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A sizeable literature has shown that child marriage is associated with an increased risk for intimate partner violence (IPV). However, this research has been cross-sectional, and the temporality of the association has not been investigated. Specifically, no study has yet examined whether IPV is a predictor of child marriage and adolescent pregnancy. This study uses prospective longitudinal data on a cohort of adolescent girls from the Malawi Longitudinal Study of Families and Health to evaluate whether IPV victimization predicts child marriage or adolescent pregnancy. Using survival models, we find that adolescent girls who experienced physical IPV (measured at survey baseline, in 2017-2018) are more likely to enter child marriages (measured at survey follow-up, in 2021) (hazard ratio [HR] = 2.7 [1.44, 5.08]). Experiencing sexual IPV is also significantly associated with adolescent pregnancy (HR = 1.97 [1.16, 3.33]). These findings indicate the need for greater intervention to ensure healthy adolescent relationships, as well as further research to understand how abusive relationships shape early transitions to adulthood., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Background: A sizeable literature shows that adverse childhood experiences (ACEs) are associated with poor health outcomes in later life. However, most studies on the prevalence and predictors of ACEs have been carried out in high-income countries using cross-sectional approaches., Objective: The present study explores the prevalence and predictors of ACEs in Malawi, a low-income country, using prospective longitudinal data collected on adolescents., Participants: We use data on 1375 adolescents and their biological mothers from the Malawi Longitudinal Study of Families and Health (MLSFH). ACEs were reported by adolescents over two survey waves, in 2017-18 and 2021. Predictors were reported by mothers in 2008 and 2010., Methods: Multivariate ordinary least square and logistic regression analyses of ACEs exposure reported by adolescents on indicators of family arrangements and resources., Results: Adolescents report having been exposed to nearly seven ACEs on average. Among indicators of family arrangements and resources, the only significant predictors of cumulative ACEs exposure are polygyny (linked to parental absence) and mother's SF-12 mental health score (linked to physical abuse and witnessing domestic violence)., Conclusions: ACEs are much more prevalent in the low-income country under study than in middle- and high-income countries surveyed in prior research. Despite adversity being widespread, most indicators of family arrangements and resources highlighted in prior studies are not associated with adolescents' cumulative ACEs exposure in this context. Mothers' mental health in childhood nevertheless emerges as a significant predictor of adolescents' self-reported ACEs. These findings inform efforts aimed at preventing ACEs in high-adversity contexts., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15-19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience - International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents.

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The Adverse Childhood Experiences (ACE) cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-ACE) is a study of adolescents surveyed during 2017-2021. It provides an important opportunity to examine the longitudinal impact of ACEs on health and development across the early life course. The MLSFH-ACE cohort provides rich data on adolescents, their children and adult caregivers in a low-income, high-HIV-prevalence context in sub-Saharan Africa (SSA)., Participants: The MLSFH-ACE cohort is a population-based study of adolescents living in three districts in rural Malawi. Wave 1 enrolment took place in 2017-2018 and included 2061 adolescents aged 10-16 years and 1438 caregivers. Wave 2 took place in 2021 and included data on 1878 adolescents and 208 offspring. Survey instruments captured ACEs during childhood and adolescence, HIV-related behavioural risk, mental and physical health, cognitive development and education, intimate partner violence (IPV), marriage and aspirations, early transitions to adulthood and protective factors. Biological indicators included HIV, herpes simplex virus and anthropometric measurements., Findings to Date: Key findings include a high prevalence of ACEs among adolescents in Malawi, a low incidence of HIV and positive associations between ACE scores and composite HIV risk scores. There were also strong associations between ACEs and both IPV victimisation and perpetration., Future Plans: MLSFH-ACE data will be publicly released and will provide a wealth of information on ACEs and adolescent outcomes in low-income, HIV-endemic SSA contexts. Future expansions of the cohort are planned to capture data during early adulthood., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits., Methods: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries., Results: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics., Conclusions: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs., (© 2024. The Author(s).)

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Bhuwania 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.)

Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Dietrich 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.)

Child marriage has adverse consequences for young girls. Cross-sectional research has highlighted several potential drivers of early marriage. We analyse drivers of child marriage using longitudinal data from rural Malawi, where rates of child marriage are among the highest in the world despite being illegal. Estimates from survival models show that 26% of girls in our sample marry before age 18. Importantly, girls report high decision-making autonomy vis-à-vis the decision to marry. We use multivariate Cox proportional hazard models to explore the role of 1) poverty and economic factors, 2) opportunity or alternatives to marriage, 3) social norms and attitudes, 4) knowledge of the law and 5) girls' agency. Only three factors are consistently associated with child marriage. First, related to opportunities outside marriage, girls lagging in school at survey baseline have significantly higher rates of child marriage than their counterparts who were at or near grade level. Second, related to social norms, child marriage rates are significantly lower among respondents whose caregivers perceive that members of their community disapprove of child marriage. Third, knowledge of the law has a positive coefficient, a surprising result. These findings are aligned with the growing qualitative literature describing contexts where adolescent girls are more active agents in child marriages.

