Perceived neighborhood social cohesion and functional disability among older adults: The moderating roles of sex, physical activity, and multi-morbidity

Kofi Awuviry-Newton; Dinah Amoah; Daniel Doh; Williams Agyemang-Duah; Kwadwo Ofori-Dua; Paul Kowal; Seth Christopher Yaw Appiah

doi:10.1371/journal.pone.0293016

. 2024 Jan 31;19(1):e0293016. doi: 10.1371/journal.pone.0293016

Perceived neighborhood social cohesion and functional disability among older adults: The moderating roles of sex, physical activity, and multi-morbidity

Kofi Awuviry-Newton ^1,^2,^*, Dinah Amoah ^1,³, Daniel Doh ^1,⁴, Williams Agyemang-Duah ^1,⁵, Kwadwo Ofori-Dua ^1,⁶, Paul Kowal ⁷, Seth Christopher Yaw Appiah ⁶

Editor: Nestor Asiamah⁸

PMCID: PMC10830004 PMID: 38295112

Abstract

Though the Ghanaian social structure is largely communal in several of its social life and social spaces, the extent to which cohesive neighbourhood affects functional ability of older persons and the moderating factors of the relationship, are unknown in Ghana. This study examines the moderating roles of sex, multimorbidity, and physical activity on the association between neighbourhood social cohesion and functional disability among older people in Ghana. A cross-sectional study of 4,446 people—50 years and older—from WHO’s Study on global AGEing and adult health Ghana Wave 2 was employed. Functional disability—WHO Disability Assessment Schedule 2.0—and neighbourhood social cohesion measured with community-level participation, perceived trust and safety were studied. Generalised Logistic regressions with interactional tests were used to examine the associations. A more socially cohesive neighbourhood was significantly associated with a lower functional disability among older people (OR = 0.94, 95%CI: 0.93, 0.94; P<0.001). A similar relationship was found for community-level participation (aOR = 0.94, 95%CI: 0.94, 0.95; P<0.001) and perceived trust (aOR = 1.00, 95%CI: 0.99, 1.00; P<0.001). Community-level participation is associated with a lower functional disability among older people who were physically active (aOR = 0.98, 95%CI: 0.96, 0.99; P<0.001). Among the three individual-level measures of neighbourhood social cohesion, only physical activity (OR = 0.98, 95%CI: 0.98, 0.99; P<0.01) moderated the association between community-level participation and functional disability. Community-level participation, along with physical activity, may be relevant in improving functional ability among older people. The results highlight the usefulness of policy to ensure a more socially cohesive neighbourhood for older people in Ghana to improve their quality of life.

Introduction

As the proportion and number of older people grow globally including Ghana [1], opportunities emerge to understand how neighborhood social cohesion can strengthen older people’s functional abilities. The term perceived neighborhood social cohesion—defined in this study—refers to a sense of trust, safety, and participation among people who live in the same place [2–4]. Often, neighborhood social cohesion is considered an important element in public health due to its influential role in the wellbeing of older people [5]. As people age, chronic illness and difficulty in daily activities increase. Older people may respond to the decline in physical health by using social resources, including connections, trust, and social bond [4]. The assumption is that when perceptions of trust, safety and participation prevail in a community where older adults are residents, they will be freely involved in all activities, eventually strengthening their functional capacities. Owing to this reasoning and evidence, perceived neighborhood social cohesion may be associated with functional disability—the difficulty individuals experience in engaging in activities of daily living such as bathing, using public transport, caring for households and toileting [6, 7] among older people in Ghana.

Although life expectancy of Ghanaian older people is increasing—52 years in 2005 compared to 58 years in 2019; 2.81% rise [8]—, functional disability among older people in Ghana is noticeable. For instance, a nationally representative study comparing functional disability scores among six countries (China, Mexico, Ghana, South Africa, India, and Russia) that participated in the global study on AGEing and adults’ health (SAGE) project reported a lowest in China, highest in India with Ghana and South Africa recording the next higher score [9]. About 90% of older people in Ghana reported a difficulty across domains functioning assessment including cognition, mobility, self-care, getting along with people, engagement in household responsibility and participation in society [9]. A recent qualitative study exploring older people’ lived experiences of their functional disability revealed that they feel anxious and restricted in being productive [10]. Given this emerging functional disability prevalence among older people in Ghana, they may rely on informal social networks and other organized events to overcome daily life demands, including dealing with functional disability. In this context, cohesive neighborhoods could be an essential channel to influence functional disability among older people. Though the Ghanaian social structure is mainly communal in several of its social life and social spaces [11], there is very little understanding of the extent to which cohesive neighbourhood is associated with the functional disability of older persons and the nature of the relationship in Ghana. Significant evidence on the relationship between neighbourhood social cohesion and the three measures (perceived safety, trust, and participation) and functional disability exist in western countries. These studies revealed that older people who report higher levels of perceived social cohesion have a lower chance of developing stroke, and myocardial infarction [12, 13]. On the other hand, lower perceived social cohesion through living alone is associated with isolation, reduced social activities and interpersonal ties [4, 14], increased likelihood of developing functional disability [15, 16], thereby perceived social cohesion acting as protective factor against functional disability. In the study by Stephens, Allen [17], a greater accessibility of neighborhoods and higher level of trust among neighbours associate with better mental health.

