Search

Background: The COVID-19 pandemic has underscored the need for increased vaccine availability and uptake, with vaccine hesitancy posing a significant barrier, particularly among young adults. Evidence from various countries highlight high levels of hesitancy among young people, necessitating targeted interventions. Engaging young adults as key stakeholders in shaping public health strategies is crucial, as their perspectives can enhance vaccine acceptance. This study aimed to assess the overall acceptability of the COVID-19 vaccine among young people and to explore the factors influencing their willingness or reluctance to be vaccinated now and in the future., Methods: This study used qualitative data from 165 young adults in Nigeria, South Africa, and Zambia, to explore their suggestions for policies and strategies aimed at enhancing the acceptance of the Covid-19 vaccination among their age group. Data collection involved focus groups and interviews that explored participants' perceptions and recommendations regarding COVID-19 vaccination acceptability. Thematic analysis was used to analyse the data., Results: Thematic analysis identified several factors influencing vaccine acceptability among young people and suggested recommendations to improve it. The themes included developing targeted communication strategies for accurate vaccine information, offering alternative vaccination methods, promoting vaccine education in schools, and using trusted public figures to share accurate information., Conclusions: Persistent dissatisfaction with vaccine information dissemination underscores the need for more targeted communication strategies among young adults. Recommendations include developing non-injection vaccine options, incorporating vaccine education into school curricula and community programs, and leveraging influential public figures to build credibility. These insights are valuable for designing future programs to enhance vaccine acceptance among adolescents., Competing Interests: Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Biomedical Research Ethics Committee of the University of the Western Cape (BM21/10/39). The research was conducted in accordance with the Declaration of Helsinki. We obtained written consent from all participants, with additional consent obtained from parents or guardians for participants under 18 years of age. Consent forms were translated into the relevant local languages and explained verbally to participants. As a token of appreciation for their involvement in the research, IDI participants received airtime compensation, while the FGD participants were provided with snacks and a hot meal and reimbursed for their transport expenses. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Informal caregivers support relatives in healthcare facilities globally. However, their involvement in hospitalization care while residing in and around the hospital is more prevalent in under-resourced settings. This article examined the challenges and multifaceted consequences of hospital-based informal caregiving in a Nigerian tertiary health facility. The study adopted a non-experimental exploratory research design and ethnographic and qualitative techniques were used to collect data from 75 participants, comprising 21 informal caregivers, 15 inpatients, 36 hospital staff, and 3 ad-hoc/paid caregivers. The challenges identified include: physical health effects and infection risks; livelihood and economic impact; mental health effects; inadequate access to basic services; exposure to safety risks and violence; conflict and barriers within the health system; and social impact. These challenges have negative consequences on informal caregivers, including heightening their vulnerability to poor health and burdening them economically and socially. Informal caregivers play a crucial role in under-resourced settings. Policymakers should create a supportive healthcare environment that meets their needs, ultimately improving the overall quality of care provided in tertiary health facilities., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

There is limited evidence around the cost-effectiveness of interventions to reduce violence against children in low- and middle-income countries. We used a decision-analytic model to evaluate the cost-effectiveness of three intervention scenarios for reducing adolescent emotional, physical, and sexual abuse in Mpumalanga Province, South Africa. The intervention scenarios were: 1) Community grant outreach to link households to South Africa's Child Support Grant (CSG) if they are eligible, but not receiving it; 2) Group-based parenting support; and 3) Group-based parenting support 'plus' linkage to the CSG. We estimated average cost-effectiveness ratios (ACERs) for intervention scenarios over a ten-year time horizon, and compared them to a South Africa-specific willingness-to-pay (WTP) threshold (USD3390). Health effects were expressed in disability-adjusted life years (DALYs) averted. Our model considered four combinations of routine service versus trial-based costing, and population-average versus high prevalence of violence. Under routine service costing, ACERs for grant outreach and parenting support were below the WTP threshold when considering a population-average prevalence of violence USD2850 (Lower: USD1840-Upper: USD10,500) and USD2620 (USD1520-USD9800) per DALY averted, respectively; and a high prevalence of violence USD1320 (USD908-USD5180) and USD1340 (USD758-USD4910) per DALY averted, respectively. The incremental cost-effectiveness of parenting support plus grant linkage relative to parenting support alone was USD462 (USD346-USD1610) and USD225 (USD150-USD811) per DALY averted at a population-average and high prevalence of violence, respectively. Under trial-based costing, only the ACER for grant outreach was below the WTP threshold when considering a high prevalence of violence USD2580 (USD1640-USD9370) per DALY averted. Confidence intervals for all ACERs crossed the WTP threshold. In conclusion, grant outreach and parenting support are likely to be cost-effective intervention scenarios for reducing violence against adolescents if they apply routine service costing and reach high risk groups. Combining parenting support with grant linkage is likely to be more cost-effective than parenting support alone., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Rudgard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Intervention acceptability has become an increasingly key consideration in the development, evaluation and implementation of health and social interventions. However, to date this area of investigation has been constrained by the absence of a consistent definition of acceptability, comprehensive conceptual frameworks disaggregating its components, and few reliable assessment measures. This paper aims to contribute to this gap, by proposing a conceptual framework and exploratory model for acceptability with a specific priority population for health and developmental interventions: adolescents and youth in Africa. We document our multi-staged approach to model development, comprising both inductive and deductive components, and both systematic and interpretative review methods. This included thematic analyses of respective acceptability definitions and findings, from 55 studies assessing acceptability of 60 interventions conducted with young people aged 10-24 in (mainly Southern and Eastern) Africa over a decade; a consideration of these findings in relation to Sekhon et al.'s Theoretical Framework of Acceptability (TFA); a cross-disciplinary review of acceptability definitions and models; a review of key health behavioural change models; and expert consultation with interdisciplinary researchers. Our proposed framework incorporates nine component constructs: affective attitude, intervention understanding, perceived positive effects, relevance, perceived social acceptability, burden, ethicality, perceived negative effects and self-efficacy. We discuss the rationale for the inclusion and definition of each component, highlighting key behavioural models that adopt similar constructs. We then extend this framework to develop an exploratory model for acceptability with young people, that links the framework components to each other and to intervention engagement. Acceptability is represented as an emergent property of a complex, adaptive system of interacting components, which can influence user engagement directly and indirectly, and in turn be influenced by user engagement. We discuss opportunities for applying and further refining or developing these models, and their value as a point of reference for the development of acceptability assessment tools., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Maximising access to and the success of fertility treatments should be a priority for global reproductive health, as should overall patient well-being. The demand for in vitro fertilization (IVF) and other assisted fertility treatments has increased over the past decade and is likely to further increase in years to come. Nevertheless, there is still considerable unmet demand for infertility support worldwide. Moreover, the high emotional, physical and financial burden experienced by individuals undergoing IVF cycles can be a risk for their mental and physical health, which in turn can influence treatment continuation and the likelihood of IVF success. Studies from various parts of the world show that most individuals undergoing IVF also use adjunct alternative medicines and procedures, the most common being traditional Chinese medicine (TCM). The complementary and synergistic role of TCM for individuals undergoing IVF is an area that merits further attention and research, both for its potential positive effects on IVF success rates and for its broader physical and mental health benefits. However, much of the existing evidence is not sufficiently robust or consistent for findings to be adopted with confidence. This commentary argues that much work must be done to understand the efficacy and clinical best practices for these integrated approaches. This can be achieved in part by developing more robust and clinically relevant randomized controlled trial protocols, collecting and triangulating evidence through a variety of study designs and methods, and strengthening the collection and pooling of clinic-level data., Competing Interests: Declaration of competing interest The author declares that she has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Journal of Integrative Medicine Editorial Office. Published by Elsevier B.V. All rights reserved.)