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

Adverse childhood experiences (ACEs)-including child maltreatment, witnessing violence, and household dysfunction-have been robustly associated with poor health in later life. There is also increasing evidence that those who experience childhood adversity are more likely subsequently to be victims or perpetrators of intimate partner violence (IPV). Most evidence, however, is cross-sectional and concentrated in high-income settings, and cannot be generalized to more diverse contexts. In contrast, this study assessed longitudinal relations between ACEs and IPV in a low-income country. We interviewed 1,878 adolescents in rural Malawi between 2017 and 2018 (aged 10-16) and again in 2021 (aged 13-20). Adolescents completed the Adverse Childhood Experience-International Questionnaire. Past-year physical, sexual, and emotional IPV victimization and perpetration were measured using the WHO's Violence Against Women Instrument. We estimated multivariate regression models between cumulative adversity (0-13 adversities) at baseline and IPV at follow-up among respondents who reported any romantic or sexual partnerships. The cumulative ACEs score was associated with emotional IPV victimization for boys ( OR  = 1.12 per ACE) and sexual IPV victimization for girls ( OR  = 1.18). The ACEs score demonstrated a significant association with perpetration for girls only ( OR  = 1.33 for emotional IPV). By using longitudinal data, we more rigorously demonstrated the critical role of childhood adversity in shaping later IPV behavior. There are ongoing efforts toward primary prevention of childhood adversity. Given the burden that adolescents already carry (six ACEs on average in our sample), we also need secondary interventions that can help interrupt the pathway from adversity to IPV. This calls for increased collaboration between those working to address violence against children and violence against women.

Background: When COVID-19 stay-at-home orders were instituted, there were concerns that isolation may lead to increases in domestic violence (DV). Reports of increased rates of DV during the stay-at-home period have been suggestive of this but inconsistent across different locations. We sought to complement the existing studies by characterizing changes in DV trends in US cities of Chicago, Los Angeles (LA), New York City (NYC), Philadelphia, and Phoenix using police call volume data from January 1st, 2018, through Dec 31st, 2020., Methods: The stay-at-home orders were generally instituted for most US states in the second half of March 2020. We used the call volume for the pre-COVID-19 period (Jan. 2018 to Feb. 2020) to model a forecast against the stay-at-home order period (Mar. - May 2020) and the period after lifting the order (June - Dec. 2020) using the interrupted autoregressive integrated moving average (ARIMA) time series model., Results: During the stay-at-home order, increases in mean DV calls relative to pre-COVID-19 were observed in Chicago (47.8%), Phoenix (18.4%), NYC (3.5%), and LA (3.4%), but a decrease in Philadelphia (-4.9%). After lifting the stay-at-home order, changes in mean calls relative to pre-COVID-19 remained elevated in Chicago, slightly elevated in Phoenix, and returned to baseline in NYC and LA., Conclusion: Results suggest that the stay-at-home orders may have contributed to an increase in DV calls in some cities (Phoenix, and to a smaller extent LA, NYC), but the increase seen in Chicago (and to some extent Phoenix) persisted beyond the stay-at-home order and therefore may not be attributable to the stay-at-home orders. Additional studies are needed to help explain why the association between stay-at-home orders and DV police call volume seems to only appear in some locations., (© 2022. The Author(s).)

Objective: Adverse childhood experiences have been robustly associated with poor sexual health in later life. In low-income countries, there is growing evidence that children experience greater adversity than those in higher income countries. Research suggests this may contribute to later sexual risk taking and HIV infection, though most studies to date have been cross-sectional., Design: We use longitudinal data on adolescents to examine the temporal relationship between adversity and HIV-related behavioral and biological outcomes., Methods: We interviewed 1878 adolescents living in Malawi in 2017-2018 (age 10-16) and again in 2021 (age 13-20). Adolescents completed the Adverse Childhood Experience - International Questionnaire. HIV-risk was assessed through both behavioral (e.g. condom use) and biological (HIV and herpes simplex virus 2 [HSV2] infection) outcomes. ordinary least squares (OLS) and logistic multivariate regression models are used to explore associations between adversity and HIV risk., Results: In longitudinal analyses, adverse childhood experiences (ACEs) were significantly associated with intimate partner violence and girls' behavioral risk scores only. HIV incidence was too low to model; there were no significant associations with HSV2. In cross-sectional analyses, ACEs were additionally associated with an early sexual debut, lack of condom use, a greater number of sexual partnerships, and sexually transmitted infection symptoms., Conclusions: Our findings emphasize the importance of collecting prospective data: results from longitudinal and cross-sectional analyses drew qualitatively different conclusions. Cross-sectional analyses may not be accurate representations of longitudinal processes. However, they suggest that recent adversity and distress drives HIV-related behavior, perhaps more than early adversity. Interventions that combat emotional abuse or peer violence during adolescence could potentially reduce HIV risk., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Despite women being disproportionally affected by cancer deaths at young ages, there are no global estimates of the resulting maternal orphans, who experience health and education disadvantages throughout their lives. We estimated the number of children who became maternal orphans in 2020 due to their mother dying from cancer in that year, for 185 countries worldwide and by cause of cancer-related death. Female cancer deaths-by country, cancer type and age (derived from GLOBOCAN estimates)-were multiplied by each woman's estimated number of children under the age of 18 years at the time of her death (fertility data were derived from United Nations World Population Prospects for birth cohort), accounting for child mortality and parity-cancer risk associations. Globally, there were 1,047,000 such orphans. Over half of these were orphans due to maternal deaths from breast (258,000, 25%), cervix (210,000, 20%) and upper-gastrointestinal cancers (136,000, 13%), and most occurred in Asia (48%: India 15%, China 10%, rest of Asia 23%) and Africa (35%). Globally, there were 40 new maternal orphans due to cancer per 100,000 children, with a declining trend with a higher Human Development Index (range: 121 in Malawi to 15 in Malta). An estimated 7 million children were prevalent maternal orphans due to cancer in mid-2020. Accelerating the implementation of the World Health Organization's cervical and breast cancer initiatives has the potential to avert not only millions of preventable female cancer deaths but also the associated, often-overlooked, intergenerational consequences of these deaths., (© 2022. The Author(s).)

