, and poor adherence were 78%, 15%, and 7%, respectively. The mean (SD) stigma score was 16.9 (1.4) and was not associated with VL and PWV. Suboptimal and poor adherence were associated with higher PWV [beta = 4.18 (95% confidence interval (CI): 1.79 to 6.57)] at 12 months and between 12 and 36 months [beta = 1.30 (95% CI: 0.06 to 2.55)] in mixed model analyses in PLWH older than 49 years, respectively. PWV increased by 0.21 min/s (95% CI: 0.02 to 0.40; P = 0.03) between 12 and 36 months overall. Conclusions: In this study, poor ART adherence was associated with higher PWV. The stigma score was low and not associated with ART adherence and PWV.

Sleep and mental health difficulties have been observed in response to COVID-19 pandemic-induced lockdowns, but few studies have described the impact of lockdown on individuals with self-reported insomnia. The purpose of this study was to compare the impact of lockdown on changes in symptoms of insomnia, depression and anxiety between persons with and without self-identified insomnia. In total, 1048 adult participants from the general South African population took part in this retrospective observational study during Alert Levels 4 and 3 in May and June 2020. They completed an online survey assessing current and past self-reported sleep disorders. Symptom profiles of insomnia (Insomnia Severity Index), depression (Patient Health Questionnaire-2) and anxiety (Generalised Anxiety Disorder 7-item scale) were assessed immediately before and during a 5-week lockdown (March–April 2020). Comparative analyses were conducted between participants who identified a current or previous diagnosis of insomnia (n = 135, Insomnia group, irrespective of whether they had current symptoms or not) and those reporting no sleep disorders (n = 700, No-Insomnia group). Participants who reported multiple sleep disorders were excluded from the analyses (n = 213). Symptoms of insomnia (p < 0.001), depression (p = 0.001) and anxiety (p = 0.001) worsened in all participants during lockdown compared to pre-lockdown measures. Time-by-group interaction effects were observed for all measures (p < 0.001) such that the Insomnia group reported larger increases in insomnia (p < 0.001), depression (p < 0.001) and anxiety (p < 0.001) scores compared to the No-Insomnia group during lockdown. Participants with self-reported insomnia, even if currently asymptomatic, were more vulnerable to worsening insomnia and depressive and anxiety-related symptoms during lockdown compared to those with no insomnia. This highlights vulnerability to mental-health-altering situations in individuals with self-identified insomnia, and thus the necessity to provide mental health support for this patient population.

HIV majorly contributes to the disease burden in South Africa. Depressive symptoms are common in people living with HIV (PLHIV). Few studies compared depressive symptoms between PLHIV and those without HIV. The aim of the study was to examine the association of HIV status and depressive symptoms. Moreover, the study aimed to explore the comparison between HIV-negative participants and the different HIV-positive sub-groups regarding their depressive symptoms. A cross-sectional analysis was conducted among PLHIV and HIV-negative participants in rural South Africa, using the baseline data of the Ndlovu Cohort study. Data was collected on demographics, socioeconomic status, and depressive symptoms using the PHQ-9 questionnaire. A score of 10 and above indicated depressive symptoms. Logistic regression analysis on the relationship between HIV status and depressive symptoms was used while adjusting for age, sex, level of education, employment status, income, and ever smoking. The study included 1,927 participants; 46% were PLHIV and 239 (12.5%) had depressive symptoms. PLHIV were more likely to have depressive symptoms than HIV-negative participants (OR 1.34, 95% CI 1.01–1.77). This association was not statistically significant after adjusting for confounders (OR 1.22, 95% CI 0.92–1.63). Compared to HIV-negative participants, ART (antiretroviral treatment) naïve participants had statistically significant higher odds of depressive symptoms (OR 1.84, 95% CI 1.20–2.78). This association remained after adjusting for confounders (OR 1.72, 95% CI 1.11–2.61). There was no statistically significant difference in depressive symptoms between HIV-negative participants and those on ART, regardless of treatment regimen. In general, higher odds of depressive symptoms in ART-naïve PLHIV could reflect poor coping with diagnosis of HIV. Future research to investigate the relation between ART regimen and depressive symptoms, to establish causality and to identify changes over time, is warranted.

Background: HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high‐income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle‐income country. Methods and Results: This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36‐month follow‐up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV‐negative participants ( P P P P <0.001). Conclusions: CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV‐negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population‐based prevention of CVD risk factors in sub‐Saharan Africa is warranted, regardless of HIV status.

Background: Antiretroviral therapy (ART) is associated with weight gain, but this has been shown to be more marked with dolutegravir and other integrase strand transfer inhibitors. Objectives: We studied weight gain in people living with HIV (PLWH) on ART compared to the general population in the period before dolutegravir was introduced in a rural South African cohort. Method: Longitudinal analysis of the Ndlovu Cohort Study including 36–48 months’ follow-up data. From 2014 to 2019, data were collected annually in Limpopo, rural South Africa. Linear mixed models using HIV status, demographics, ART use and cardiovascular risk factors were used to estimate trends in body mass index (BMI) over time. Results: In total, 1518 adult, non-pregnant participants were included, of whom 518 were PLWH on ART (79.8%), 135 PLWH not yet on ART (20.2%) and 865 HIV-negative. HIV-negative participants had significantly higher BMIs than PLWH on ART at all study visits. There was a significant increase in BMI in all subgroups after 36 months (PLWH on ART, BMI +1.2 kg/m2, P < 0.001; PLWH not on ART, BMI +1.8 kg/m2, P < 0.001 and HIV-negative, BMI +1.3 kg/m2, P < 0.001). Conclusion: The increase in BMI in PLWH and HIV-negative participants is a serious warning signal as obesity results in morbidity and mortality.