There is limited research on the relationship between neighborhood social cohesion and functional disability among older people in low- and middle-income countries such as Ghana. Rahman and Singh [18] used data from six countries of WHO SAGE project on functional disability and social cohesion and reported that functional disability is associated with lower social cohesion, with social cohesion being highest among males, rural dwellers, currently married, currently working, better educated, and higher on the socio-economic ladder across all six countries [18]. For example, participating in health behaviour promoting activities such as physical activity and healthy diet habits may delay the development of functional disability [19, 20]. In Ghana, studies on associations between functional disability and other variables such as food insecurity [21, 22], and social isolation, neighbourhood walkability and loneliness [23, 24], physical activity [25], and long-term care [26] exist with limited understanding of how perceived neighborhood social cohesion and its measures associate with functional disability.

Known factors from western literature that moderate the association between perceived neighborhood social cohesion and functional disability include physical activity [19, 20, 27], chronic conditions such as stroke and heart attack [12] and, age and sex [18, 28]. In Ghana, very little is known about the moderating factors of the association between perceived neighborhood social cohesion and functional disability.

In this study, we examined the potential effect of perceived neighborhood social cohesion on functional disability, particularly identifying how the association between perceived community-level participation, trust, and safety within communities and functional disability are moderated by sex, multi-morbidity, and physical activity in Ghana. The findings will serve as a baseline for policymakers and researchers in Ghana, but also to extract important lessons regarding social policies for ageing populations in low- and middle-income countries.

Methods

Study sample

The Study on global AGEing and adult health (SAGE) Ghana Wave 2 data, which was collected within two years (2014–2015) across all regions of Ghana was used in this study. The actual number of participants who participated in SAGE Ghana Wave 2 was 4,704, however only 4,446 responded to questions related to the independent variable—functional disability. SAGE is a longitudinal study that used multistage cluster sampling techniques to explore health and social care information of older adults (50+years) and compared with a few sample of 18-49years across Russia, Mexico, India, China, South Africa and Ghana [29]. In Ghana, Department of Community Health at the University of Ghana with the help of the WHO sort to the implementation of the Wave 2 of SAGE.

Variables

Functional disability

The version 2.0 of the WHO Disability Assessment Schedule (WHODAS) was used to define functional disability in this study. WHODAS 2.0 has a five-response category (none = 0, mild = 1, moderate = 2, severe = 3, and extremely severe = 4). See S1 Appendix for detail. The WHODAS 2.0 is made up of 12-items under six broad areas comprising of participation in society, engaging in life activities, getting along with people, caring for self, moving around and cognition [30] Similar to other studies, we scored the 12 items between 0 and 100 inclusive to determine functional disability severity [9, 31, 32]. We categorised those who scored less than 90.18% as having “no disability” and those with a score of 90.18% or greater as living “with a disability.”

Perceived neighborhood social cohesion

Perceived neighborhood social cohesion was measured from three domains namely perceived community participation, perceived trust, and perceived safety used in WHO SAGE 2 [29]. Nine questions each with a 5-response category were used to measure older people’s perception of their participation in their communities (See details at S2 Appendix). In the resulting scale for community-level participation, we found a range from 9 to 45, with higher values denoting higher levels of community participation. The reliability coefficient was 0.87. Three questions were used to measure perceptions of feeling of trust among participants in the community. Five responses namely to a very great extent = 1, to a great extent = 2, neither great nor small extent = 3, to a small extent = 4, and to a very small extent = 5 (see S2 Appendix). These responses were reversed coded so that a higher number represented higher neighbours trust level. For instance, to a very great extent was coded 5” whereas the to a very small extent was coded 1. The responses were highly reliable at alpha = 0.889. Perceived safety was measured with two variables with 5 response categories with 1 representing completely safe, 2 representing very safe, 3 moderately safe, 4 slightly safe and 5 representing not safe at all. These responses were reversed coded so that a higher number represented higher neighbours perceived feeling of safety. For instance, “completely safe” was coded “5” whereas the “not safe at all “1”. The reliability coefficient was 0.847, with values ranging from 2 to 10.

