




































Humanitas: Indonesian Psychological Journal  

Vol. 19 (1), February 2022, 23-30 
ISSN:  2598-6368(online); 1693-7236(print)                                                                 

        humanitas@psy.uad.ac.id  http://dx.doi.org/10.26555/humanitas.v19i1.10 

Hand grip strength and depression among rural older South Africans 

Karl Peltzer1,2 

1Department of Psychology, Asia University, Taiwan 
2Department of Research Administration and Development, University of Limpopo, South Africa 
Corresponding author: kfpeltzer@gmail.com 

 

 

Introduction 

Depressive disorders, with a prevalence of 12.1% depressive symptoms, are contributing to 
a large extent to the worldwide disease burden, including in lower-resourced countries 
(Ferrari et al., 2013). In nationally representative surveys in South Africa, 9.7% of the 
population reported major depression in their lifetime (Tomlinson et al., 2009), and about a 
third of older adults (≥65 years) had depressive symptoms (CES-D scores ≥ 10) (Tomita & 
Burns, 2013). To deal with the high burden of depression in later life, it has been suggested, 
in addition to treatment, to decrease the onset of depressive disorder in the community 
(Almeida, 2012; Whyte & Rovner, 2006).  

In this context, it would be important if, for example, muscle strength contributes to 
developing or maintaining depressive symptoms. Muscle strength can be objectively 
measured through handgrip strength (HGS) (Ashdown-Franks et al., 2019). HGS assessed 
during middle-age in population-based studies has been shown to predict mortality in older 
age (Buckner et al., 2019). A recent review of eight prospective studies (1 in China and 7 in 
high-income countries) found that low HGS increases the odds of depressive symptoms 
among men but not women (Huang et al., 2021). A prospective study among ageing adults in 
Ireland showed that HGS was inversely associated with incident depression among females 
but not males (McDowell et al., 2018). Additional studies are needed to investigate these sex 
differences (Huang et al., 2021). Furthermore, several studies also found a positive 
association between lower HGS and persistent depression (Carvalho et al., 2021). However, 

ART ICLE  INFO  

 

AB ST R ACT  

 

Article history 

Received January 21, 2022 

Revised February 4, 2022 

Accepted February 10, 2022 

 The study aimed to assess the relationship between hand grip strength 
(HGS) and depressive symptoms among ageing women and men in a 
longitudinal study in rural South Africa. We analyzed longitudinal 
data from two consecutive population-based surveys in Agincourt, 
South Africa, 2014/2015-2018/2019. Results indicate that in all, 835 
adults of 3268 participants without depression in Wave 1 (25.0 
percent) had incident depression in Wave 2, and 184 adults of 3866 
participants who had depression in Wave 1 (4.8 percent) screened 
positive for depression at both Wave 1 and 2 (persistent depression). 
The prevalence of weak HGS was 51.5 percent at baseline. In the fully 
adjusted model, weak HGS increased the odds of incident depressive 
symptoms between both sexes (AOR: 1.24, 95 percent CI: 1.04-1.47) 
among women (AOR: 1.33, 95 percent CI: 1.05-1.68), but not among 
men. No models among both sexes, among men and women, showed 
an increased odds of weak HGS with persistent depressive symptoms. 
Weak HGS was independently associated with the incident, but not 
persistent depressive symptoms between the two sexes and between 
women but not between men. 

    

 
Keywords 

hand grip strength; 

longitudinal study; 

persistent depression; 

South Africa. 

 

mailto:humanitas@psy.uad.ac.id
http://dx.doi.org/10.26555/humanitas.v19i1.10
mailto:kfpeltzer@gmail.com


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Peltzer (Hand grip strength and depression among rural older South Africans) 

the relationship between HGS and incident and persistent depressive symptoms in Africa has 
not been researched. Consequently, the study aimed to assess the relationship between HGS 
and incident and persistent depressive symptoms among men and women in a longitudinal 
study in South Africa. 

Method 

Participants 

We analyzed longitudinal data from two consecutive population-based surveys (HAALSI) in 
Agincourt, South Africa. Full information on the sampling methodology has been reported 
previously (Gómez-Olivé et al., 2018). The first survey (November 2014 to November 2015) 
included 5,059 individuals (≥40 years), with a response rate of 86% (Gómez-Olivé et al., 
2018), and the second survey (October 2018 to November 2019) included 4,176 members of 
the Wave 1 HAALSI cohort (595 died during follow-up: 12%, 254 declined participation: 
5%, 34 were not found: <1%, and response rate: 94%) (Kobayashi et al., 2021a).  

