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Digital cognitive assessments have emerged as promising tools in limited resource settings, with the potential for adaptability and scalability in Alzheimer's Disease and Related Dementia research. However, it is important to demonstrate their practical usability relative to traditional paper-based tests for widespread adoption. This study compares the feasibility of both modalities in a healthy older adult multilingual Kenyan population. We enrolled 135 community-dwelling Kenyan adults [mean (SD) age in years=55.2 (8.6), min = 45, max=79; 64.4% female], ranging in education from primary to doctoral-level [median education = 11 years]. Participants completed a cognitive test battery that included the Tablet-based Cognitive Assessment Tool [TabCAT] and paper-based cognitive tests assessing memory, attention, and executive function. All tests were available in English and culturally adapted to Swahili. Feasibility metrics included error types, language-switching (as a potential indicator of increased cognitive load), valid task completion, learning curves (as a reflection of user engagement), and practice trial success. Digital assessments had a 12.9% error rate, mainly due to technical issues (10.6%); whereas, paper-based tests had an 8.2% error rate, mainly due to examinee-related issues (4.2%). Language-switching was common in paper-based tests, particularly in tasks involving months (88%) and numbers (97%) but was less common in digital tests, ranging from 5% to 12%. Completion rates were high for digital tasks such as Birdwatch (100%), Match (100%), Line Orientation (100%), and Flanker (98%), with slightly lower rates for Set-Shifting (90%). Completion rates were 100% for paper-based tests, except for Trail making Test A (3% of participants timed out). Positive learning curves were apparent across paper-based and digital learning trials on memory tests, indicating effective user engagement. Digital test practice trials had high success rates prior to actual test trials (100% for Flanker and Match, 97% for Set-Shifting, 87% for Line Orientation), indicating effective task design and user engagement. Culturally and linguistically adapted digital tools have the potential for scalable, user-friendly, and adaptable cognitive testing in resource-limited settings. Technical issues with digital tests and the additional cognitive load of language-switching on working memory tasks should be addressed prior to scaling.

Transcultural adaptation and psychometric validation of cognitive assessment tools developed in high-income countries (HICs) is essential for fair use in low- and middle-income countries (LMICs). This study aims to evaluate the factor structure of a multi-domain, multi-modal (paper/pencil & digital) cognitive test battery and whether it conforms to globally recognized neuropsychological domains in cognitively unimpaired (CU) multilingual Kenyan adults. A neuropsychological test battery was administered to an initial sample of 135 CU adults [36% males; mean (sd) age: 55 (7) y, range: 44- 79 y] and an independent validation sample of 218 CU adults (42% males; mean (sd) age: 52 (11) y, range: 35-81 y). Exploratory factor analysis (EFA) was conducted in the initial sample using Principal Axis Factoring (PA) with oblique rotation (Promax) and confirmatory factor analysis was conducted in the independent sample. Input features were aligned across samples and included subtest scores from classic word list learning, story recall, and semantic fluency tests (NIH HCAP battery), as well as novel tablet-based tests (Tablet-based Cognitive Assessment Tool [TabCAT] Flanker, Match, Set-Shifting, Birdwatch). EFA revealed a three-factor structure that explained 62.6% of the total variance. Episodic memory subtests loaded strongly on Factors 1 and 2. Factor 1 loadings included word learning (0.8), delayed word recall (1.0), and word recognition (0.7). Factor 2 loadings included immediate story recall (1.0) and delayed story recall (1.0). Factor 3 loadings included measures of attention, executive function, and visual associative memory from TabCAT (Match: 0.8, Set-shifting: 0.9, Flanker: 0.5, and Birdwatch: 0.4). The language variable demonstrated very weak factor loadings across all 3 factors (PA1 = 0.1, PA2 = 0.2, PA3 = 0.3). The CFA showed moderate model fit, after adding one covariance between delayed story recall and word recognition, as per modification indices (χ 2 = 62.72, DF = 23, N = 218, p < .001, RMSEA = .089, CFI = . 963, TLI = .943, SRMR = .055). Findings support the construct validity of a multi-domain cognitive test battery in Kenyan adults, although the low loading of semantic fluency suggests the need for further modification to enrich the language domain in this multilingual population.