The three individual-level variables 1) Perceived community-level participation, 2) perceived trust and 3) perceived safety were put together using transformation scale to measure perceived neighborhood social cohesion. The higher the score the higher levels of perceived neighborhood social cohesion. The values range from 14 to 70 with higher values indicating a more cohesive neighborhood. The Cronbach’s alpha of 0.839 represented a high reliability.

Sex

The question what your sex is dichotomised as Male = 1 and Female = 2 was used.

Physical activity (PA)

We measured PA with three separate measures (walking, moderate activity, and vigorous activity). Participants involvement in vigorous activity related work such as heavy lifting, digging, or chopping wood categorised as “yes” or “no” were used to measure vigorous activity. Involvement in work-related moderate activities such as brisk walking, carrying light loads, cleaning, cooking, or washing clothes for at least 10 minutes continuously were used to accessed moderate activity engagement (Yes or No). Walk was measured with participants involvement in walk or use a bicycle (pedal cycle) for at least 10 minutes continuously to get to and from places under yes or no response category.

The overall PA was generated by aggregating the three measures into “yes” representing engagement in one or more of the measures of physical activity) and “no” representing engagement in none of three measures (Cronbach’s α = 0.61).

Multimorbidity

Multimorbidity was generated from the presence chronic condition: stroke, hypertension, depression, diabetes, angina, arthritis, chronic lung disease, asthma, cataract, and oral health among older people. The response categories measuring the presence of a chronic conditions was “no condition = 1”; “one chronic condition = 2”; and “at least two chronic conditions = 3”.

Covariates

We considered sociodemographic and health related variables as potential confounders. Sociodemographic included age, marital status (never married = 1, married/cohabiting = 2, separated/divorced = 3, widowed = 4), education (less than primary school = 1, primary education completed = 2, senior high completed = 3, university degree/post = 4), and rural/urban location of residence. Health variable considered in this study was self-reported health status (good = 1, moderate = 2, bad = 3).

Data analysis

First, we used percentages and means and standard deviations to describe the variables in the study. Second, chi-square, Fisher’s test, and t-test to establish relationships between functional disability and neighbourhoods’ social cohesion and its domains. Finally, we carried out multivariate logistic regression to estimate the odds ratios (Crudes and adjusted) and 95% confidence intervals (CI) for the associations between perceived neighbourhood social cohesion and functional disability. A moderation analysis (multiplicative terms) of sex, multimorbidity and physical activity in the relationship were estimated at 0.05.

Ethical consideration

The World Health Organisation Ethical Research Committee provided ethical approval for this study (#ID3925). Participants provided a written and/or verbal consent for the study [29].

Results

Characteristics of study participants

S1 Table shows the features of study participants. The average age of participants with functional disability was approximately 74 years, with higher proportion of females reporting higher functional disability compared to the proportion of males (64.5% vs 35.5%). A high prevalence of functional disability was found among widowed (46.5%), rural dwellers (61.1%), senior high school leavers (39.5%), those who reported health as bad (68.2%) and lived with at least two chronic conditions (45.0%). A high prevalence of older people who reported absence physical activity engagement of any kind suffered functional disability (55.6%) compared to those who are physically active (55.6% vs 44.4%). Older people with no functional disability had a higher mean perceived community level participation score compared with older people with functional disability (24.8 vs. 18.3, P<0.001).

Neighbourhood social cohesion and functional disability

In the unadjusted model, overall perceived neighbourhood social cohesion was statistically associated with functional disability (OR = 0.94, 95%CI: 0.93, 0.94; P<0.001). When adjusted for potential confounders including age, sex and marital status, the strength of association existing between overall perceived neighbourhood social cohesion and functional disability was still significant and of similar magnitude (aOR = 0.94, 95%CI: 0.93, 0.95; P<0.001) (S2 Table).

In S3 Table, the associations between perceived community-level participation level and perceived trust with functional disability were significant after adjusting for potential confounders. However, the adjusted association between perceived safety and functional disability (after controlling for potential confounders) shows to be statistically insignificant.