During the early stages of the COVID-19 pandemic, almost all countries implemented school closures to prevent disease transmission. However, prolonged closures can put children at risk of leaving school permanently, a decision that can reduce their long-term potential and income. This study investigated the extent to which the COVID-19 pandemic and associated school closures reduced school attendance in Malawi, a low-income African country. We used longitudinal data from a cohort of adolescents interviewed before (2017/18; at age 10-16) and after (2021; at age 13-20) the pandemic school closures. Of those students who had been attending school prior to school closures, we find that 86% returned when schools re-opened. Dropouts were more pronounced among older girls: over 30% of those aged 17-19 did not return to school. This resulted in further lowering the gender parity index to the greater disadvantage of girls. We also found that students already lagging behind in school were more likely to dropout. Thus, our data suggest that the COVID-19 pandemic has magnified gender inequalities in schooling, at least partially erasing recent progress towards inclusive education. Urgent investments are needed to find and re-enroll lost students now, and to create more resilient and adaptable educational systems before the next pandemic or other negative shock arrives., Competing Interests: The authors declare no conflicts of interest., (© 2022 Elsevier Ltd. All rights reserved.)

A sizeable literature documents the associations between adverse childhood experiences (ACEs) and poor health in later life. By and large, ACEs are measured using retrospective self-reports. Little is known about the longitudinal consistency of these self-reports in panel data with multiple measurements. This is especially true in adolescence, as most studies using ACEs self-reports have been conducted among adults. Furthermore, very few studies have explored the consistency of ACEs self-reports in low- and middle-income countries, where the reported prevalence of ACEs tends to be higher than in high-income countries. Addressing these gaps, the current study examines the consistency of ACEs self-reports among a cohort of adolescents (N = 1,878, age 10 to 16 at survey baseline) in rural Malawi. We use data from two waves of the ACE project of the Malawi Longitudinal Study of Families and Health carried out in 2017-18 and 2021. In addition to the high prevalence of self-reported ACEs among adolescents in our sample, we document very low consistency of self-reports over time (average Kappa coefficient of 0.11). This low consistency is attributable not only to adolescents reporting more ACEs over time, which could be due to new exposures, but also to adolescents reporting fewer ACEs over time. Analyses of survey vignettes indicate that individual and sociocultural perceptions of abuse do not explain this low consistency. We find that external events (such as changes in socioeconomic status and negative economic shocks) and internal psychological states (such as depression and post-traumatic stress disorder) both predict inconsistencies in ACEs self-reports. Compared with results from prior studies, our findings indicate that the longitudinal consistency of ACEs self-reports may be lower in adolescence than in adulthood. Taken together, these findings suggest that ACEs self-reports provided by adults may be biased by key processes unfolding in adolescence., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors.)

We provide new evidence of the association between moderate negative economic shocks in utero or shortly after birth and adolescents' cognitive outcomes and educational attainment in Malawi. This is one of the first studies to analyze the effect of not one, but multiple moderate negative economic shocks in a sub-Saharan African (SSA) low-income country (LIC). This focus is important as multiple economic shocks in early life are more representative of the experiences of adolescents in LICs. Combining data on adolescents aged 10-16 from the Adverse Childhood Experiences (ACE) project with the Malawi Longitudinal Study on Families and Health (MLSFH) ( N  = 1, 559) , we use linear and probit regression models to show that girls whose households experienced two or more economic shocks in their year of birth have lower cognitive scores, which are measured using working memory, reading and mathematical tests. Girls also have lower educational attainment, conditional on age. These effects are gendered, as we do not observe similar effects among boys. Overall, our results point to lasting effects of early-life adversity on adolescents, and they highlight that, even in a LIC context where early-life adversity is common, policymakers need to intervene early to alleviate the potential long-term educational impacts of in utero or early life shocks among girls., Competing Interests: The authors have no relevant financial or non-financial interests to disclose., (© 2022 The Authors.)

Competing Interests: We declare no competing interests.

Objective: We evaluate whether community norms, caregiver beliefs, and adolescents' own beliefs and perceptions, focused on early marriage, predict adolescent marriage aspirations in a low-income context., Background: The processes that contribute to adolescent marriage aspiration formation have received little attention in low-income contexts, particularly sub-Saharan Africa. Understanding how marriage aspirations are formed is important because they are associated with critical education and health outcomes., Method: Using data that links Malawian adolescents (N=2,089) with their caregivers (N=1,452), we analyze gender stratified ordered logistic regression models to examine key relationships., Results: We show that community norms for youngest acceptable marriage age predict when boys want to marry, but do not find conclusive evidence that they predict when girls want to marry. We also show that adolescents who believe it is acceptable to marry at an early age are more likely to want to marry early themselves., Conclusion: Both community norms and adolescents' own beliefs are central to the formation of their marriage aspirations., Implications: We recommend that programs incorporate adolescent beliefs and perceptions when designing child marriage interventions and measuring their impact. We also recommend theory-driven measurement of community norms to better evaluate their impact on both marriage aspirations and marriage age.

Over three million youth live with HIV worldwide. Very little is known about whether youth disclose their HIV status to family, friends or sexual partners, and what risks and benefits may accrue from doing so. This study characterizes HIV disclosure among 250 youth with perinatally-acquired HIV (PHIV; age 13-24 years) living in Soweto, South Africa. A third had self-disclosed their HIV status to at least one person; similarly, only a third of sexually-active PHIV had disclosed their HIV status to their most recent partner. It is not clear whether HIV disclosure alone leads to positive impact: we found perceived social support from the family was negatively associated with disclosure (aOR 0.81, 95% 0.70-0.94). PHIV who spoke to a provider about disclosure were more likely to share their HIV status with a sexual partner (aOR 2.48; 95% CI 1.28-4.81). However, those PHIV who disclosed their status were no more likely to use a condom. The World Health Organization recommends that health providers advise adolescent patients on safe disclosure, but we still lack evidence on the consequences for young people and effective tools to help them weigh benefits and risks.