Acceptability has become a key consideration in the development, evaluation and implementation of health and social interventions. This commentary paper advances key learnings and recommendations for future intervention acceptability research with young people in Africa, aimed at supporting the achievement of developmental goals. It relates findings of the adolescent acceptability work conducted within the Accelerate Hub, since mid 2020, to broader inter-disciplinary literatures and current regional health and social priorities. We argue that, in order to strengthen the quality and applied value of future acceptability work with young people, we need to do three things better. First, we need to consolidate prior findings on acceptability, within and across intervention types, to inform responses to current public health and social challenges and further the conceptual work in this area. Second, we need to better conceptualise acceptability research with young people, by developing stronger conceptual frameworks that define acceptability and its constructs, and predict its relationship with intervention engagement. Third, we need to better contextualise findings by considering acceptability data within a broader social and political context, which in turn can be supported by better conceptualisation. In this paper we describe contributions of our work to each of these three inter-connected objectives, and suggest ways in which they may be taken forward by researchers and practitioners. These include aggregating evidence from past interventions to highlight potential barriers and enablers to current responses in priority areas; involving key actors earlier and more meaningfully in acceptability research; further developing and testing behavioural models for youth acceptability; and working collaboratively across sectors towards programmatic guidance for better contextualisation of acceptability research. Progress in this field will require an inter-disciplinary approach that draws from various literatures such as socio-ecological theory, political economy analysis, health behaviour models and literature on participatory research approaches.

Objective: Interventions aimed at improving adolescent health and social outcomes are more likely to be successful if the young people they target find them acceptable. However, no standard definitions or indicators exist to assess acceptability. A cceptability research with adolescents in low-and-middle-income countries (LMICs) is still limited and no known reviews systhesise the evidence from Africa. This paper maps and qualitatively synthesises the scope, characteristics and findings of these studies, including definitions of acceptability, methods used, the type and objectives of interventions assessed, and overall findings on adolescent acceptability., Design: We conducted a systematic review of peer-reviewed studies assessing intervention acceptability with young adults (aged 10-24) in Africa, published between January 2010 and June 2020., Data Sources: Web of Science, Medline, PsycINFO, SociIndex, CINAHL, Africa-wide, Academic Search Complete and PubMed were searched through July 2020., Eligibility Criteria for Selecting Studies: Papers were selected based on the following inclusion criteria: if they (1) reported primary research assessing acceptability (based on the authors' definition of the study or findings) of one or more intervention(s) with adolescents and young adults 10-24; (2) assessed acceptability of intervention(s) aimed at positively influencing one or more development outcome(s), as defined by sustainable development goal (SDG) indicators; (3) reported on research conducted in Africa; (4) were in the English Language; (5) were peer-reviewed and and (6) were published between 1 January 2010 and 30 June 2020., Data Extraction and Synthesis: Abstracts were reviewed independently by the two first authors to determine relevance. Full text of potentially eligible studies were retrieved and independently examined by the same two authors; areas of disagreement or lack of clarity were resolved through discussion by the two authors and-where necessary-the assessment of a third author., Results: 55 studies were considered eligible for inclusion in the review. Most studies were conducted in Southern Africa, of which 32 jointly in South Africa and Uganda. The majority of interventions assessed for acceptability could be classified as HIV or HPV vaccine interventions (10), E-health (10), HIV testing interventions (8), support group interventions (7) and contraceptive interventions (6). The objectives of most interventions were linked to SDG3, specifically to HIV and sexual and reproductive health. Acceptability was overall high among these published studies. 22 studies provided reasons for acceptability or lack thereof, some specific to particular types of interventions and others common across intervention types., Conclusions: Our review exposes considerable scope for future acceptability research and review work. This should include extending acceptability research beyond the health (and particularly HIV) sector and to regions in Africa where this type of research is still scarce; including adolescents earlier, and potentially throughout the intervention process; further conceptualising the construct of acceptability among adolescents and beyond; and examining the relationship between acceptability and uptake., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Community violence is a prevalent form of interpersonal violence in South Africa for children living in low-income areas. Trauma arising from violence exposure is of concern in contexts where access to treatment is often unattainable. As simultaneous multisectoral strategies show higher potential to counter interpersonal violence than single interventions, the World Health Organization with partners created INSPIRE. INSPIRE takes an integrated approach coordinated across formal and informal settings of civil and private society. Responding to research paucity on methods that counter community violence in LMIC settings, this study employed a cross-sectional correlational design consisting of a sample of 2,477 children aged 10 to 17 years from the Young Carers 2009-2010 study conducted in a low-income, HIV-endemic province of South Africa highly affected by community violence. Multiple logistic regressions assessed individual and dose associations between four INSPIRE-based violence prevention strategies-positive parenting, basic necessities, formal social support, and school structural support-and direct and indirect community violence outcomes. Three strategies had significant associations with community violence outcomes: necessities (direct p < .001; adjusted odds ratio [AOR] = .57; indirect p < .01; AOR = .62), formal support (direct p < .05; AOR = .83; indirect p < .05; AOR = .73), and school support (direct p < .001; AOR = .53; indirect p < .001; AOR = .49). Combined interventions in direct and indirect community violence analyses demonstrated that children reporting a higher number of strategies were less likely to have experienced community violence. This outcome extends the results of longitudinal studies in South Africa highlighting social protection with care as a means to overcome structural deprivation strains, thereby reducing the likelihood of children's exposure to community violence. Moreover, these findings uphold the INSPIRE model as an effective cross-sectoral approach to prevent and reduce the community violence that children experience.