Safety is central to brain health; yet, there are currently no tools to assess perceived safety. Here, we describe preliminary psychometric data from a novel Lifetime Sense of Safety (LSS) scale in healthy Kenyan adults. The LSS evaluates self-perception of safety across childhood and adulthood settings, cumulatively referred to as \"the protectome. The 6-item LSS scale was collaboratively developed in English and Kiswahili. Respondents are asked to retrospectively evaluate perceived safety in childhood at (1) home, (2) school, and (3) neighbourhood, as well as in adulthood at (4) home, (5) work, and (6) neighborhood, using a color bar with a corresponding number range from \"0\" (lowest) to \"10\" (highest) sense of safety. The LSS scale was administered to 163 Kenyan adults (97 f; 66 m), ranging in age from 35 to 80 years (m=53; sd=10), with broad educational attainment (primary to doctoral level). We evaluated internal consistency, factor structure, sex effects, and convergent validity between LSS total score and measures of perceived stress (PSS-4) and resiliency (Connor Davidson Resiliency Scale - CDRS). Data were normally distributed and internal consistency was good (α = 0.86). Suitability for factor analysis was established by sampling adequacy (KMO=0.81) and item cross-correlations (Bartlett's test=455; p < 0.001). Exploratory factor analysis with oblimin rotation revealed two latent factors. Childhood items 1-3 exhibited high loadings on Factor 1 (0.83-0.95), while adulthood items 4-6 displayed high loadings on factor 2 (0.72-0.91). Results support the LSS scale as a measure of two latent factors (childhood and adulthood safety) accounting for 75% of total variance. There were no sex effects on latent factors. The LLS total score was negatively correlated with PSS total score (r = -0.30; p < 0.001) and positively correlated with CDRS total score (r = 0.26; p <0.001). The LSS scale is a psychometrically sound measure of \"perceived safety\", with 2 latent factors reflecting childhood and adulthood safety. Perceived safety is negatively associated with stress and positively correlated with resiliency, which supports use of the LSS scale in investigations of the lifetime \"protectome\" on late-life brain health.

Dementia research accounts for only 0.1% of all research in Africa, making it the lowest among all low- and middle-income country (LMIC) regions. The development and adaptation of biological and psychosocial measures in ethnically and culturally diverse populations remain limited but are essential for culturally informed research. This is particularly critical for examining sex- and gender-based vulnerabilities to Alzheimer's disease and related dementias (ADRD), including factors such as reproductive health and fertility. We conducted a thorough review of our clinical and health questionnaires for cultural relevance and sensitivity through a series (n = 3) of focus groups discussions. These focus groups included a diverse range of participants, such as expert clinical and academic stakeholders, local community members, health promoters, community leaders, and representatives, ensuring a well-rounded and inclusive approach. Certain questions about sexual behavior, sexually transmitted diseases, biological and adopted children, and fertility were deemed culturally inappropriate and required rephrasing for sensitivity. To build rapport, these questions were strategically placed after less sensitive topics. Additionally, gaps were identified, including missing questions on traditional fertility practices (e.g., herbal remedies), male puberty characteristics, and partner support during and after childbirth. Addressing these gaps by incorporating local beliefs and traditions will enable a more holistic understanding of reproductive health behaviors. Furthermore, translations overlooked subtle linguistic nuances, highlighting the need for more detailed explanations or alternative concepts in Swahili to ensure clarity and accuracy. The Fember-Africa study aims to bridge a critical gap in understanding sex- and gender-specific differences in Africa, shedding light on the disproportionately higher prevalence of dementia among women of African ancestry. Through the culturally sensitive adaptation of reproductive health assessment tool, the study seeks to generate valuable insights that can inform the prevention and management of Alzheimer's disease and related dementias (ADRD) in this underrepresented population.