Background: HIV testing remains low among adolescents. Making public health services more adolescent-friendly is one strategy used to encourage testing. However, it remains unclear whether government-led initiatives have a meaningfully impact., Methods: The current study is observational and utilizes two sources of data (health-facility and adolescent-level) from one round of data collection of an on-going, longitudinal impact evaluation of a pilot cash plus program targeting adolescents. This study linked data from adolescent surveys (n = 2191) to data collected from nearby government-run health facilities (n = 91) in two rural regions of Tanzania. We used log binomial regression models to estimate the association between specific adolescent-friendly health service (AFHS) characteristics and adolescents' uptake of 1) HIV testing and 2) visiting a health care facility in the past year for sexual and reproductive health (SRH) services., Results: Most adolescents (67%) lived in a village with a health facility, and all offered HIV services. We find, however, that AFHS have not been fully implemented. For example, less than 40% of facilities reported that they had guidelines for adolescent care. Only 12% of facilities had a system in place for referral and follow-up with adolescent clients, yet this was an important predictor of both past-year HIV testing (RR = 1.28, p < 0.1) and SRH visits (RR = 1.44, p < 0.05). Less than half (44%) offered services for survivors of gender-based violence (GBV), a significant predictor of past-year HIV testing (RR = 1.20, p < 0.05) and SRH visits (RR = 1.41, p < 0.01) among sexually-active adolescents., Conclusions: We find that national guidelines on AFHS have not been fully translated into practice at the local level. We highlight particular gaps in adolescent referral systems and GBV services. Scaling up these two essential services could encourage greater HIV testing among a high-risk population, in addition to providing much needed support for survivors of violence.

Over a third of new HIV infections occur in adolescents aged 10-19 globally. Pre-exposure prophylaxis (PrEP) could be a powerful tool for prevention. Understanding more about the drivers of PrEP interest could inform implementation strategies among this age group. Moreover, family dynamics may play a uniquely critical role for this younger age group, thus it is important to gauge whether caregivers would support their children's use of PrEP. We surveyed 2,089 adolescents (aged 10-16) and their caregivers in Malawi during 2017-2018. Data were collected on PrEP interest, factors that may facilitate PrEP use, and preferences for PrEP modality. We used multivariate logistic regression to estimate the association between the above characteristics and PrEP interest. We find that young adolescents are engaging in behaviors that would put them at substantial risk of acquiring HIV, would likely benefit from PrEP, are largely (82%) interested in using such, would prefer to get an injection over taking a daily pill, and are considerably discouraged by the prospect of side effects. Endorsement by caregivers was even greater (87%). Our findings demonstrate initial support for adolescent PrEP, and suggest parents may be a surprising advocate.

Background: Intimate partner violence (IPV) is prevalent in high- as well as low-income contexts. It results in a substantial public health burden and significant negative socioeconomic and health outcomes throughout the life-course. However, limited knowledge exists about IPV during early adolescence. This period is critical during the transition to adulthood for at least two reasons: it is when the majority of adolescents in low-income countries first encounter dating, sexuality and partnerships, often with older adolescents or adults, and it is also the period when lifelong patterns of violence and norms about acceptable IPV are formed. The current study is one of the first to measure IPV prevalence among young adolescents in a low-income setting, examine the potential etiology, and investigate relationships with gender ideology, poverty, mental health and childhood adversity., Methods: We surveyed 2,089 adolescents aged 10-16 in Malawi using standardized instruments. We estimated the prevalence of IPV, and use multivariate logistic regression to test potential correlates., Results: More than a quarter (27%) of ever-partnered adolescents in Malawi report being victimized. A substantial proportion of both male and female adolescents (15%) report committing violence against their partner. Girls were more likely than boys to report being a victim of sexual IPV (24% versus 8%), and boys more likely to perpetrate such (9% versus 1%). Almost 10% of the sample had both committed and been a victim of IPV. Cumulative childhood adversity (e.g., physical abuse, witnessing domestic violence) was a consistent and strong correlate of IPV victimization (adjusted odds ratio (aOR) 1.30) and of perpetration (aOR 1.35). Depression and PTSD were likewise associated with IPV victimization in the overall sample. Notably, gender ideology was not predictive of either victimization or perpetration, even among boys., Conclusions: IPV is common for both male and female young Malawian adolescents, and includes both victimization and perpetration. IPV compounds other adversities experienced by adolescents in this low-income setting, and it is rarely alleviated through help from the health system or other formal support. These findings underscore the need to intervene early when interventions can still break destructive pathways and help foster healthier relationships. This focus on early adolescence is particularly critical in low-income countries given the early onset and rapid pace of the transition to adulthood, with sexual activity, dating and partnership thus being common already in young adolescence. Promising interventions would be those that reduce violence against or around children, as well as those that reduce the impacts of such trauma on mental health during adolescence., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Childhood adversity is robustly associated with poor health across the life course. However, very few studies have examined the prevalence and implications of adverse childhood experiences in low- and middle-income countries. The objective of this study is to measure adverse childhood experiences among adolescents in Malawi and examine the association with mental and physical health outcomes., Methods: From 2017 to 2018, baseline data were collected among adolescents aged 10-16 years (n=2,089). Respondents were interviewed in their local language at their homes. Respondents completed questions on childhood adversity (Adverse Childhood Experiences-International Questionnaire), self-rated health, mortality expectations, and mental health (Beck Depression Inventory and Post-Traumatic Stress Disorder Scale). Stunting, obesity, and grip strength were measured. Analyses were conducted in 2018. Frequencies described the prevalence of adverse childhood experiences, and adjusted multivariate models examined whether cumulative adversity predicts current health., Results: Adolescents reported a high burden of adversity (i.e., 5 lifetime adverse childhood experiences on average). Adolescents who scored in the top adverse childhood experiences quintile were more likely to report depression (OR=3.11, 95% CI=2.10, 4.60), post-traumatic stress disorder (OR=4.19, 95% CI=2.43, 7.23), worse self-rated health (OR=3.72, 95% CI=2.03, 6.81), and a higher expected likelihood of dying in the next 5 years (RR=5.02, 95% CI=2.15, 7.88) compared with those in the bottom quintile. However, adverse childhood experiences did not demonstrate a graded relationship with obesity, stunting, or grip strength., Conclusions: These patterns are quite consistent with evidence from high-income countries and suggest that primary prevention of adverse childhood experiences should be a priority to ensure lifelong health in low-resources settings., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate whether adverse childhood experiences are important determinants of sexual debut and HIV testing., Design: Adolescents (age 10-16; N = 2089) from rural Malawi were interviewed in 2017-2018 for the baseline wave of a longitudinal study of childhood adversity and HIV risk., Methods: Respondents were interviewed in their local language. Surveys captured 13 lifetime childhood adversities (using the Adverse Childhood Experience - International Questionnaire); sexual debut; and previous HIV testing. We used multivariate regression models to test whether adversity, measured both cumulatively and separately, predicted HIV risk., Results: For each additional adversity, there was a significant rise in the odds of sexual debut (odds ratio 1.13, confidence interval 1.07-1.20) and HIV testing (odds ratio 1.10, confidence interval 1.04-1.16)., Conclusion: Preventing HIV among all young people necessitates a paradigm shift that recognizes the importance of early life social determinants in structuring HIV risk.

