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ObjectivesWe investigated whether self-reported disability was associated with mortality in adults in rural Malawi.SettingKaronga Health and Demographic Surveillance Site (HDSS), Northern Malawi.ParticipantsAll adults aged 18 and over residing in the HDSS were eligible to participate. During annual censuses in 2014 and 2015, participants were asked if they experienced difficulty in any of six functional domains and were classified as having disabilities if they reported ‘a lot of difficulty’ or ‘can’t do at all’ in any domain. Mortality data were collected until 31 December 2017. 16 748 participants (10 153 women and 6595 men) were followed up for a median of 29 months.Primary and secondary outcome measuresWe used Poisson regression to examine the relationship between disability and all-cause mortality adjusting for confounders. We assessed whether this relationship altered in the context of obesity, hypertension, diabetes or HIV. We also evaluated whether mortality from non-communicable diseases (NCD) was higher among people who had reported disability, as determined by verbal autopsy.ResultsAt baseline, 7.6% reported a disability and the overall adult mortality rate was 9.1/1000 person-years. Adults reporting disability had an all-cause mortality rate 2.70 times higher than those without, and mortality rate from NCDs 2.33 times higher than those without.ConclusionsSelf-reported disability predicts mortality at all adult ages in rural Malawi. Interventions to improve access to healthcare and other services are needed.

IntroductionSub-Saharan Africa is projected to have the highest increase in the number of people with diabetes worldwide. However, the drivers of diabetes in this region have not been clearly elucidated. The aim of this study was to evaluate the incidence of diabetes and the predictors of progression in a population-based cohort with impaired fasting glucose (IFG) in Malawi.MethodsWe used data from an extensive rural and urban non-communicable disease survey. One hundred seventy-five, of 389 individuals with impaired fasting glucose (IFG) at baseline, age 48 ±15 years and body mass index 27.5 ±5.9 kg/m2 were followed up for a median of 4.2 years (714 person-years). Incidence rates were calculated, and predictors of progression to diabetes were analysed using multivariable logistic regression models, with overall performance determined using receiver operator characteristics (ROC) curves.ResultsThe median follow-up was 4.2 (IQR 3.4 – 4.7) years. Forty-five out of 175 (26%) progressed to diabetes. Incidence rates of diabetes were 62.9 per 1000 person-years 95% CI, 47.0-84.3. The predictors of progression were higher; age (odds ratio [OR] 1.48, 95% CI 1.01-2.19, P=0.046), BMI (OR 1.98, 95% CI 1.34-2.94,P=0.001), waist circumference (OR 2.50, 95% CI 1.60-3.91,P<0.001), waist-hip ratio (OR 1.40, 95%CI 0.98-2.01,P=0.03), systolic blood pressure (OR 1.56, 95% CI 1.10-2.21,P=0.01), fasting plasma glucose (OR 1.53, 95%CI 1.08-2.16,P=0.01), cholesterol (OR 1.44, 95% CI 1.00-2.08,P=0.05) and low-density lipoprotein cholesterol (OR 1.80, 95% 1.23-2.64,P=0.002). A simple model combining fasting plasma glucose and waist circumference was predictive of progression to diabetes (ROC area under the curve=0.79)ConclusionThe incidence of diabetes in people with IFG in Malawi is higher than those seen in Europe (35.0 per 1,000 person-years) but similar to those seen in India (61.0 per 1,000 person-years). Predictors of progression are like those seen in other populations. A simple chart with probabilities of progression to diabetes based on waist circumference and fasting plasma glucose could be used to identify those at risk of progression in clinical settings in sub-Saharan Africa.