Infertility and its treatment via in-vitro fertilization (IVF) represent a global health area of increasing importance. However, the physical and psychological burden of IVF can negatively impact psychological wellbeing, as well as treatment retention and success. Social support has been found to have positive health effects among populations facing health-related stressors worldwide, and its potential protective role for IVF patients merits further attention. We present a protocol for a systematic review of peer-reviewed published studies quantitatively investigating associations between social support and i) mental health; ii) the decision to (dis)continue with IVF treatment cycles and; iii) IVF success (pregnancy and birth rates); among individuals who are undertaking or have undertaken IVF cycles. Studies will be included if they work with human subjects, provide correlation coefficients between measures of social support and at least one of the outcomes of interest, and are in the English language. Social support may derive from both naturally occurring networks and more formalized sources or interventions. The protocol for this systematic review was developed according to the PRISMA-P guidelines. Ten health-, psychology- and sociology-related databases will be searched using composite search terms that include keywords for 'IVF' and 'social support'. To assess methodological quality, the authors will use a modified version of the Newcastle-Ottawa Scale. Should three or more moderate or good quality studies be identified for any one outcome of interest, correlation meta-analyses, using the Hedges-Olkin method, will be conducted to pool effect sizes and heterogeneity will be assessed. Should the number, quality and characteristics of eligible studies not allow for reliable quantitative synthesis, the authors will limit the analysis to qualitative synthesis, with a focus on implications of findings for future research and programming., Competing Interests: The authors have declared that no competing interests exist.

Background: Identifying risk and protective factors for adolescent antiretroviral therapy (ART) adherence is a public health priority, given high HIV-related mortality in this population. An area that merits further investigation is the relationship between bullying victimization, mental health problems, and ART nonadherence among adolescents living with HIV (ALHIV). However, no known studies assess effects of bullying on adolescent nonadherence or risk and protective factors that could moderate this relationship., Setting: This study investigates (1) the direct longitudinal relationship between bullying exposure and ART nonadherence, and the indirect relationship via psychological distress, and (2) potential risk and modifiable protective factors moderating these pathways, among vertically and horizontally infected ALHIV who initiated treatment across 53 public health care facilities in a South African health district., Methods: Survey data were collected at 2 time points, between 2014 and 2017, with 1046 ALHIV (94% retention). Various mediation and moderated mediation models were run as part of a staged analysis approach., Results: A significant longitudinal relationship was found between bullying victimization and nonadherence, operating indirectly through psychological distress [B = 0.07; 95% confidence interval (CI): (0.03 to 0.13)]. Moderation analyses indicated that older adolescents exposed to bullying are more at risk of nonadherence [B = 0.52; 95% CI: (0.07 to 0.97) P < 0.05], and parental monitoring is a potential protective factor buffering indirect effects of bullying on nonadherence [B = -0.22; 95% CI: (-0.42 to -0.02) P < 0.05]., Conclusions: These findings underscore the importance of interventions that address bullying and psychological distress, and strengthen parental monitoring, particularly among older ALHIV., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question., Methods: The study traced adolescents aged 10-19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents., Results: Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97-0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98-1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92-0.97, p<.0001) and anxiety (0.91, 95% CI 0.89-0.94, p<.0001) symptoms reported by adolescents., Conclusions: Findings highlight open and supportive adolescent-caregiver communication and good caregiver supervision as potential factors for guarding against mental health problems among adolescents living with HIV in South Africa. Several evidence-informed parenting programmes aim to improve adolescent-caregiver communication and caregiver supervision, and their effect on depression and anxiety among adolescents living with HIV should be rigorously tested in sub-Saharan Africa. How to improve communication in other settings, such as schools and clinics, and provide communication support for caregivers, adolescents, and service providers through these existing services should also be considered.

Despite ample evidence of the protective role of social support for mental and physical health, key gaps remain in our understanding of the pathways and mediating processes explaining these relationships in specific vulnerable populations. The author applies a theoretical framework developed by House et al. to qualitative data, collected with 24 caregivers of children living in HIV-endemic South African communities, to explore potential effects and processes linking social support to health. The data used for this analysis were part of a sequential mixed-methods research study with caregivers of children; previous survey findings ( n = 2,477) showed significant associations between more social support and better mental health and self-reported physical health. Results point to multiple pathways and biopsychosocial mediating processes possibly explaining the support-health relationship. The author develops an exploratory model to illustrate these findings, based on the House et al. framework, and discusses implications for research, interventions, and theory.

The UN has described the health, social and economic consequences of Covid-19 as a global crisis unlike any other encountered in its history. Although a pandemic of this nature was not unforeseeable, its arrival seems to have caught the world off guard, hurling us into a state of partly haphazard disaster mitigation. It has shed sharper light on the failure of global health in its current form to tackle acute and systemic challenges in a rapidly changing world, and the unequal patterns in society that leave us vulnerable. This commentary argues that, despite its devastating effects, the Covid-19 pandemic can be a longer-term positively transformative event for global health. However, this will require going beyond the development of more effective plans for health emergency preparedness, to confront the crisis in global health governance and leadership, and rethink the roles of key actors involved in world health. It ultimately calls us back to the very concept of 'global health': the values it should encompass, what we should expect from it and how we might envisage reshaping or 'co-creating' it for the future.