A strong and consistent association between migration and health has been found in many settings, but the overwhelming focus of this research has been on adults. In addition, identifying the effect of migration on health largely remains an unresolved challenge, due in part to the inability to distinguish between the effect of migration on health and the selection of children of differing health status into migration streams. In this research we examine the relationship between internal migration and child health in Malawi. We use longitudinal panel data with pre- and post-migration health measures for children and their mothers, which permits us to measure both migration health selection and the effect of migration on health. We also examine if child health changes over time in post-migration destinations. We do not find evidence of migration health selection: children who move have similar pre-migration health status to non-migrant children. We find that the impact of migration on child health is mediated by mothers' characteristics. Before controlling for mothers' health status, we find a strong negative impact of migration on health, particularly for children moving to rural areas or cities, and children moving due to changes in mothers' marital status. After controlling for mothers' health status, however, the negative impact of migration on child health disappears. We also find that child health is worse with longer durations spent in post-migration residence, compared to children who don't move., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Adverse childhood experiences (ACEs) can have lifelong adverse impacts on health and behavior. While this relationship has been extensively documented in high-income countries, evidence from lower-income contexts is largely missing. In order to stimulate greater research on the prevalence and consequences of ACEs in low-income countries, the World Health Organization (WHO) developed the ACE-International Questionnaire (ACE-IQ)., Objective: In this paper, we explore the factor structure, validity and reliability of the original ACE-IQ, and evaluate whether potential adaptations improve its predictive validity., Participants and Setting: Four hundred and ten adolescents (age 10-16 years old) from Malawi., Methods: The adolescents answered an adapted version of ACE-IQ and Beck Depression Inventory (BDI)., Results: Taken together, our results suggest that (a) the ACE-IQ is structured in three dimensions: household disruption, abuse, and neglect; (b) there is support for the validity of the scale evidenced by the correlation between subdimensions (average across 13 correlations, phi = .20, p < 0,01; across subdomains (phi = .10, p < 0,01); partial agreement among children with the same caregiver (ICC = .43, p < .001) and correlation between ACE and depression (predictive validity; r = .35, p < .001); (c) information on the timing of the adversities ("last year" in addition to "ever") modestly improved the predictive value of the ACE-IQ in models of depression (from R 2  = .12 to .15, p < .001); and (d) additional HIV-related questions showed low endorsement and a modest correlation with BDI (r = .25, p < 0,01)., Conclusion: Our findings suggest that the ACE-IQ is appropriate for use among adolescents from a low-income context., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

A growing population of youth who acquired HIV from their mothers are surviving into adulthood. This group is unique in that they experience both internalized stigma (due to their HIV status) and associative stigma (due to their mothers' HIV status). Results of a cross-sectional survey of 250 perinatally HIV-infected South African youth suggests that internalized stigma is associated with greater risk of depression, and associative stigma is associated with greater risk of depression and substance use problems. Interventions currently focus on internalized stigma; this study highlights the importance of also addressing associative stigma to improve outcomes among perinatally HIV-infected youth.

The Sustainable Development Goals set ambitious targets for health. Meeting such will require drastic improvements in the social conditions for women and girls. Understanding which social conditions have the greatest impact on health can help prioritise action, yet there is little comparative data. We use microdata from 338,580 women in 47 low- and middle-income countries to estimate the relative contributions of improved social determinants in bringing about maternal and child health gains over the past 20 years. Regression analyses examine determinants related to education, work, health services, family, and violence; the potential health benefit that could be derived from improving conditions is calculated. Secondary education and child marriage emerge as the strongest and most consistent predictors of health. The largest impact is seen on adolescent births: we estimate that achieving universal completion of secondary schooling for young women could lower adolescent births by 18 percentage points; eliminating child marriages could lower adolescent births by 11 points. Intervening in these two areas could also bring about substantial reductions in the unmet need for family planning, past-year intimate partner violence, and child mortality. Thus, we suggest prioritising policies targeting secondary education and child marriage in order to accelerate gender equity and health.