S4 Table shows the interactional effect of sex, multimorbidity and physical activity on the neighborhood association with functional disability. None of the interactional variables studied moderated the association between overall neighborhood social cohesion and functional disability.

Among the three measures of perceived neighborhood social cohesion studied, the association between perceived community-level participation and functional disability was significant with the moderators (OR = 0.94, 95%CI: 0.94, 0.95; P<0.001). Even among the three moderators, only physical activity moderated the association between perceived community-level participation and functional disability. Older people participating in community and physical activities were 2% less likely to experience functional disability (OR, 0.98, 95%CI: 0.98, 0.99; P<0.01) (see S5 Table).

Discussion

Evidence on the effect of sex, physical activity, and multi-mobility on the association between perceived social cohesion and functional disability is least established in the gerontological literature from low- and middle- income countries. To contribute to addressing this knowledge gap, the aim of this study was to determine the moderating role of sex, physical activity, and multi-morbidity on the association between perceived neighbourhood social cohesion and functional disability. The important findings for policy and practice implications are discussed.

The current study finding that a more socially cohesive neighbourhood was associated with a lower functional disability among older people confirms available studies in other low- and middle-income countries [33–35]. Adding to this evidence, in a high income country such as Japan, previous gerontological study has reported that social cohesive neighbourhoods reduce functional disability [35]. In a related study, Aida, Kondo [34] reported that higher incidence of functional disability is linked to lower community social capital among women in Japan. Three important reasons may explain the relationship between social cohesion and functional disability among older people in the literature. Firstly, with high socially cohesive neighborhoods, older people may have higher odds of getting access to social support when they have health problems [36]. With access to social support, they can seek early health treatment(s) to prevent the onset of functional disability [16]. Secondly, social cohesion reduces the development of functional disability through social networking and group activities which result in positive health behaviour such as physical activity and healthy diets [37, 38]. Lastly, increased social cohesion is linked to improved mental and physical wellbeing which lessen the functional disability [16, 39]. Our results thus suggest that older people with higher socially cohesive neighbourhoods tend to demonstrate better functional and psychological health. Given the significant effect of social cohesion on functional disability, ensuring socially cohesive neighborhood is likely to improve functional status of older people and also reduce the risk of functional disability associated with ageing [16]. This implies that to ensure improved health of older people, social cohesion such as social connections and trust should be considered as a health priority [35]. Our results further imply that to lessen functional disability, community-based measures which foster social capital may be important [34].

It is important to highlight that perceived trust and perceived community-level participation, which are part of the framework for measuring socially cohesive neighborhoods were both associated with functional disability. Interestingly, the study revealed that increased in social trust and community-level participation reduces functional disability. This finding underscores the need to promote social trust and community participation in old age to reduce the risks of development of functional disability at the community levels. Clear evidenced based policy initiatives are required to be implemented to foster social trust building at the community level. The findings from this study are consistent with the observations made by previous gerontological studies conducted elsewhere [40, 41]. Corroborating the present findings, a study conducted in China reiterates how increase in social participation in old age predicts lower risk of the developing functional disability [42]. This finding further affirms Fujihara, Miyaguni [41] assertion that older people with increased level of community participation (such as sports) are less likely to report better functional health. This result further reinforces Chen, Min [40] finding that participating in community moderates functional disability and life satisfaction association.

Our finding that increased level of community-level participation lowers the risk of functional disability in old age may be attributed to four possible reasons. In the first place, older people who participate actively and more in community events such as communal labour and other outdoor activities are less likely to be sedentary and as a result have better functional health. Secondly, older people with increased community-level participation have lower odds of being homebound compared with those with low level of community participation thereby reducing their financial disability [41]. Thirdly, social participation enhances access to health-relevant information in old age, which is important to promoting functional health. Lastly, social participation enables older people to stay active (such as dressing each day to leave home) and these daily functions help to improve their functional health [43].

The above reasons are based on our finding that physical activity moderated the association between community-level participation and functional disability. These findings highlight several important policy implications. First, preventive programme and/or policy to improve functional ability among older people should encourage older people to participate frequently and more actively in social events at the community levels. Second, healthcare providers rendering care to older people need to gain a better understanding of the relevance of socially cohesive neighborhoods in improving functional ability in old age. Third, to improve functional ability of older people, diverse indicators for measuring socially cohesive neighborhood (such as social capital) should be considered [39]. This is because several factors such as trust and community-level participation as a dimension of socially cohesive neighbourhoods have proven to reduce the risk of functional disability in old age. Lastly, social workers can use the media to promote the need for physical activity in old age for a desired functional health and quality of life. Social workers working within communities can sensitize older adults and families on the need to incorporate physical activity in their daily activities.