Background: Adolescents living with HIV may be at elevated risk of psychological problems, which are correlated with negative health outcomes. In cross-sectional research with HIV-affected adolescents, bullying victimisation and internalised HIV stigma have been associated with poorer psychological health. We extended these findings and tested longitudinal associations between bullying victimisation, internalised stigma, and mental health among adolescents living with HIV. We also tested whether relationships between bullying victimisation and psychological symptoms were mediated by internalised stigma., Method: Adolescents living with HIV (n = 1060, 10-19 years, 55% female), who had ever initiated HIV treatment in 53 public health facilities in the Eastern Cape, South Africa, were interviewed and followed up 18 months later (n = 995, 94% retention). Participants completed well-validated measures of depression, anxiety, posttraumatic stress, bullying victimisation, and internalised stigma., Results: After adjusting for baseline mental health and sociodemographic characteristics, baseline internalised stigma prospectively predicted poorer outcomes on all psychological measures. Bullying victimisation at baseline was not directly associated with any psychological measures at follow up; however, it was indirectly associated with all psychological measures via internalised stigma., Limitations: Reliance on self-report measures and poor reliability of the depression scale., Conclusions: Bullying victimisation is associated with internalised stigma, which in turn predicts psychological symptoms over time. Interventions reducing internalised stigma and associated psychological distress are needed, and these should be integrated into HIV care to ensure optimal HIV management. The implementation of bullying prevention programs may reduce internalised stigma and promote mental health among adolescents living with HIV., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Efficacious antiretroviral treatment (ART) enables people to live long and healthy lives with HIV but young people are dying from AIDS-related causes more than ever before. Qualitative evidence suggest that various forms of HIV-related discrimination and resulting shame act as profound barriers to young people's engagement with HIV services. However, the impact of these risks on adolescent retention in HIV care has not been quantified. This study has two aims: (1) to examine whether and how different types of discrimination compromise retention in care among adolescents living with HIV in South Africa; and (2) to test whether internalized stigma mediates these relationships., Methods: Between 2014 and 2017, adolescents living with HIV (aged 10 to 19) from 53 health facilities in the Eastern Cape, South Africa, were interviewed at baseline (n = 1059) and 18-month follow-up (n = 979, 92.4%), with responses linked to medical records. Data were analysed through multiple regression and mediation models., Results: About 37.9% of adolescents reported full retention in care over the 2-year period, which was associated with reduced odds of viral failure (OR: 0.371; 95% CI: .224, .614). At baseline, 6.9% of adolescents reported discrimination due to their HIV status; 14.9% reported discrimination due to HIV in their families and 19.1% reported discrimination in healthcare settings. Healthcare discrimination was associated with reduced retention in care both directly (effect: -0.120; CI: -0.190, -0.049) and indirectly through heightened internalized stigma (effect: 0.329; 95% CI: 0.129, 0.531). Discrimination due to family HIV was associated with reduced retention in care both directly (effect: -0.074, CI: -0.146, -0.002) and indirectly through heightened internalized stigma (effect: 0.816, CI: 0.494, 1.140). Discrimination due to adolescent HIV was associated with reduced retention in care only indirectly, through increased internalized stigma (effect: 0.408; CI: 0.102, 0.715)., Conclusions: Less than half of adolescents reported 2-year retention in HIV care. Multiple forms of discrimination and the resultant internalized stigma contributed to this problem. More intervention research is urgently needed to design and test adolescent-centred interventions so that young people living with HIV can live long and healthy lives in the era of efficacious anti-retroviral treatment., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Adolescents represent a growing proportion of people living with HIV worldwide and the highest risk population group for treatment attrition and AIDS-related mortality. There is an urgent need to design, implement, and test interventions that keep young people in HIV treatment and care. However, previous systematic reviews show scarce and inconclusive evidence of effective interventions for this age group. Recent years have seen an increase in focus on adolescent health and a rapidly changing programmatic environment. This systematic review article provides an evidence update by synthesizing empirical evaluations of interventions designed to improve antiretroviral therapy adherence and retention among adolescents (10-19) and youth (15-24) living with HIV, published between January 2016 and June 2018. A search of 11 health and humanities databases generated 2425 citations and 10 relevant studies, the large majority conducted in sub-Saharan Africa. These include six clinic-level interventions, one individual-level m-Health trial, and three community- or household-level interventions. Implications of their findings for future programming and research with young adults are discussed, in relation to previous reviews and the broader empirical evidence in this area. Findings highlight the need to further develop and test multi-faceted interventions that go beyond health facilities, to address broader social barriers to adherence and retention. In particular, further intervention studies with adolescents (10-19) should be a priority, if we are to retain these young people in treatment and care and aspire to achieve the United Nation's Sustainable Development Goals and 90-90-90 targets.

Introduction: This paper presents the costs and cost-effectiveness of 'Parenting for Lifelong Health: Sinovuyo Teen', a non-commercialised parenting programme aimed at preventing violence against adolescents in low-income and middle-income countries., Methods: The effectiveness of Sinovuyo Teen was evaluated with a cluster randomised controlled trial in 40 villages and peri-urban townships in the Eastern Cape of South Africa from 2015 to 2016. The costs of implementation were calculated retrospectively and models of costs at scale estimated, from the perspective of the programme provider. Cost-effectiveness analysis considers both the cost per incident of abuse averted, and cost per disability-adjusted life year averted. Potential economic benefits from the societal perspective were estimated by developing a framework of possible savings., Results: The total implementation cost for Sinovuyo Teen over the duration of the trial was US$135 954, or US$504 per family enrolled. Among the 270 families in the treatment group, an estimated 73 incidents of physical and emotional abuse were averted (95% CI 29 to 118 incidents averted). During the trial, the total cost per incident of physical or emotional abuse averted was US$1837, which is likely to decrease to approximately US$972 if implemented at scale. By comparison, the economic benefits of averting abuse in South Africa are large with an estimated lifetime saving of US$2724 minimum per case., Conclusion: Parenting programmes are a cost-effective intervention to prevent the abuse of adolescents by their caregivers in South Africa, when compared with existing violence prevention programmes and cost-effectiveness thresholds based on GDP per capita., Competing Interests: Competing interests: LDC and JIS were involved in developing the Sinovuyo Caring Families Programme for Parents and Teens, which is licensed under a Creative Commons 4.0 Noncommercial No Derivatives license.

Background: Adolescents living with HIV represent a high-risk population for suicidal ideation and attempts, especially in low-income settings. Yet little is known about risk and protective factors for suicide in this population., Methods: A moderated mediation model was employed to test for potential (a) effects of stigma on suicidal ideation and attempts, both direct and mediated through depression and (b) direct and stress-buffering effects of social support resources on depression and suicidal ideation and attempts, among 1053 HIV-positive 10-19-year-old adolescents from a resource-scarce health district in South Africa. The survey data was collected using full community sampling of 53 clinics and tracing to over 180 communities. Effects of two support resources were tested: perceived support availability from the adolescents' social network and structured clinic support groups. Stigma was measured using the ALHIV-SS scale, depression through the CDI short form and social support through items from the MOS-SS., Results: Stigma was a risk factor for depression (B = 0.295; p < 001) and for suicidal thoughts and behaviour (B = 0.185; p < .001). Only perceived support availability was directly associated with less depression (B = -0.182, p < .001). However, both perceived support availability and support group participation contributed to the overall stress-buffering effects moderating the direct and indirect relationships between stigma and suicidal thoughts and behaviour., Limitations: The data used in this study was self-reported and cross-sectional., Conclusions: Findings suggest that strengthening multiple social support resources for HIV-positive adolescents, through early clinic and community-based interventions, may protect them from experiencing poor mental health and suicidal tendencies., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Although declining in all other age groups, AIDS-related deaths among adolescents are increasing. In the context of HIV, mental health problems are associated with negative health outcomes, including non-adherence to life-saving ART. For effective programming it is essential to identify factors associated with psychological outcomes in this population. Adopting a socioecological perspective, we aimed to identify correlates of internalising and externalising symptoms in a large, representative sample of South African adolescents living with HIV. HIV-positive adolescents (n = 1060), who received care in public health facilities in South Africa's Eastern Cape, completed measures of internalising and externalising symptoms. Hypothesised correlates included HIV and health-related factors (physical health, mode of infection, medication side-effects, disclosure, stigma), health-service related factors (negative interactions with clinic staff, clinic support group), interpersonal factors (abuse, bullying victimisation, social support), parenting-related factors (orphanhood, positive parenting, parental monitoring, parent communication), as well as individual and demographic-related factors (self-efficacy, age, gender, urban/rural location, poverty). Correlates operating across a variety of contexts were identified. Bullying victimisation, self-efficacy, and positive parenting may be particularly salient intervention targets as they were associated with better outcomes on most or all mental health measures, can be addressed without directly targeting adolescents living with HIV (reducing the chances of accidental exposure and stigma), and are associated with better adolescent mental health in South Africa more generally.