Repeated exposure to childhood adversity (abuse, neglect and other traumas experienced before age 18) can have lifelong impacts on health. For HIV-infected adolescents and youth, such impacts may include onward transmission of HIV. To evaluate this possibility, the current study measured the burden of childhood adversity and its influence on risky health behaviors among perinatally-infected adolescents and youth. We surveyed 250 perinatally-infected adolescents and youth (13-24 years) receiving care in Soweto, South Africa. Both male and female participants reported on childhood adversity (using the ACE-IQ), sexual behavior, and psychosocial state. Viral load was also abstracted from their charts. We used logistic regressions to test the association between cumulative adversity and behavioral outcomes. Half the sample reported eight or more adversities. Overall, 72% experienced emotional abuse, 59% experienced physical abuse, 34% experienced sexual abuse, 82% witnessed domestic violence, and 91% saw someone being attacked in their community. A clear gradient emerged between cumulative adversities and behavioral risk. Having experienced one additional childhood adversity raised the odds of risky sexual behavior by almost 30% (OR 1.27, 95% CI 1.09-1.48). Viral suppression was poor overall (31% had viral loads >400 copies/ml), but was not related to adversity. Adversity showed a robust relationship to depression and substance abuse. Childhood adversity is common, influences the current health of HIV-positive adolescents and youth, and puts their sexual partners at risk for HIV infection. Greater primary prevention of childhood adversity and increased access to support services (e.g., mental health) could reduce risk taking among HIV-positive adolescents and youth., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: As perinatal HIV-infected youth become sexually active, the potential for onward transmission becomes an increasing concern. In other populations, intimate partner violence (IPV) is a risk factor for HIV acquisition. We build on this critical work by studying the role of IPV in facilitating onward transmission among HIV-infected youth-an important step toward effective intervention., Setting: Soweto, South Africa., Methods: Self-report surveys were completed by 129 perinatal HIV-infected female youth (aged 13-24 years). We calculated the IPV prevalence and used logistic models to capture the association between IPV and health outcomes known to facilitate onward HIV transmission (eg, risky sex, poor medication adherence, depression, and substance abuse)., Results: A fifth of perinatal HIV-infected participants reported physical and/or sexual IPV in the past year; one-third reported lifetime IPV. Childhood adversity was common and positively associated with IPV. Past-year physical and/or sexual IPV was positively correlated with high-risk sex [odds ratio (OR) = 8.96; 95% confidence interval (CI): 2.78 to 28.90], pregnancy (OR = 6.56; 95% CI: 1.91 to 22.54), poor medication adherence to antiretroviral therapy (OR = 5.37; 95% CI: 1.37 to 21.08), depression (OR = 4.25; 95% CI: 1.64 to 11.00), and substance abuse (OR = 4.11; 95% CI: 1.42 to 11.86). Neither past-year nor lifetime IPV was associated with viral load or HIV status disclosure to a partner., Conclusions: We find that IPV may increase risk for onward HIV transmission in perinatal HIV-infected youth by both increasing engagement in risky sexual behaviors and lowering medication adherence. HIV clinics should consider integrating primary IPV prevention interventions, instituting routine IPV screening, and collocating services for victims of violence.

Purpose: Why do orphans have higher rates of HIV infection than nonorphaned peers? Research consistently assumes that orphans acquire HIV primarily through sexual behavior, but infections may instead be due to maternal transmission. Although these two pathways have very different implications for HIV programs and policies, their relative contribution has not been previously examined. In this research, we compare the contribution of maternal and sexual transmission to HIV infection among orphans in Africa., Methods: We use Demographic and Health Survey data for 21,463 women and 18,359 men from 17 countries. We propose a conceptual framework linking orphanhood to HIV, and use mediation analysis and structural equation modeling to compare the potential contribution of maternal transmission (measured through direct pathways from orphanhood to HIV) and sexual transmission (measured through reports of risky sexual behavior) to orphan HIV infection., Results: Our results suggest that maternal transmission is the predominant pathway of HIV infection among orphaned adolescents: there is strong evidence for a direct pathway from maternal (odds ratio [OR]: 2.45; 95% confidence interval [CI]: 1.72-3.51 for females and OR: 2.45; 95% CI: 1.53-3.90 for males) and double orphanhood (OR: 2.69; 95% CI: 1.97-3.66 and OR: 2.53; 95% CI: 1.68-3.82, respectively) to HIV; greater excess HIV risk in maternal versus paternal orphans. The contribution of sexual behavior is largely not significant. We do not observe correspondingly high orphan disparities in other sexually transmitted diseases., Conclusions: Maternal transmission is a more likely explanation than sexual transmission for heightened HIV infection among orphans. These results suggest that programs designed to address HIV infection among adolescents should focus on reducing maternal transmission and on identifying and testing undiagnosed HIV among orphans., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: : Studies in South Asia suggest that child marriage is a strong risk factor for intimate partner violence (IPV), but evidence outside the region is lacking., Methods: : This study uses standardized data from demographic and health surveys in 34 countries to test the hypothesis that young women (age 20-24) who married as children are at increased risk of past year physical and/or sexual IPV as compared with those women who married as adults., Results: : Globally, 9% of respondents were married before they turned 15; another 25% were married between the ages of 15 and 17. Past year physical and/or sexual IPV was higher among women who married as children (29%) compared with those who married as adults (20%). This difference persisted in logistic regression models that adjust for sociodemographic characteristics [odds ratio (OR) 1.41 (1.30-1.52) for marriage before 15, and 1.42 (1.35-1.50) for marriage at 15-17]. However, there was considerable heterogeneity between countries: marriage before age 15 was associated with a combined measure of past year physical and/or sexual IPV in nine countries; women married between 15 and 17 were at increased risk of physical and/or sexual IPV in 19 countries. This heterogeneity was most evident in sub-Saharan Africa, and warrants further investigation in so far as it may help identify protective policies and norms., Conclusion: : Substantial reductions in IPV will likely require interventions to combat child marriage itself and to protect women from IPV within child marriages., (© The Author 2016; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association)