Procedures 

The study was conducted by trained field workers at the homes of the participants after written 
informed consent was provided. The study was approved by the “University of the 
Witwatersrand Human Research Ethics Committee (ref. M141159), the Harvard T.H. Chan 
School of Public Health, Office of Human Research Administration (ref. C13–1608–02), and 
the Mpumalanga Provincial Research and Ethics Committee” (Gómez-Olivé et al., 2018). 

Instruments 

Outcome variable 
In the first and second survey depressive symptoms were assessed with the “Center for 
Epidemiological Studies-Depression Scale eight-item scale (CES-D 8)” (Radloff, 1977) or 
CES-D 20 modified to CES-D 8 (Steffick, 2000), (Cronbach’s alpha .66 in the first and .79 
at the second survey). Scores ≥3 on the CES-D 8 indicated depressive symptoms (Steffick, 
2000). 

 
Exposure variable 
HGS was measured with the Smedley© Digital Hand Dynamometer (12–0286) (Gómez-Olivé 
et al., 2018), and weak HGS was defined as “<30 kg for men and <20 kg for women using 
the mean value of two HG measurements with the dominant hand” (Carvalho et al., 2021; 
Cruz-Jentoft et al., 2010).  

 
Covariates 

1. Sociodemographic information included country of birth, age, sex, educational level, 
and a quintile of asset-based household wealth.  

2. Two items on current smokeless tobacco use and current tobacco use assessed current 
tobacco use (Gómez-Olivé et al., 2018). Using as a cut-off ≥2 affirmative responses on 
the 4-item CAGE scale defined alcohol dependence (A., 1984), (Cronbach’s alpha was 
.82).  

3. Body Mass Index (BMI) was measured and classified according to WHO criteria 
(WHO, 2000).  

4. Hypertension was measured based on the last two of three blood pressure readings and 
classified based on National Committee criteria (Chobanian et al., 2003).  



Humanitas: Indonesian Psychological Journal 25 

 

             Peltzer (Hand grip strength and depression among rural older South Africans)   

5. Dyslipidemia was defined as: “total cholesterol > 6.21 mmol/L, HDL-C < 1.19 mmol/L, 
LDL-C > 4.1 mmol/L, triglycerides >2.25 mmol/L,” ever diagnosed or medication use 
for high cholesterol (Gómez-Olivé et al., 2018).  

6. Diabetes was “classified with fasting glucose (defined as > 8 hours) > 7mmol/L (126 
mg/dL),” ever diagnosed or medication use for diabetes (Gómez-Olivé et al., 2018).  

7. Physical activity and its levels were assessed and classified with the “General Physical 
Activity Questionnaire (GPAQ)” (Armstrong & Bull, 2006; WHO, 2009). 

 
Data Analysis 
The proportion of persons with the incident and persistent depression was calculated and 
described. The first longitudinal logistic regression analysis excluded those with depression 
at baseline, including a sample of 4092 participants, to estimate incident depression, and the 
second logistic regression analysis estimated longitudinal persistent depression. In the logistic 
regression model, HGS was the main predictor, controlled for sociodemographics, substance 
use, physical activity, BMI, and chronic conditions. Inverse probability weights were applied 
to account for attrition and mortality at follow-up (Kobayashi, Morris, et al., 2021b). p <.05 
was accepted as significant. All analyzes were performed with StataSE 15.0 (College Station, 
TX, USA).  

Results 

Participant characteristics by the incident and persistent depression 
In total, 835 adults out of 3268 participants without depression in Wave 1 (25.0%) had 
incident depression in Wave 2, and 184 adults out of 3866 participants who had depression 
in Wave 1 (4.8%) screened positive for depression at both Wave 1 and 2 (persistent 
depression). The prevalence of weak HGS was 51.5%. Table 1 shows sample characteristics 
of participants by the incident and persistent depression. 
 