Women who inject drugs are disproportionately affected by HIV and intimate partner violence (IPV); however, the link between IPV and HIV remains under-researched among substance-using women in low- and middle-income countries. This study examined associations and additive effects of different forms of IPV victimization (psychological, physical and/or injurious, and sexual) on HIV sexual risk behavior among women who inject drugs in Indonesia. Respondent-driven sampling (RDS) was used to recruit 731 women from Greater Jakarta and Bandung, West Java. RDS-II weighted prevalence of any past-year IPV was 68.9% (95% CI 65.0, 72.6) in Jakarta and 55.9% (95% CI 48.0, 63.5) in Bandung. In separate logistic regressions controlling for socio-demographic covariates, all three forms of IPV showed statistically significant associations with sexual risk behavior. After adjusting for all IPV types, psychological (OR 1.87; 95% CI 1.17, 2.99; p = 0.009) and sexual (OR 1.98; 95% CI 1.22, 3.21; p = 0.006) IPV independently predicted women's sexual risk behavior. Marginal effects models suggested that co-occurrence of multiple forms of IPV had greater adverse consequences: sexual risk behavior was reported by 64.1% of women who did not experience any IPV, but increased to 89.9% among women exposed to all three types. Comprehensive harm reduction services that integrate IPV monitoring and prevention are urgently needed to reduce both HIV and IPV.

Introduction: There are two million HIV-positive adolescents in southern Africa, and this group has low retention in care and high mortality. There is almost no evidence to identify which healthcare factors can improve adolescent self-reported retention. This study examines factors associated with retention amongst antiretroviral therapy (ART)-initiated adolescents in South Africa., Methods: We collected clinical records and detailed standardized interviews (n = 1059) with all 10- to 19 year-olds ever initiated on ART in all 53 government clinics of a health subdistrict, and community traced to include lost-to-follow-up (90.1% of eligible adolescents interviewed). Associations between full self-reported retention in care (no past-year missed appointments and 85% past-week adherence) and health service factors were tested simultaneously in sequential multivariate regression and marginal effects modelling, controlling for covariates of age, gender, urban/rural location, formal/informal housing, maternal and paternal orphanhood, vertical/horizontal HIV infection, overall health, length of time on ART and type of healthcare facility., Results: About 56% of adolescents had self-reported retention in care, validated against lower detectable viral load (AOR: 0.63, CI: 0.45 to 0.87, p = 0.005). Independent of covariates, five factors (STACK) were associated with improved retention: clinics Stocked with medication (OR: 3.0, CI: 1.6 to 5.5); staff with Time for adolescents (OR: 2.7, CI: 1.8 to 4.1); adolescents Accompanied to the clinic (OR: 2.3, CI: 1.5 to 3.6); enough Cash to get to clinic safely (OR: 1.4, CI: 1.1 to 1.9); and staff who are Kind (OR: 2.6, CI: 1.8 to 3.6). With none of these factors, 3.3% of adolescents reported retention. With all five factors, 69.5% reported retention., Conclusions: This study identifies key intervention points for adolescent retention in HIV care. A basic package of clinic and community services has the potential to STACK the odds for health and survival for HIV-positive adolescents., (© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Physical, emotional and sexual child abuse are major problems in South Africa. This study investigates whether children know about post-abuse services, if they disclose and seek services, and what the outcomes of help-seeking behaviour are. It examines factors associated with request and receipt of services. Confidential self-report questionnaires were completed by adolescents aged 10-17 (n = 3515) in South Africa. Prevalence of frequent (>weekly) physical abuse was 7.4%, frequent emotional abuse 12.4%, and lifetime contact sexual abuse 9.0%. 98.6% could name one suitable confidante or formal service for abuse disclosure, but only 20.0% of abuse victims disclosed. Of those, 72% received help. Most common confidantes were caregivers and teachers. Of all abuse victims, 85.6% did not receive help due to non-disclosure or inactivity of services, and 14.4% received help: 4.9% from formal health or social services and 7.1% through community vigilante action. Emotional abuse, sexual abuse and female gender were associated with higher odds of help-seeking. While children in South Africa showed high knowledge of available services, access to and receipt of formal services among abused children was low. Notably fewer children received help from formal services than through community vigilante action. Urgent action is needed to improve service access for child abuse victims.

Considerable attention has been provided to the potential adverse outcomes for youth in the context of HIV and AIDS. Using data from a large community-based study on the psychosocial well-being of youth affected by HIV and AIDS, this paper advances a strength-based, resiliency perspective that is centred on the construct of prosociality. Data was derived from the Young Carers South Africa Project, where a cross-sectional household survey was conducted with 2,477 child-carer pairs in an HIV endemic community in the province of KwaZulu-Natal, South Africa. Analysis in this paper focuses on a subset of 2,136 child-carer pairs. Perceptions of child prosociality were assessed using the Prosocial Scale of the Strengths and Difficulties Questionnaire (SDQ). Both child and carer responses were obtained to provide insight into the functioning of carer-child dyads. Descriptive and inferential analysis was conducted to explore ratings of child prosociality across different relational contexts affected by HIV and involving care for orphaned youths. Dual-affected households, where carers are ill with opportunistic infections and youth are orphaned due to AIDS, yielded the highest discrepancies with carers reporting low child prosociality and children self-reporting high prosociality. Carer ill health appears to play a role in differentiating child prosociality across relational contexts involving non-orphaned youth. Further research is needed to explore child prosociality as a protective mechanism in high HIV-endemic communities.

Caregiver social support has been shown to be protective for caregiver mental health, parenting and child psychosocial outcomes. This is the first known analysis to quantitatively investigate the relationship between caregiver social support and adolescent psychosocial outcomes in HIV-endemic, resource-scarce Southern African communities. A cross-sectional household survey was conducted over 2009-2010 with 2,477 South African adolescents aged 10-17 and their adult caregivers (18 years or older) in one urban and one rural community in South Africa's KwaZulu-Natal province. Adolescent adjustment was assessed using adult caregiver reports of the Strengths and Difficulties questionnaire (SDQ), which measures peer problems, hyperactivity, conduct problems, emotional symptoms and child prosocial behavior. Hierarchical linear regressions and multiple mediation analyses, using bootstrapping procedures, were conducted to assess for: (a) direct effects of more caregiver social support on better adolescent psychosocial wellbeing; and (b) indirect effects mediated by better parenting and caregiver mental health. Direct associations (p < .001), and indirect associations mediated through better parenting, were found for all adolescent outcomes. Findings reinforce the importance of social support components within parenting interventions but also point to scope for positive intervention on adolescent psychosocial wellbeing through the broader family social network.