Background: Despite extensive resources and numerous programmes directed towards orphans in sub-Saharan Africa, evidence of their disadvantage is surprisingly limited. While initial research suggests that orphans are at greater risk of being HIV-positive, the evidence is limited in geographic scope., Methods: To rigorously test disparities in HIV prevalence related to orphanhood and parental HIV status in sub-Saharan Africa, we used Demographic and Health Survey data from 19 countries in sub-Saharan Africa. We conducted pooled multilevel logistic regression on adolescents aged 15-17 years with HIV test results (N=22 837 girls and 20 452 boys)., Results: Regardless of their gender, orphans who lost their mother, lost both parents or had an HIV-infected mother were two to three times more likely to test positive for HIV infection (ORs 1.87-3.17). The loss of a father was also associated with HIV infection risk for females, but of slightly lower magnitude (OR 1.63)., Conclusions: To better inform interventions, future research is needed to quantify the relative contribution of perinatally-acquired and sexually-acquired infections, and to investigate the specific mechanisms that may account for disparities in the latter. In the meantime, programmes serving HIV-infect adults as well as those serving orphaned and vulnerable children should invest in family-based HIV testing in order to identify adolescents in need of treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

In the wake of the HIV/AIDS epidemic, caregivers are struggling to support HIV-affected children. For reasons of equity and efficiency, their needs can be best met through strong social protections and policies. This paper presents a conceptual framework to help address the needs of HIV-affected caregivers and to prioritize policies. We describe the needs that are common across diverse caregiving populations (e.g., economic security); the needs which are intensified (e.g., leave to care for sick children) or unique to providing care to HIV-affected children (e.g., ARV treatment). The paper then explores the types of social policies that would facilitate families meeting these needs. We outline a basic package of policies that would support HIV-affected families, and would meet goals agreed to by national governments. We examine the availability of these policies in 25 highly affected countries in sub-Saharan Africa. The majority of countries guarantee short-term income protection during illness, free primary school, and educational inclusion of children with special needs. However, there are significant gaps in areas critical to family economic security and healthy child development. Fewer than half of the countries we analyzed guarantee a minimum wage that will enable families to escape poverty; only six have eliminated tuition fees for secondary school; and only three offer paid leave to care for sick children. Filling these policy gaps, as well as making mental health and social services more widely available, is essential to support caregiving by families for HIV-affected children. As part of the HIV agenda, the global community can help national governments advance towards their policy targets. This would provide meaningful protection for families affected by HIV, as well as for millions of other vulnerable families and children across the region.

There are compelling reasons to believe that orphans - many millions due to the AIDS epidemic - are more likely to be sexually victimized during childhood. Few studies have empirically investigated sexual violence disparities, and those that do suffer from methodological limitations and limited geographic scope. We used nationally representative data on female adolescents (15-17 years) from 13 countries in sub-Saharan Africa. We built multilevel logistic models to test for an association between the dependent variables (orphanhood and parental absence) and sexual violence, both within countries and pooled across all countries. Approximately 10% of adolescent girls reported past experiences of sexual violence; a third of those victimized were 14 years or younger at the time of their first forced encounter. Paternal orphaning (OR 1.36, p≤0.01), double orphaning (OR 1.47, p≤0.05), and paternal absence (OR 1.28; p≤0.05) were significantly associated with experiencing sexual violence in pooled analyses. Fewer findings reached significance within individual countries. Our findings suggest that the lack of a father in the home (due to death or absence) places girls at heightened risk for childhood sexual abuse; further research identifying pathways of vulnerability and resilience specific to this population is needed. Our findings also indicate that abuse often starts at an early age; thus promising programs should be adapted for younger age groups and rigorously tested., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

HIV places acute stressors on affected children and families; especially in resource limited contexts like sub-Saharan Africa. Despite their importance, the epidemic's potential consequences for family dynamics and children's psychological health are understudied. Using a population-based sample of 2,487 caregivers and 3,423 children aged 8-14 years from the Central Province of Kenya, analyses were conducted to examine whether parental illness and loss were associated with family functioning and children's externalizing behaviors. After controlling for demographics, a significant relationship between parental illness and externalizing behaviors was found among children of both genders. Orphan status was associated with behavioral problems among only girls. Regardless of gender, children experiencing both parental loss and illness fared the worst. Family functioning measured from the perspective of both caregivers and children also had an independent and important relationship with behavioral problems. Findings suggest that psychological and behavioral health needs may be elevated in households coping with serious illness and reiterate the importance of a family-centered approach for HIV-affected children.