Over 55 million people worldwide live with dementia, with more than 60% residing in low- and middle-income countries. Alzheimer's disease, the most common form of dementia, accounts for 60-70% of cases. Early and accurate diagnosis remains a global challenge, necessitating novel approaches to mitigate the disease burden. Biomarkers hold significant promise in improving diagnostic accuracy and predicting disease progression. Validated biomarkers for the preclinical stages of dementia are crucial for advancing diagnosis and therapeutic strategies. We aimed to identify potential clinical markers for early dementia detection and assess their predictive accuracy in identifying high-risk individuals. We analyzed blood samples from dementia cases (n = 30) and controls (n = 75) for clinical parameters, including renal and liver function tests, lipid profiles, thyroid function tests, glomerular filtration rate (GFR), vitamin B12, and fasting glucose. Dementia cases showed significantly elevated high-density lipoprotein (HDL), free thyroxine (FT4), and vitamin B-12 (P = 0.0002, P = 0.015, and P = 0.004, respectively) compared to controls. We also observed significant reductions in GFR, free triiodothyronine (FT3), and the cholesterol-to-HDL ratio (P = 0.003, P = 0.0002, and P = 0.05, respectively). Logistic regression confirmed associations between HDL (Odds: 10.8, 95% CI: 0.34-5.01, P = 0.04) and FT4 (Odds: 33.78, 95% CI: 0.64-7.20, P = 0.028) with dementia after adjusting for age and sex. Vitamin B-12, FT3, GFR, and the cholesterol-to-HDL ratio were not significantly associated with dementia (P > 0.05). Predictive models demonstrated strong performance (R  = 0.47-0.52). Our findings demonstrated the potential of HDL and FT4 as blood-based clinical markers for early detection of cognitive impairment and dementia.

Background Developing culture‐fair tests that measure constructs equivalently across different ethno‐lingual groups is challenging, given the diverse cultural variations that impact neurocognitive measurement. Multi‐level measurement invariance must be established before interpreting scores similarly across groups, both within and between cultures for meaningful comparisons. Method We set out to test whether a neurocognitive tool (BENCI) behaves the same way across the males (n = 311) and the females group (n = 291) using measurement invariance testing with multigroup confirmatory factor analysis. We used a four factor model that had an excellent fit in a Kenyan pooled sample when modified to have four correlated first‐order factors i.e., Fluency, Reasoning, Memory, and Flexibility. We evaluated configural, metric, scalar and lastly strict invariance model and then tested whether the different restraint in the models resulted in a significant chi‐square difference. Result The four‐factor model showed good model fit (RMSEA = .034, CFI = .959, TLI = .930, χ2 (92, n = 604) = 154.309, p < .001), with metric measurement invariance (RMSEA = .033, CFI = .957, TLI = .933, χ2 (100, n = 604) = 164.368, p < .001; Δχ2 = 10.059, DF = 8, p = 261, ΔCFI = 0.002), scalar measurement invariance (RMSEA = .032, CFI = .957, TLI = .938, χ2 (108, n = 604) = 172.831, p < .001; Δχ2 = 8.463, p = .390, ΔCFI = 0.000), and the strict measurement invariance (RMSEA = .031, CFI = .955, TLI = .940, χ2 (118, n = 604) = 186.563, p < .001; Δchi‐square = 22.195, df = 18, p = .223, ΔCFI 0.002) between the females and males. Conclusion Metric, scalar and strict invariance is achieved indicating that indicator items, indicator intercepts (same starting point on the BENCI) and residuals (except Visual Memory Delayed CA residuals) of the BENCI are comparable across the male and female samples, and we can compare the association of BENCI with other invariant constructs across the two groups, including the latent mean comparisons. These results are promising and suggest that cross‐gender comparisons may also be tenable for other clinical group comparisons in Kenya and cross‐cultural data harmonization in multi‐national research programs.