Social support has been shown to be a protective resource for mental health among chronically ill adults and caregiver populations. However, to date no known studies have quantitatively explored the relationship between social support and depression among women caring for children in HIV-endemic Southern Africa, although they represent a high risk population for mental health conditions. Using data from a household survey with 2,199 adult female caregivers of children, living in two resource-deprived high HIV-prevalence South African communities, we conducted hierarchical logistic regression analysis with interaction terms to assess whether social support had a main effect or stress-buffering effect on depression. Findings provide evidence of stress-buffering of non-HIV-related chronic illness, but not HIV-related illness. Results reinforce the importance of social support for the mental health of chronically ill caregivers, and suggest that factors related to the specific nature of HIV/AIDS may be hindering the potential stress-buffering effects of social support among people living with the disease. Implications for future research and interventions are discussed.

Purpose: Informal family and community support deriving from social relations can play an important role in protecting mental and physical health in resource-scarce contexts and may help facilitate health service access and uptake. Yet, to date, there has been surprisingly little empirical research investigating the role of social support as a resource for health in HIV-affected Southern African communities, despite the known importance of social connectedness, high rates of physical and mental health conditions, and existing 'treatment gaps'., Methods: This paper brings together and discusses findings of multiple linked analyses, from the first large-scale explanatory sequential mixed methods research investigating the relationship between social support and health with caregiver populations in HIV-endemic South Africa., Results: Overall, findings highlight the protective role of social support for caregiver mental health, the multiple perceived psychological and behavioural mechanisms possibly explaining the relationship between social support and both mental and physical health, and gender differences in the provision, effects, and availability of support., Conclusions: Drawing from these findings and the broader literature, four potential foci for future research in Southern Africa are identified and discussed, as are implications for research design and methodologies. These involve achieving a better understanding of the following: The pathways and processes explaining common and differential effects of social support across different population groups; the potential protective role of social support for physical health; and the role of factors such as gender and social and cultural norms in shaping the relationship between social support and health. Statement of contribution What is already known on this subject? Mental and physical health are closely related. HIV increases the risk of mental health conditions. Studies mainly from high-income countries have shown social relations and support to be protective of health. What does this study add? First mixed methods research of this dimension on social support and health in Southern Africa. Highlights importance of social support for mental health among caregivers of children in HIV-endemic South Africa. Points to biological and psychological pathways explaining the support-health relationship in this sample., (© 2014 The British Psychological Society.)

Objective: Social support provided to caregivers of children has been shown to be protective for caregiver health, parenting and child psychosocial outcomes. However, little work in Southern Africa provides insight on the relationship between caregiver social support and child wellbeing. This report discusses exploratory qualitative findings from a larger mixed methods study, on caregivers' perceptions of the pathways through which received support affects their children's lives., Methods: In-depth semi-structured interviews were conducted with 24 adult primary caregivers of children (aged 10-17 years) living in an HIV-endemic resource-constrained urban South African community. Thematic analysis of the data was supported by NVivo., Results: Caregivers perceived the social support they received to positively affect their children's health and behaviour, both directly and through a positive influence on their (the caregivers') mental health, parenting and decision making. Information, advice and encouragement emerged as key types of support explaining perceived effects., Conclusion: Future research should continue to explore pathways explaining the relationship between caregiver social support and child psychosocial wellbeing with similar populations, and quantitatively investigate direct and indirect effects of potential mediating factors. Findings speak both to the importance of psychosocial support for parenting interventions and the potential to strengthen child-focused interventions through the broader family social network.

Increased caregiving burden and HIV-related disability have important implications for affected populations and health and social security systems in southern Africa. Based on a review of HIV, caregiving, and disability literature, and of existing disability models, the authors discuss the potential interrelationships between caregiving and disability in the context of HIV. They develop an exploratory model to illustrate these linkages. Co-existing experiences of disability and caregiving burden may lead to a vicious cycle of deteriorating well-being among affected households and place additional strain on social security systems. HIV may exacerbate this cycle at both a micro and a macro level. Research, policy, and practice should aim to provide more effective synergies between rehabilitation, HIV treatment, care and support, and household livelihood interventions. Particular attention should be paid to the ability of social systems to meet the specific needs of informal care providers with disability and their care recipients., (Copyright © 2014 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.)

Adults caring for children in HIV-endemic communities are at risk for poor psychological outcomes. However, we still have a limited understanding of how various HIV impacts--including caregiver's own HIV illness, responsibilities of caring for a child orphaned by AIDS, or both--affect psychological outcomes among caregivers. Furthermore, few studies have explored the relationship between stigma, HIV, and psychological outcomes among caregivers of children in HIV-endemic communities. A cross-sectional survey conducted from 2009 to 2010 assessed anxiety among 2477 caregivers of children in HIV-endemic South Africa. Chi-square tested differences in anxiety among caregivers living with HIV, caregivers of a child orphaned by AIDS, and caregivers affected with both conditions. Multivariate logistic regressions identified whether the relationship between HIV impacts and anxiety remained after controlling for socio-demographic co-factors. Mediation analysis tested the relationship between stigma, HIV, and anxiety. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were two and a half times greater among caregivers living with HIV compared to nonaffected caregivers. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were greatest among caregivers living with HIV and caring for a child orphaned by AIDS. Exposure to AIDS-related stigma partially mediated the relationship between HIV and anxiety. Interventions are needed to address caregiver psychological health, particularly among caregivers affected with both conditions of living with HIV and caring for a child orphaned by AIDS.

Caring for children can be a source of joy and fulfilment, but also a source of stress, especially for caregivers living with illness and/or coping with difficult socio-economic conditions. Risks for poor caregiver mental health are especially salient in many parts of southern Africa affected by a generalised HIV-epidemic, high rates of physical illness, difficult livelihood conditions and an increasing number of orphaned and vulnerable children in need of care. Given limited availability and low uptake of formal mental health services in South Africa, the potential protective role of informal community or "social" resources for caregiver populations requires greater attention. To our knowledge, this is the first study to quantitatively assess the relationship between social support and symptomatic anxiety among caregivers of children living in HIV-endemic southern African communities. The data are from household survey interviews with 2477 adult primary caregivers of children aged 10-17 years living in two (urban and rural) resource-deprived HIV-endemic South African communities. Hierarchical logistic regression analysis with interaction terms was conducted to assess whether HIV and other illness were significant stressors for caregiver anxiety, whether social support had main or stress-buffering protective effects on anxiety and whether gender moderated the association between social support and anxiety. Our findings showed significant main effects of social support on caregiver anxiety, but no evidence of stress-buffering effects of support or of gender moderating the support-anxiety relationship. This suggests that social support is a general mental health resource for both male and female caregivers of children in these HIV-endemic communities, regardless of whether they are facing specific stressors related to HIV or other illness. Our results highlight the importance of paying greater attention to the social environment when designing and implementing caregiver health interventions, and indicate that social support could be a valuable component of such interventions.