The study has some limitations that need to be considered. The extent of the analysis is limited by the availability of data. Issues regarding internal validity—e.g., due to other variables that could be mediating the relationship between social cohesion and functional disability—and external validity that need to be considered. However, results are in line with other studies showing a promising research and policy area that has not been extensively explored, especially in Ghana and other low- and middle-income contexts. Data from the SAGE study Wave 2 collected during 2014/2015 could be dated; however, given the current trends in population ageing and functional disability, it is expected that results have even more relevance today.

Our findings arise as important for policymakers, since they highlight the relevance of social policies that help building social cohesion not just as important per se and to improve community wellbeing but also as a strategy to address the expected increase in long-term care needs coming from population ageing and the rise in the prevalence of functional disability. The results are important for Ghana and other low- and middle-income countries since can be seen as an efficient policy—freeing two birds with one key—for addressing the pressing social security demands in these countries.

Conclusion

Findings from this nationally representative study demonstrated the importance of a socially cohesive neighbourhood in reducing the risk of functional disability among older people, through physical activity in their long-term care. The findings have implications for policy makers to ensure social cohesiveness is improved by fostering the establishment of social support groups and local community network groups in any health and social care systems that seek to address an aspect of the long-term care needs of older people. Setting up community centres where older people could enhance companionship and engage in physical health enhancing activities such as exercises and walks with peers would be essential. Such facility will offer older people the privilege for social interaction to reduce incidence of loneliness and its associated functional disability experienced by older people. Healthcare providers should also emphasise on the need for older people to be physically active while family friendly relationships should be strengthened. A holistic approach is needed to ensure a socially cohesiveness community rather than a single entity. Further study is warranted to establish the nature and trajectory of community-level participation that help reduce functional disability.

Supporting information

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

Click here for additional data file.^{(35.1KB, docx)}

S1 Table. Univariate and bivariate analysis of independent variables and functional disability.

(DOCX)

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S2 Table. Relationship between perceived neighbourhood social cohesion (overall) and functional disability adjusted for confounders.

(DOCX)

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S3 Table. Effects of confounding on the relationship between measures of perceived neighbourhood social cohesion and functional disability.

(DOCX)

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S4 Table. Sex, multimorbidity and physical activity moderation on perceived neighbourhood social cohesion association with functional disability.

(DOCX)

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S5 Table. Sex, multimorbidity and physical activity moderation on perceived community-level participation association with functional disability.

(DOCX)

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S1 Appendix. List of the 12 variables included in the WHODAS score and cut points.

(DOCX)

Click here for additional data file.^{(13.8KB, docx)}

S2 Appendix. Perceived neighborhood social cohesion measure.

(DOCX)

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S1 Data

(XLSX)

Click here for additional data file.^{(309.7KB, xlsx)}

Data Availability

Minimal dataset has been included.

Funding Statement

The author(s) received no specific funding for this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0293016.r001

Decision Letter 0

Nestor Asiamah

24 May 2023

PONE-D-23-14414Perceived neighborhood social cohesion and functional disability among older adults in Ghana: the moderating roles of sex, physical activity, and multi-morbidityPLOS ONE

Dear Dr. Awuviry-Newton,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Nestor Asiamah, PhD

Academic Editor

PLOS ONE

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Thanks for submitting your manuscript to PLOS ONE. Your manuscript's similarity is currently at 34% (without the reference list and author information), which is above the minimum value allowed by PLOS ONE. Ideally, your manuscript should be 10% or less. Can I ask you to edit your work carefully to bring its similarity to the acceptable level? The file showing your similarity index is attached. Please note that your manuscript has not been peer-reviewed, so this decision is only formative and applies to the manuscript's originality.

I look forward to recieving the edited manuscript.

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Attachment

Submitted filename: 2023-05-24-1940.pdf

Click here for additional data file.^{(2.6MB, pdf)}

PLoS One. 2024 Jan 31;19(1):e0293016. doi: 10.1371/journal.pone.0293016.r002

Author response to Decision Letter 0

12 Jul 2023

Response to reviewers

Dear editor and reviewers,

We appreciate the privilege extended to us to revise the manuscript. We acknowledge that the comments raised are relevant and they have substantially improved the manuscript.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response

We have formatted the manuscript to conform to the Plos One’s style requirements.