Background Transcultural adaptation and psychometric validation of cognitive assessment tools developed in high‐income countries (HICs) is essential for fair use in low‐ and middle‐income countries (LMICs). This study aims to evaluate the factor structure of a multi‐domain, multi‐modal (paper/pencil & digital) cognitive test battery and whether it conforms to globally recognized neuropsychological domains in cognitively unimpaired (CU) multilingual Kenyan adults. Method A neuropsychological test battery was administered to an initial sample of 135 CU adults [36% males; mean (sd) age: 55 (7) y, range: 44‐ 79 y] and an independent validation sample of 218 CU adults (42% males; mean (sd) age: 52 (11) y, range: 35‐81 y). Exploratory factor analysis (EFA) was conducted in the initial sample using Principal Axis Factoring (PA) with oblique rotation (Promax) and confirmatory factor analysis was conducted in the independent sample. Input features were aligned across samples and included subtest scores from classic word list learning, story recall, and semantic fluency tests (NIH HCAP battery), as well as novel tablet‐based tests (Tablet‐based Cognitive Assessment Tool [TabCAT] Flanker, Match, Set‐Shifting, Birdwatch). Result EFA revealed a three‐factor structure that explained 62.6% of the total variance. Episodic memory subtests loaded strongly on Factors 1 and 2. Factor 1 loadings included word learning (0.8), delayed word recall (1.0), and word recognition (0.7). Factor 2 loadings included immediate story recall (1.0) and delayed story recall (1.0). Factor 3 loadings included measures of attention, executive function, and visual associative memory from TabCAT (Match: 0.8, Set‐shifting: 0.9, Flanker: 0.5, and Birdwatch: 0.4). The language variable demonstrated very weak factor loadings across all 3 factors (PA1 = 0.1, PA2 = 0.2, PA3 = 0.3). The CFA showed moderate model fit, after adding one covariance between delayed story recall and word recognition, as per modification indices (χ 2 = 62.72, DF = 23, N = 218, p < .001, RMSEA = .089, CFI = . 963, TLI = .943, SRMR = .055). Conclusion Findings support the construct validity of a multi‐domain cognitive test battery in Kenyan adults, although the low loading of semantic fluency suggests the need for further modification to enrich the language domain in this multilingual population.

Background Digital cognitive assessments have emerged as promising tools in limited resource settings, with the potential for adaptability and scalability in Alzheimer's Disease and Related Dementia research. However, it is important to demonstrate their practical usability relative to traditional paper‐based tests for widespread adoption. This study compares the feasibility of both modalities in a healthy older adult multilingual Kenyan population. Method We enrolled 135 community‐dwelling Kenyan adults [mean (SD) age in years=55.2 (8.6), min = 45, max=79; 64.4% female], ranging in education from primary to doctoral‐level [median education = 11 years]. Participants completed a cognitive test battery that included the Tablet‐based Cognitive Assessment Tool [TabCAT] and paper‐based cognitive tests assessing memory, attention, and executive function. All tests were available in English and culturally adapted to Swahili. Feasibility metrics included error types, language‐switching (as a potential indicator of increased cognitive load), valid task completion, learning curves (as a reflection of user engagement), and practice trial success. Result Digital assessments had a 12.9% error rate, mainly due to technical issues (10.6%); whereas, paper‐based tests had an 8.2% error rate, mainly due to examinee‐related issues (4.2%). Language‐switching was common in paper‐based tests, particularly in tasks involving months (88%) and numbers (97%) but was less common in digital tests, ranging from 5% to 12%. Completion rates were high for digital tasks such as Birdwatch (100%), Match (100%), Line Orientation (100%), and Flanker (98%), with slightly lower rates for Set‐Shifting (90%). Completion rates were 100% for paper‐based tests, except for Trail making Test A (3% of participants timed out). Positive learning curves were apparent across paper‐based and digital learning trials on memory tests, indicating effective user engagement. Digital test practice trials had high success rates prior to actual test trials (100% for Flanker and Match, 97% for Set‐Shifting, 87% for Line Orientation), indicating effective task design and user engagement. Conclusion Culturally and linguistically adapted digital tools have the potential for scalable, user‐friendly, and adaptable cognitive testing in resource‐limited settings. Technical issues with digital tests and the additional cognitive load of language‐switching on working memory tasks should be addressed prior to scaling.