Families affected by HIV/AIDS in the developing world experience higher risks of psychosocial problems than nonaffected families. Positive parenting behavior may buffer against the negative impact of child AIDS-orphanhood and caregiver AIDS-sickness on child well-being. Although there is substantial literature regarding the predictors of parenting behavior in Western populations, there is insufficient evidence on HIV/AIDS as a risk factor for poor parenting in low- and middle-income countries. This paper examines the relationship between HIV/AIDS and positive parenting by comparing HIV/AIDS-affected and nonaffected caregiver-child dyads (n=2477) from a cross-sectional survey in KwaZulu-Natal, South Africa (27.7% AIDS-ill caregivers; 7.4% child AIDS-orphanhood). Multiple mediation analyses tested an ecological model with poverty, caregiver depression, perceived social support, and child behavior problems as potential mediators of the association of HIV/AIDS with positive parenting. Results indicate that familial HIV/AIDS's association to reduced positive parenting was consistent with mediation by poverty, caregiver depression, and child behavior problems. Parenting interventions that situate positive parenting within a wider ecological framework by improving child behavior problems and caregiver depression may buffer against risks for poor child mental and physical health outcomes in families affected by HIV/AIDS and poverty.

There is evidence to suggest that social support may be an important resource for the mental and physical health of caregivers and children affected by HIV/AIDS, especially in HIV-endemic areas of the developing world. Drawing from theory on social relations and health, in this paper we argue that it is important to assess not only the existence and direction of associations, but also the effects and processes explaining these. We refer to House et al's (in Annu Rev Sociol 14;293-318, 1988) theoretical framework on social support structures and processes as a guide to present and discuss findings of a systematic review of literature assessing the relationship between social support and health among caregivers living with HIV or caring for HIV/AIDS-affected children. Findings confirm the importance of social support for health among this population, but also expose the absence of empirical work deriving from the developing world, as well as the need for further investigation on the biopsychosocial processes explaining observed effects.

It is widely accepted that researchers have an obligation to inform survey participants of research results. However, there is little evidence on the effectiveness of various dissemination strategies. The emerging field of knowledge transfer and exchange (KTE) may offer insight given its focus on techniques to enhance the effectiveness of communicating evidence-based information. To date, KTE has focused primarily on information exchange between researchers and policy-makers as opposed to study participants; however, there are principles that may be relevant in this new context. This gap in the literature becomes even more salient in the context of public health research where research results can reveal particular misunderstandings or shortcomings in knowledge that threaten to severely compromise participants' health. The objective of this article is to describe how KTE principles were used to inform dissemination of results of a self-administered sexual health survey to adolescent study participants in a resource-deprived, peri-urban area of South Africa. Strategies for enhancing two-way information exchange included constructing interactive dissemination sessions led by young, isiZulu fieldworkers. We also employed techniques to create a safe space for dialogue, encouraged the shared ownership of results and crafted targeted messages. Particularly noteworthy was the benefit accrued by the research team through this process of exchange, including novel explanations for study findings and new ideas for future research.

Background: In many parts of the developing world, rural health requires focused policy attention, informed by reliable, representative health data. Yet there is surprisingly little published material to guide health researchers who face the unique set of hurdles associated with conducting field research in remote rural areas., Methods: In this paper we provide a detailed description of the key challenges encountered during health survey field research carried out in 2010 in a deep rural site in KwaZulu-Natal, South Africa. The aim of the field research was to collect data on the health of children aged 10 to 17 years old, and their primary adult caregivers, as part of a larger national health survey; the research was a collaboration between several South African and foreign universities, South African national government departments, and various NGO partners. In presenting each of the four fieldwork challenges encountered on this site, we describe the initial planning decisions made, the difficulties faced when implementing these in the field, and the adaptive strategies we used to respond to these challenges. We reflect on learnings of potential relevance for the research community., Results: Our four key fieldwork challenges were scarce research capacity, staff relocation tensions, logistical constraints, and difficulties related to community buy-in. Addressing each of these obstacles required timely assessment of the situation and adaptation of field plans, in collaboration with our local NGO partner. Adaptive strategies included a greater use of local knowledge; the adoption of tribal authority boundaries as the smallest geopolitical units for sampling; a creative developmental approach to capacity building; and planned, on-going engagement with multiple community representatives., Conclusions: We argue that in order to maintain high scientific standards of research and manage to 'get the job done' on the ground, it is necessary to respond to fieldwork challenges that arise as a cohesive team, with timely, locally-relevant, and often creative, solutions. Budgeting sufficient time and project resources for capacity building and community buy-in processes is also essential when working in remote communities unaccustomed to research. Documenting and sharing field experiences can provide valuable information for other researchers planning to conduct fieldwork in similar contexts.

A number of studies indicate that social support is associated with better health outcomes among HIV-positive caregivers of children, suggesting its potential importance for interventions aimed at safeguarding the well-being of this population. However, there is very little published literature assessing the support-health relationship or evaluating applied social support interventions with HIV-positive populations in HIV-endemic contexts of the developing world. The global literature on social support and health suggests that, in order to refine theory and improve interventions, greater attention should be paid to specific dimensions of support, such as types and sources, as well as the processes through which support may be affecting health outcomes. This article presents and discusses data from in-depth interviews with 12 HIV-positive primary caregivers of children living in an HIV-endemic, low-resourced, urban South African community. The primary aim of this qualitative work was to provide further insight into survey findings of a positive relationship between social support and self-reported general health and functioning, by exploring caregivers' personal experiences of being supported within their community, and their perceptions on how this "informal" support may be influencing their health. Our qualitative data highlight the importance of instrumental and emotional support for this population, the relevance of support provider characteristics and some of the processes or pathways that are likely explaining the support-health link. These processes include psychological factors such as mastery and hope, coping strategies and positive health behaviours. We provide recommendations for future research to further this work, and discuss implications for health interventions.

Drawing upon a sample of 1,599 adults caring for children in HIV-endemic Umlazi Township in South Africa, this cross-sectional survey investigated whether perceived social support varied among caregivers of AIDS-orphaned children (n=359) as compared to caregivers of children orphaned by other causes (n=171) and caregivers of non-orphaned children (n=1,069). Results of multivariate linear regressions indicate that caregivers of AIDS-orphaned children reported significantly lower levels of social support compared to caregivers of other-orphaned children and non-orphaned children independent of socio-demographic covariates. Caregivers of other-orphaned and non-orphaned children reported similar levels of social support. In terms of sources of support, all caregivers were more likely to draw support from family and significant others rather than friends. These findings indicate a need to develop interventions that can increase levels of social support for caregivers of AIDS-orphaned children, particularly networks that include friends and significant others.

The value of collaborative international research in addressing global public health challenges is increasingly recognized. However, little has been written about lessons learned regarding fieldwork to help guide future collaborative efforts. Through a research partnership between two Northern universities, one Southern university, and a Southern faith-based organization, we evaluated a school-based HIV prevention intervention with South African adolescents. In this article, we highlight the seven key fieldwork-related challenges experienced and identify the lessons learned. The underlying theme is that of reconciling a structured and reasoned "desk" planning process with the more fluid and unpredictable reality of conducting fieldwork. This concern is particularly significant in resource-deprived environments and/or contexts that are less familiar to Northern partners. Fieldwork is unpredictable, but obstacles can be minimized through meaningful participation in both planning and field research. Sharing practical lessons from the field can prove a useful resource for both researchers and practitioners.