2. Thank you for stating the following financial disclosure:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Response

This was an error and so we have rectified this error. The funding declaration now reads as “The authors received no specific funding for this work.”

Response

Authors have provided the minimal dataset underlying this manuscript. We have uploaded this as a supplementary document.

4. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Response

We have provided the ethics statement in the “Methods” section, with a mention of the ethics committee and reflection on participants consent. It now states as “The World Health Organisation Ethical Research Committee provided ethical approval for this study (#ID3925). Participants provided a written and/or verbal consent for the study” under “ethical consideration”.

5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response

All references have been cross-checked. All citations have their corresponding list of references towards the end of the manuscript.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response

Captions for all supporting documents have been included at the end of the manuscript.

7. Thanks for submitting your manuscript to PLOS ONE. Your manuscript's similarity is currently at 34% (without the reference list and author information), which is above the minimum value allowed by PLOS ONE. Ideally, your manuscript should be 10% or less. Can I ask you to edit your work carefully to bring its similarity to the acceptable level? The file showing your similarity index is attached. Please note that your manuscript has not been peer-reviewed, so this decision is only formative and applies to the manuscript's originality.

Response

I have paraphrased all areas. This are evident on the manuscript.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(16.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0293016.r003

Decision Letter 1

Nestor Asiamah

11 Sep 2023

PONE-D-23-14414R1Perceived neighborhood social cohesion and functional disability among older adults in Ghana: the moderating roles of sex, physical activity, and multi-morbidityPLOS ONE

Dear Dr. Awuviry-Newton,

Though your manuscript has some merit, it needs some improvement before it can be published. Please revise your manuscript based on the comments of the two reviewers.

Please submit your revised manuscript by Oct 26 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Nestor Asiamah, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

Please revise the manuscrip based on the comments of the two reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. This is a well written article, and I really enjoyed reading it. It will be a worthwhile addition to the journal. The authors' compelling Introduction argues for the necessity of their study. In general, the methods used were clearly described. The authors' presentation of the findings is engaging and convincing. The results were integrated into the more general literature during the discussion. Findings and recommendations were explicit. However, the authors could improve the paper by considering some minor points/ suggestions which can be looked at.

2. Page 2. Introduction: line 6. It seems there is omission of a word in: “due to its influential role on the wellbeing older people”

3. Methods - Sample size: Page 5. Line 1 Authors did not provide any justification for the use of the instrument and also

did not provide evidence of the regions where the sample size (4406) were drawn from in Ghana.

5. page 9-10 (Tables). Authors did not provide any Table /link to how PA was measured

6. Page 10 Tables. Authors should be consistence with the use of sex and gender. Though sex was used throughout the work, gender was used in the tables instead

7. Page 13. Paragraph 1 line 11. The last sentence. “Lastly there is the need to promote PA……”

It will be appropriate if authors provide measures or strategies that can be adopted to promote older people’s participation in PA. authors should also provide the agency or body to which this recommendation is been address to.

Reviewer #2: General comments

There were no line numbers in the document. Thus, it made it quite difficult to make my references to identified issues. The manuscript needs to undergo grammar checking and sentence construction.

Introduction

1. “Given this significant functional disability prevalence among older people in Ghana,”

The use of the word “significant” in this sentence is not justified, given the context in which it was used. A much milder term may be used.

2. “the extent to which cohesive neighbourhood associate with functional disability of older persons and the nature of the relationship, is unexplored in Ghana”

The use of the word “unexplored” should be revised. There are works relating to the subject under investigation.

3. In text citation number 17, should be written properly.

4. In low-and middle-income countries including Ghana

A comma (,) should be placed after Ghana

5. In low-and middle-income countries including Ghana evidence on neighbourhood social cohesion and its measures, and functional disability among older people is scant.

Again, much milder constructions should be considered. There are works in this area.

Methods

Physical activity

1. “the overall PA”

Start with a capital T

Results

1. The significance level values were not stated in the writing of the results. E.g., (OR=0.94, 95%CI: 0.93, 0.94). Only the odds ratio and confidence intervals were stated. Authors can add the P values. Also, I am aware the adjusted odds ratios are written as “AOR”. Authors should kindly check in on this. These should be updated in the abstract results also.

2. That is, participating in in community activities and report engaging in physical activity by older adults were 2% less likely to experience functional disability (OR, 0.98, CI: 0.98, 0.99).

There are typos in the sentence. Also, I do not seem to follow the 2% less likelihood from the stated results (OR, 0.98, CI: 0.98, 0.99).