Background Alzheimer's disease and related dementias (ADRD) are rapidly increasing in Low‐and Middle‐Income Countries (LMICs), disproportionately affecting women. Beyond biological vulnerability, socioeconomic and reproductive health factors contribute to this gender disparity. Multidimensional poverty (MP)‐encompassing education, healthcare access, and living conditions‐is a known risk factor for cognitive decline, particularly among women. Additionally, subjective memory complaints (SMC), a potential early marker of dementia, are more frequently reported by women and more strongly associated to cognitive decline and dementia risk in women. This study assessed gender disparities in MP and their association with SMC in Kenya, with implications for sex‐specific dementia risk and precision health interventions. Method Analysis utilized data from individuals recruited for brain health and dementia studies at Aga Khan University, Nairobi. The Multidimensional Poverty Index assessed deprivation across nine domains: education, food/water insecurity, barriers to healthcare, income, electricity, household assets, living standards (flush toilet access), and cooking methods. SMC was assessed via structured questionnaire [\"Have you noticed a change in your memory?\" yes/no]. MP was defined using a 33.33% deprivation threshold. Gender‐stratified Fisher's tests and linear regression models examined associations between poverty indicators and SMC. Result Among 335 cognitively unimpaired participants (208 women, mean age: 53 ± 10 years) and 17 dementia cases (13 women, mean age: 71 ± 7 years), women were significantly more deprived across all poverty indicators and more frequently reported SMC. Healthcare access barriers were the most prevalent form of deprivation, disproportionately affecting women. Income deprivation was also higher in women (Table 1). Notably, none of the dementia cases were classified as multidimensionally poor, potentially indicating low health literacy, late‐stage diagnosis, and limited healthcare access among lower‐income groups. Conclusion Gendered disparities in education, healthcare, and financial security may heighten dementia risk in women, particularly in LMICs, where early‐life socioeconomic disadvantage intersects with reproductive health challenges. These findings underscore the urgent need for targeted interventions addressing poverty‐related dementia risk factors in women, particularly access to education and reproductive healthcare. Future research will explore sex‐specific interactions between multidimensional poverty, hormonal changes, and cognitive decline, informing precision prevention strategies for ADRD in LMICs.

Background Safety is central to brain health; yet, there are currently no tools to assess perceived safety. Here, we describe preliminary psychometric data from a novel Lifetime Sense of Safety (LSS) scale in healthy Kenyan adults. The LSS evaluates self‐perception of safety across childhood and adulthood settings, cumulatively referred to as “the protectome. Method The 6‐item LSS scale was collaboratively developed in English and Kiswahili. Respondents are asked to retrospectively evaluate perceived safety in childhood at (1) home, (2) school, and (3) neighbourhood, as well as in adulthood at (4) home, (5) work, and (6) neighborhood, using a color bar with a corresponding number range from “0” (lowest) to “10” (highest) sense of safety. The LSS scale was administered to 163 Kenyan adults (97 f; 66 m), ranging in age from 35 to 80 years (m=53; sd=10), with broad educational attainment (primary to doctoral level). We evaluated internal consistency, factor structure, sex effects, and convergent validity between LSS total score and measures of perceived stress (PSS‐4) and resiliency (Connor Davidson Resiliency Scale ‐ CDRS). Result Data were normally distributed and internal consistency was good (α = 0.86). Suitability for factor analysis was established by sampling adequacy (KMO=0.81) and item cross‐correlations (Bartlett's test=455; p < 0.001). Exploratory factor analysis with oblimin rotation revealed two latent factors. Childhood items 1‐3 exhibited high loadings on Factor 1 (0.83‐0.95), while adulthood items 4‐6 displayed high loadings on factor 2 (0.72‐0.91). Results support the LSS scale as a measure of two latent factors (childhood and adulthood safety) accounting for 75% of total variance. There were no sex effects on latent factors. The LLS total score was negatively correlated with PSS total score (r = ‐0.30; p < 0.001) and positively correlated with CDRS total score (r = 0.26; p <0.001). Conclusion The LSS scale is a psychometrically sound measure of “perceived safety”, with 2 latent factors reflecting childhood and adulthood safety. Perceived safety is negatively associated with stress and positively correlated with resiliency, which supports use of the LSS scale in investigations of the lifetime “protectome” on late‐life brain health.