This study represents the first qualitative exploration of how condoms are perceived by at-risk youth, their parents, their teachers and HIV prevention programme staff in an abstinence-plus HIV prevention programme. Behavioural interventions for HIV prevention with youth may be divided into three categories, each with a different approach to condoms: abstinence-only, abstinence-plus and comprehensive approaches. Research has highlighted the limitations of abstinence-only approaches and the emergence of early support for abstinence-plus interventions as HIV prevention strategies. Furthermore, research consistently demonstrates that condoms are socially mediated, reflecting diverse norms. However, there is a gap in the literature in terms of how condom use is framed, understood and represented by those delivering and receiving an abstinence-plus programme. This is critically important because advocates of a comprehensive approach to HIV prevention have flagged concern with the degree to which abstinence-plus programming may undermine confidence in condom use. Therefore, this study analyses meanings attached to condom use by stakeholders in an abstinence-plus HIV prevention programme in South Africa. Results demonstrate diverse meanings attached to condom use, including: condoms as second best to abstinence; condoms as a gendered response to HIV; condoms as a source of mockery; condoms as futile in a high-prevalence setting; condoms as part of conspiracy beliefs along racial and colonial lines; and, condoms as popular in HIV prevention because they can be counted. These findings have particular bearing for abstinence-plus HIV prevention programmes, which face the double challenge of (1) engaging with condom promotion in a way that takes into account their diverse social meanings, and (2) promoting condoms within their hierarchical framework of options in a way that does not inadvertently discourage their use.

It has become evident that sexual health and HIV-risk behaviours cannot be addressed effectively without paying adequate attention to constructions of gender and sexuality. While the body of literature examining these themes is growing and becoming more nuanced, there is still a significant gap in our understanding of the relationship between gendered sexual identities and vulnerabilities to disease. In particular, few studies have explored how youths themselves perceive this relationship, and how these perceptions may differ among males and females. The purpose of this study was to investigate the differing 'gendered' perceptions of HIV risk among young women and men in a high-HIV-prevalence community in South Africa. Five focus groups were conducted with youths involved with a local school-based HIV-prevention programme in a resource-deprived, peri-urban community in KwaZulu-Natal Province. The data were recorded, transcribed, translated and thematically coded. We used a critical social science approach to inform our collaborative analysis. The findings reveal diverse understandings of the relationship between gender and HIV risk. The majority of the participants felt that females are more vulnerable to HIV as a result of gender inequalities; a minority felt that males are more vulnerable because of limited perceived control over their sex drive. Others felt that both sexes are equally vulnerable because 'the virus doesn't have a friend.' The theme of 'responsibility for spreading HIV emerged inductively from the data and also involved multiple understandings of gendered responsibility. Explicitly engaging with youths in targeted discussions on gendered HIV-related vulnerability and responsibility can offer an opportunity to challenge stereotypes and gender inequities, as well as inform interventions.

HIV and AIDS remains one of the most serious problems facing youths in many sub-Saharan African countries. Among young people in South Africa, gender is linked with a number of HIV-risk behaviours and outcomes. The literature suggests that factors such as socioeconomic status, intimate partner violence, and several psychosocial factors contribute to gendered differences in sexual behaviour among youths in South Africa. However, the existing body of literature scarcely addresses the interaction between gender, confounding factors (particularly peer norms) and sexual behaviour outcomes. This study uses a survey design (n = 809) to examine how gender and socioeconomic status moderate the effects of norms and attitudes on higher-risk sexual behaviours among secondary school learners in a low-income community in South Africa. The findings suggest that gender interacts significantly with peer norms to predict sexual behaviour. Peer norms and the experience of intimate partner violence were significantly associated with sexual risk behaviour among girls participating in the study. The article discusses both the wider implications of these findings and the implications for school-based and peer-facilitated HIV interventions.

Faith-based organisations (FBOs) are receiving growing attention for their roles in addressing HIV and AIDS in southern Africa. These roles, however, are not without philosophical challenges. Yet, to date, most references to the successes or limitations of FBOs have remained the domain of theoretical and, often, ideological debate. In this context, discussions about the roles of faith and FBOs in responding to HIV and AIDS often evoke extreme positions-either advocating for or critiquing their involvement. In place of this there is a need for empirical evidence and analyses that shed light on both the challenges and opportunities of faith-based HIV-prevention programming. This article presents a critical sociological analysis of the complexities confronting one FBO in its effort to deliver an abstinence-focused HIV-prevention programme to school-going adolescents in a poor peri-urban area of South Africa. As one aspect of a larger mixed-methods evaluation, this analysis is based on 11 focus group discussions, variously held with parents, teachers, learners and programme facilitators, in an effort to determine how and why the participants perceived the programme to work. We present and analyse four sources of tension appearing within the data which relate to the programme's faith-based orientation: a) enthusiasm for sexual abstinence despite awareness of the structural constraints; b) a dichotomous framing of behaviours (i.e. good versus bad); c) mixed messages about condoms; and d) administering faith-based programming within secular public schools. Through this analysis we aim to identify opportunities and challenges for faith-based HIV-prevention efforts more broadly. We argue that any assessment of faith-based HIV-prevention programming ought to respect and reflect its complexity as well as the complexity of the context within which it operates.

Several countries in Southern Africa now see large numbers of their population barely subsisting at poverty levels in years without shocks, and highly vulnerable to the vagaries of the weather, the economy and government policy. The combination of HIV/AIDS, food insecurity and a weakened capacity for governments to deliver basic social services has led to the region experiencing an acute phase of a long-term emergency. "Vulnerability" is a term commonly used by scientists and practitioners to describe these deteriorating conditions. There is particular concern about the "vulnerability" of children in this context and implications for children's future security. Through a review of literature and recent case studies, and using a widely accepted conceptualisation of vulnerability as a lens, we reflect on what the regional livelihoods crisis could mean for children's future wellbeing. We argue that an increase in factors determining the vulnerability of households - both through greater intensity and frequency of shocks and stresses ("external" vulnerability) and undermined resilience or ability to cope ("internal" vulnerability) - are threatening not only current welfare of children, but also their longer-term security. The two specific pathways we explore are (1) erosive coping strategies employed by families and individuals; and (2) their inability to plan for the future. We conclude that understanding and responding to this crisis requires looking at the complexity of these multiple stressors, to try to comprehend their interconnections and causal links. Policy and programme responses have, to date, largely failed to take into account the complex and multi-dimensional nature of this crisis. There is a misfit between the problem and the institutional response, as responses from national and international players have remained relatively static. Decisive, well-informed and holistic interventions are needed to break the potential negative cycle that threatens the future security of Southern Africa's children.