3. Kindly check the reporting of your regression results again.

Discussion

1. The current study finding that a more perceived socially cohesive neighbourhood was associated with a lower functional disability among older people confirms available studies in other low- and middle-income countries [33-35].

There are typos in the sentence. Also, Reference number 34 says something about Japanese. I do not think Japan is a low- and middle-income country. Please check your reference.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

Attachment

Submitted filename: Review comments.docx

Click here for additional data file.^{(17.3KB, docx)}

PLoS One. 2024 Jan 31;19(1):e0293016. doi: 10.1371/journal.pone.0293016.r004

Author response to Decision Letter 1

16 Sep 2023

Responses to Author

Reviewer 1

Reviewer Comments Our Response

1. This is a well written article, and I really enjoyed reading it. It will be a worthwhile addition to the journal. The authors' compelling Introduction argues for the necessity of their study. In general, the methods used were clearly described. The authors' presentation of the findings is engaging and convincing. The results were integrated into the more general literature during the discussion. Findings and recommendations were explicit. However, the authors could improve the paper by considering some minor points/ suggestions which can be looked at. We appreciate this complement. Authors have responded to all comments.

2. Page 2. Introduction: line 6. It seems there is omission of a word in: “due to its influential role on the wellbeing older people” This sentence has been corrected.

3. Methods - Sample size: Page 5. Line 1 Authors did not provide any justification for the use of the instrument and also

did not provide evidence of the regions where the sample size (4406) were drawn from in Ghana. The sentence “The Study on global AGEing and adult health (SAGE) Ghana Wave 2 data, which was collected within two years (2014-2015) across all regions of Ghana was used in this study” has been provided indicating that it was a countrywide study. The details and reason for adopting multistage cluster sampling has been explained by the paper references.

4. Page7, line 12; It is not clear why “pedal cycle” was categorized as walk. The question is what type of walk? Since the energy expenditure in both activities are not the same unless walk is properly defined. It is true that the energy expenditure from these two activities are not the same, however, in this study we classified walk to represent any participant who reported taking part of any of this activities. Therefore, we interpreted the findings in relation to this measurement.

5. page 9-10 (Tables). Authors did not provide any Table /link to how PA was measured We explained under “Physical activity” how PA was measured. PA was measured with walking, moderate activity, vigorous activity.

6. Page 10 Tables. Authors should be consistence with the use of sex and gender. Though sex was used throughout the work, gender was used in the tables instead We have replaced “gender” with “sex” throughout.

7. Page 13. Paragraph 1 line 11. The last sentence. “Lastly there is the need to promote PA……”

The sentence now reads “Lastly, social workers can use the media to promote the need for physical activity in old age for a desired functional health and quality of life. Social workers working within communities can sensitize older adults and families on the need to incorporate physical activity in their daily activities”.

Reviewer 2

There were no line numbers in the document. Thus, it made it quite difficult to make my references to identified issues. We have included line numbers in the manuscript.

The manuscript needs to undergo grammar checking and sentence construction. We have done a thorough editing of the manuscript and checked for grammar as much as possible.

Introduction 1. “Given this significant functional disability prevalence among older people in Ghana,”

The use of the word “significant” in this sentence is not justified, given the context in which it was used. A much milder term may be used.

We have revised the sentence as:

Given this emerging functional disability prevalence among older people in Ghana, they may rely on informal social networks and other organized events to overcome daily life demands, including dealing with functional disability.

2. “the extent to which cohesive neighbourhood associate with functional disability of older persons and the nature of the relationship, is unexplored in Ghana”

The use of the word “unexplored” should be revised. There are works relating to the subject under investigation.

We have revised the sentence to:

There is very little understanding of the extent to which cohesive neighbourhood is associated with the functional disability of older persons and the nature of the relationship in Ghana.

3. In text citation number 17, should be written properly. corrected

4. In low-and middle-income countries including Ghana

A comma (,) should be placed after Ghana Corrected.

5. In low-and middle-income countries including Ghana evidence on neighbourhood social cohesion and its measures, and functional disability among older people is scant.

Again, much milder constructions should be considered. There are works in this area.

The sentence has been reworded:

There is limited research on the relationship between neighborhood social cohesion and functional disability among older people in low- and middle-income countries such as Ghana.

Method 1. “the overall PA”

Start with a capital T

Corrected – See line 182

Results 1. The significance level values were not stated in the writing of the results. E.g., (OR=0.94, 95%CI: 0.93, 0.94). Only the odds ratio and confidence intervals were stated. Authors can add the P values. Also, I am aware the adjusted odds ratios are written as “AOR”. Authors should kindly check in on this. These should be updated in the abstract results also.