Table 1  
Sample Characteristics by the Incident and Persistent Depression, Agincourt, South Africa, 

2014-2019 
Baseline variables Sample Incident depression Persistent depression 

  N (%) N (%) N (%) 

Age (in years) 

 

 

40-49 

50-59 

60-69 

70-79 

≥80 

884 (17.6) 

1358 (27.1) 

1274 (25.4) 

918 (18.3) 

583 (11.6) 

159 (24.1) 

221 (23.8) 

216 (26.2) 

134 (25.0) 

70 (29.2) 

20 (2.7) 

47 (3.9) 

48 (4.9) 

45 (7.0) 

22 (7.2) 

Sex 

 

Female 

Male 

2713 (53.6) 

2346 (46.4) 

457 (25.8) 

349 (24.4) 

107 (5.0) 

77 (4.6) 

Education 

 

 

None 

1-7 years 

8-11 

12 or more 

2307 (49.1) 

1613 (32.0) 

537 (10.7) 

585 (11.6) 

360 (26.7) 

251 (24.3) 

89 (23.2) 

102 (23.6) 

98 (6.1) 

64 (5.0) 

12 (2.4) 

10 (2.0) 

Wealth index Low 

Middle 

High 

2047 (40.5) 

991 (19.6) 

2021 (39.9) 

329 (27.1) 

146 (23.1) 

331 (24.2) 

80 (5.5) 

38 (5.0) 

66 (4.1) 

Alcohol dependence 

 

No 

Yes 

4988 (98.7) 

68 (1.3) 

798 (25.2) 

8 (18.0) 

178 (4.7) 

6 (11.5) 

Current tobacco use 

 

No 

Yes 

4264 (84.4) 

790 (15.6) 

671 (24.3) 

135 (29.8) 

155 (4.7) 

29 (5.2) 

Body mass index 

 

 

Normal 

Under 

Overweight 

Obesity 

1719 (36.7) 

258 (5.5) 

1328 (28.3) 

1384 (29.5) 

277 (24.8) 

37 (29.9) 

206 (23.4) 

255 (26.2) 

58 (4.5) 

14 (9.0) 

51 (4.8) 

53 (4.5) 



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Table 1 (Continue) 

Sample Characteristics by the Incident and Persistent Depression, Agincourt, South Africa, 

2014-2019 
Baseline variables Sample Incident depression Persistent depression 

  N (%) N (%) N (%) 

Hypertension No 

Yes 

2052 (41.6) 

2884 (58.4) 

340 (25.4) 

450 (24.8) 

63 (4.0) 

117 (5.4) 

Diabetes No 

Yes 

4093 (88.0) 

559 (12.0) 

668 (24.9) 

86 (29.4) 

143 (4.5) 

31 (8.1) 

Dyslipidaemia No 

Yes 

2389 (56.2) 

1862 (43.8) 

394 (25.0) 

310 (27.0) 

84 (4.5) 

77 (5.5) 

Physical activity 

 

 

Low 

Moderate 

High 

2221 (44.0) 

1143 (22.7) 

1674 (33.3) 

331 (25.5) 

202 (24.8) 

300 (24.7) 

102 (6.0) 

34 (3.6) 

63 (4.4) 

Hang grip strength Strong 

Weak 

2043 (50.8) 

1973 (49.2) 

360 (23.5) 

312 (26.5) 

69 (4.1) 

73 (5.4) 

 

 

Associations between weak HGS and incident depression 

In the fully adjusted model for individuals with no depressive symptoms at baseline, weak 

HGS increased the odds of incident depressive symptoms between the two sexes (AOR: 

1.24, 95% CI: 1.04-1.47), and among women (AOR: 1.33, 95% CI: 1.05-1.68). No models 

among men showed a significant effect of weak HGS on incident depressive symptoms (see 

Table 2). 

 

Table 2 

Association between Hand Grip Strength and Incident Depressive Symptoms, Agincourt, 

South Africa, 2014-2019 
Variable Unadjusted model Model-1 Model-2 Model-3 

 COR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) 

Box sexes     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.18 (1.04, 1.37)* 1.19 (1.01, 1.39)* 1.19 (1.01, 1.40)* 1.24 (1.04, 1.47)* 

Male     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.12 (.90, 1.39) 1.11 (.88, 141) 1.13 (.89, 1.44) 1.14 (.88, 1.49) 

Female     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.26 (1.03, 1.54)* 1.25 (1.01, 1.55)* 1.25 (1.00, 1.55)* 1.33 (1.05, 1.68)* 

*p <. 05; COR=Crude Odds Ratio; AOR=Adjusted Odds Ratio 

Model 1: Adjusted for age, sex, education, and wealth status. Model II: Adjusted for Model 1 variables, plus 

substance use, physical activity, and body mass index. Model III: Adjusted for Model I and II variables, plus 

dyslipidemia, hypertension, and diabetes.  

