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Background: Widowhood is a significant psychosocial stressor linked to adverse health outcomes, yet its causal impact on cognitive ageing remains underexplored in sub-Saharan Africa. Most existing studies are cross-sectional and prone to bias. We applied a target trial emulation framework to rigorously evaluate the effect of widowhood on cognitive decline among older adults in Ghana.
Methods: We analysed data from the WHO Study on Global AGEing and Adult Health (SAGE) Ghana, Waves 1 (2007–2010) and 2 (2014–2015). Eligible participants were married/cohabiting adults aged 50 years or older with complete marital status and cognitive data at both waves. The exposure was marital transition (married → widowed) versus remaining married. The outcome was a change in a standardised composite cognitive score (memory, verbal fluency, digit span). Inverse probability of treatment weighting (IPTW) balanced baseline covariates, including age, sex, education, wealth, depression, social engagement, and baseline cognition. Weighted linear regression was used to estimate the average treatment effect (ATE), with sensitivity and subgroup analyses conducted to test robustness.
Results: Of 816 participants, 104 (12.8%) transitioned to widowhood during follow-up. Compared with those who remained married, widowed participants experienced significantly greater cognitive decline (IPTW β = –1.55; 95% CI: –2.55, –0.55; p = 0.002). Findings were consistent in sensitivity analyses. Subgroup effects were stronger among men, participants aged 50–59 years, those without formal education, the physically inactive, and individuals in the highest wealth quintile.
Conclusion: Widowhood accelerates cognitive decline in older Ghanaians, with vulnerability varying by sociodemographic and lifestyle factors. These findings highlight widowhood as a determinant of healthy ageing in sub-Saharan Africa and demonstrate the value of target trial emulation for causal inference.