P values have been provided at respective places. All adjusted odds ratios have been written us “aOR”

2. That is, participating in in community activities and report engaging in physical activity by older adults were 2% less likely to experience functional disability (OR, 0.98, CI: 0.98, 0.99).

There are typos in the sentence. Also, I do not seem to follow the 2% less likelihood from the stated results (OR, 0.98, CI: 0.98, 0.99).

The sentence has been reworded:

Even among the three moderators, only physical activity moderated the association between perceived community-level participation and functional disability. Older people participating in community and physical activities were 2% less likely to experience functional disability (OR, 0.98, CI: 0.98, 0.99) (see S5 Table).

3. Kindly check the reporting of your regression results again.

We have checked and can confirm that is correct.

Discussion 1. The current study finding that a more perceived socially cohesive neighbourhood was associated with a lower functional disability among older people confirms available studies in other low- and middle-income countries [33-35].

There are typos in the sentence. Also, Reference number 34 says something about Japanese. I do not think Japan is a low- and middle-income country. Please check your reference.

The sentence has been corrected

Attachment

Submitted filename: Responses to Author.docx

Click here for additional data file.^{(21.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0293016.r005

Decision Letter 2

Nestor Asiamah

4 Oct 2023

Perceived neighborhood social cohesion and functional disability among older adults in Ghana: the moderating roles of sex, physical activity, and multi-morbidity

PONE-D-23-14414R2

Dear Dr. Awuviry-Newton,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Nestor Asiamah, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Congratulations to the authors!

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: All my comments and suggestions from the initial peer review were properly addressed by the authors.

Reviewer #2: Introduction

The introduction now reads better. For line 105 to 106 which reads “The findings will serve as a baseline for policymakers and researchers in Ghana, but also to extract important lessons regarding social policies for ageing populations in low- and middle-income countries”. I do not think these findings will serve as baseline study, the sentence can read “The findings will contribute to important lessons regarding social policies for ageing populations in low- and middle-income countries”.

Methods

This section is sound.

Results

All comments have been addressed except Adjusted odd ratios are still written as “aOR”.

Discussion

The section is sound.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. doi: 10.1371/journal.pone.0293016.r006

Acceptance letter

Nestor Asiamah

22 Jan 2024

PONE-D-23-14414R2

PLOS ONE

Dear Dr. Awuviry-Newton,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

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S1 Table. Univariate and bivariate analysis of independent variables and functional disability.

(DOCX)

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S2 Table. Relationship between perceived neighbourhood social cohesion (overall) and functional disability adjusted for confounders.

(DOCX)

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S3 Table. Effects of confounding on the relationship between measures of perceived neighbourhood social cohesion and functional disability.

(DOCX)

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S4 Table. Sex, multimorbidity and physical activity moderation on perceived neighbourhood social cohesion association with functional disability.

(DOCX)

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S5 Table. Sex, multimorbidity and physical activity moderation on perceived community-level participation association with functional disability.

(DOCX)

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S1 Appendix. List of the 12 variables included in the WHODAS score and cut points.

(DOCX)

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S2 Appendix. Perceived neighborhood social cohesion measure.

(DOCX)

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S1 Data

(XLSX)

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Attachment

Submitted filename: 2023-05-24-1940.pdf

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Attachment

Submitted filename: Response to reviewers.docx

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Submitted filename: Review comments.docx

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Attachment

Submitted filename: Responses to Author.docx

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Data Availability Statement

Minimal dataset has been included.

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PERMALINK

Perceived neighborhood social cohesion and functional disability among older adults: The moderating roles of sex, physical activity, and multi-morbidity

Kofi Awuviry-Newton

Dinah Amoah

Daniel Doh

Williams Agyemang-Duah

Kwadwo Ofori-Dua

Paul Kowal

Seth Christopher Yaw Appiah

Roles

Abstract

Introduction

Methods

Study sample

Variables

Functional disability

Perceived neighborhood social cohesion

Sex

Physical activity (PA)

Multimorbidity

Covariates

Data analysis

Ethical consideration

Results

Characteristics of study participants

Neighbourhood social cohesion and functional disability

Discussion

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Nestor Asiamah

Roles

Author response to Decision Letter 0

Decision Letter 1

Nestor Asiamah

Roles

Author response to Decision Letter 1

Decision Letter 2

Nestor Asiamah

Roles

Acceptance letter

Nestor Asiamah

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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