 

Associations between weak HGS and persistent depression 

Table 3 shows logistic regression models with people who had depressive symptoms at 

baseline and follow-up. In an unadjusted analysis between sexes and between men, weak 



Humanitas: Indonesian Psychological Journal 27 

 

             Peltzer (Hand grip strength and depression among rural older South Africans)   

HGS increased the odds of persistent depressive symptoms. However, in the adjusted 

analysis, among both sexes, among men and women, no significant associations with 

persistent depressive symptoms were found (see Table 3).  

 

Table 3 

Association between Hand Grip Strength and Persistent Depressive Symptoms, Agincourt, 

South Africa, 2014-2019 
Variable Unadjusted model Model-1 Model-2 Model-3 

 COR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) 

Both sexes     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.35 (1.02, 1.78)* 1.07 (.80, 1.45) 1.06 (.77, 1.45) 1.01 (.72, 1.42) 

Male     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.59 (1.04, 2.42)* 1.21 (.76, 1.91) 1.21 (.75, 1.94) 1.12 (.67, 1.88) 

Female     

Weak HGS     

   No 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 

   Yes 1.20 (.83, 1.75) .98 (.66, 1.47) .97 (.63, 1.48) .94 (.59, 1.49) 

*p < .05; COR=Crude Odds Ratio; AOR=Adjusted Odds Ratio 

Model 1: Adjusted for age, sex, education, and wealth status. Model II: Adjusted for Model 1 variables, plus 

substance use, body mass index, and physical activity. Model III: Adjusted for Model I and II variables, plus 

dyslipidemia, hypertension, and diabetes. 

Discussion 

In this first longitudinal study among people 40 years and older in Africa, we found that weak 
HGS increased the odds of incident depressive symptoms four years later, among both sexes, 
among women but not among men of ageing adults in South Africa. These results are contrary 
to a recent review that found low HGS increases the risk of depressive symptoms among 
males but not females (Huang et al., 2021), but similar to a longitudinal study among older 
adults in Ireland (McDowell et al., 2018). Possible reasons for these sex differences may be 
related to the role of estrogen in affecting muscle strength (Collins et al., 2019) and the role 
of estradiol action in the regulation of gene expression that modulates serotonin 
neurotransmission implicated in depression (Gu et al., 2021; Hernández-Hernández et al., 
2019). Still, further research is warranted on this issue (Gu et al., 2021). 

 In the unadjusted analysis, weak HGS increased the odds of persistent depressive 
symptoms between the sexes and between men but not women. However, no association was 
found in adjusted analysis between weak HGS and persistent depressive symptoms, while 
some other studies showed a positive association between lower HGS and persistent 
depression (Carvalho et al., 2021). Overall, findings partially confirm that resistance training 
to enhance muscle strength in ageing adults may be a beneficial adjunct to prevent depressive 
symptoms (McDowell et al., 2018; Straight et al., 2016). One of the possible mechanisms to 
explain the inverse association between HGS and depressive symptoms (Gu et al., 2021) may 
include that HGS reduces the risk of developing depression through enhancing muscle 
function that reduces inflammation and oxidative free radicals (Lindqvist et al., 2017; Vezzoli 
et al., 2019).  

The limitations of the study include that depression was assessed with a screening 
questionnaire and not with a diagnostic psychiatric evaluation. Furthermore, participants who 
were negative for depression in wave 1 may have had depression before. 



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Peltzer (Hand grip strength and depression among rural older South Africans) 

Conclusion 

Weak HGS was independently associated with the incident, but not persistent depressive 
symptoms between the two sexes and between women but not between men. Results suggest 
that improving HGS may help in reducing the development of depressive symptoms, in 
particular among women. 

Funding 

“HAALSI (Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community 
in South Africa) is sponsored by the National Institute on Aging (grant number 
1P01AG041710-01A1) and is conducted by the Harvard Center for Population and 
Development Studies in partnership with Witwatersrand University. The Agincourt HDSS 
was supported by the Wellcome Trust, UK, (058893/Z/99/A, 069683/Z/02/Z, 
085477/Z/08/Z and085477/B/08/Z), the University of the Witwatersrand and South African 
Medical Research Council.” 

 
 

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https://hrs.isr.umich.edu/publications/biblio/5411
https://link.springer.com/article/10.1007/s40279-015-0418-4
https://onlinelibrary.wiley.com/doi/10.1002/gps.3954
https://www.mdpi.com/2076-3921/8/10/431
https://apps.who.int/iris/handle/10665/42330
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https://onlinelibrary.wiley.com/doi/10.1002/gps.1555