Intimate partner violence (IPV) has been found to be negatively associated with contraceptive use in developing countries, but evidence from Africa is mixed. This study examines whether the above association differs in conflict settings, which have the potential for both higher levels of violence and more limited access to family planning. We use nationally representative data from the Democratic Republic of the Congo to examine the relationship between individual- and community-level IPV and modern contraceptive use, and to explore whether conflict modifies the relationship between IPV and contraceptive use. Nationally, only 6% of women reported current modern contraceptive use, while 53% reported experiencing physical IPV and 32% reported experiencing sexual IPV. In multivariate models, we found that individual-level sexual IPV was positively associated with current using modern contraceptive use, but that a combined measure of physical and sexual IPV did not demonstrate a similar association. Community-level IPV was not associated with individual-level contraceptive use. Conflict exposure was neither an independent predictor nor modifier of contraceptive use. Results suggest improved access to family planning should be a priority for programming in DRC, and efforts should ensure that sufficient resources are allocated towards the reproductive health needs of women in both conflict and non-conflict regions., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Context: Although a substantial literature suggests that orphans suffer disadvantage relative to nonorphaned peers, the nature of this disadvantage and the mechanisms driving it are poorly understood. Some evidence suggests that orphans experience elevated fertility, perhaps because structural disadvantage leads them to engage in sexual risk-taking. An alternative explanation is that orphans intentionally become pregnant to achieve a sense of normality, acceptance and love., Methods: Data from the 2006 wave of the Malawi Longitudinal Study of Families and Health on 1,033 young adults aged 15-25 were used to examine the relationship of maternal and paternal orphanhood with sexual risk indicators and desired and actual fertility. Regression analyses were used to adjust for covariates, including social and demographic characteristics and elapsed time since parental death., Results: Twenty-six percent of respondents had lost their father and 15% their mother. Orphanhood was not associated with sexual risk-taking. However, respondents whose mother had died in the past five years desired more children than did those whose mother was still alive (risk differences, 0.52 among women and 0.97 among men). Actual fertility was elevated among women whose father had died more than five years earlier (0.31) and among men whose mother had died in the past five years (1.06) or more than five years earlier (0.47)., Conclusion: The elevations in desired and actual fertility among orphans are consistent with the hypothesis that orphans intentionally become pregnant. Strategies that address personal desires for parenthood may need to be part of prevention programs aimed at orphaned youth.

Home visiting is a popular component of programs for HIV-affected children in sub-Saharan Africa, but its implementation varies widely. While some home visitors are lay volunteers, other programs invest in more highly trained paraprofessional staff. This paper describes a study investigating whether additional investment in paraprofessional staffing translated into higher quality service delivery in one program context. Beneficiary children and caregivers at sites in KwaZulu-Natal, South Africa were interviewed after 2 years of program enrollment and asked to report about their experiences with home visiting. Analysis focused on intervention exposure, including visit intensity, duration and the kinds of emotional, informational and tangible support provided. Few beneficiaries reported receiving home visits in program models primarily driven by lay volunteers; when visits did occur, they were shorter and more infrequent. Paraprofessional-driven programs not only provided significantly more home visits, but also provided greater interaction with the child, communication on a larger variety of topics, and more tangible support to caregivers. These results suggest that programs that invest in compensation and extensive training for home visitors are better able to serve and retain beneficiaries, and they support a move toward establishing a professional workforce of home visitors to support vulnerable children and families in South Africa.

The AIDS epidemic has created an unprecedented number of orphans. While largely absorbed by extended family, this additional responsibility can weigh heavily on their caregivers. The concept of caregiver burden captures multiple dimensions of well-being (e.g., physical, social and psychological). Measuring the extent and determinants of caregiving burden can inform the design of programmes to ease the negative consequences of caregiving. This study uses the baseline data from a study assessing interventions for orphans and vulnerable adolescents in the Eastern Cape, South Africa. Orphan caregivers ( n = 726) completed an adapted version of the 12-item Zarit Burden Interview. In addition to basic caregiver and household demographics, the survey also collected information on AIDS-related illness and recent deaths. Descriptive data are presented, followed by multivariate Poisson regression models to explore factors associated with caregiver burden. Approximately 40% of caregivers reported high levels of orphan caregiving burden. Feelings of stress and inadequacy concerning their care responsibilities as well as anger towards the child were common. Household food insecurity was the most important predictor of orphan caregiving burden (marginal effect = 7.82; p < 0.001 for those reporting severe hunger); income was also a significant determinant. When other AIDS impacts were added to the model, only the AIDS-related illness of the caregiver was significantly associated with burden (marginal effect = 3.77; p < 0.001). This study suggests that caregivers with economic vulnerability and those struggling with their own AIDS-related illness feel most overburdened. These findings are particularly relevant to service providers who must identify caregivers in need of immediate assistance and allocate limited resources effectively. To alleviate caregiver burden, programmes must foster greater economic security (e.g., by facilitating access to social grants or directly providing cash transfers) and coordinate services with home-based care programmes serving the chronically ill.

Children and families affected by HIV are at considerable risk for psychological distress. Community-based home visiting is a common mechanism for providing basic counseling and other services to HIV-affected families. While programs emphasize home visitor training and compensation as means to promote high-quality service delivery, whether these efforts result in measurable gains in beneficiaries' well-being remains largely unanswered. This study employs a longitudinal quasi-experimental design to explore whether these kinds of investments yield concomitant gains in psychological outcomes among beneficiaries. Baseline and follow-up data were collected over a two-year period from children aged 10-17 at the time of program enrollment and their caregivers, with 80% retention. In this sample of 1487 children and 918 caregivers, the psychological health outcomes of those enrolled in programs with home visitors who receive intensive training, organizational support, and regular compensation (termed "paraprofessional") were compared to those enrolled in programs offering limited home visiting services from lay volunteers. Applying multilevel logistic regression, no measurable improvements were found among paraprofessional enrollees, and three outcomes were significantly worse at follow-up regardless of program model. Children's behavior problems became more prevalent even after adjusting for other factors, increasing from 29% to 35% in girls and from 28% to 43% in boys. Nearly one-quarter of girl and boys reported high levels of depression at follow-up, and this was a significant rise over time for boys. Rates of poor family functioning also significantly worsened over time, rising from 30% to 59%. About one-third of caregivers reported high levels of negative feelings at follow-up, with no improvements observed in the paraprofessional group. Results highlight that children's and caregivers' psychological outcomes may be relatively impervious to change even in paraprofessional home visiting models. Findings underscore the need for programs serving HIV-affected families to add focused evidence-based psychological interventions to supplement traditional home visiting.

Pediatric HIV infections jeopardize children's health and survival. Much less is known about how the experiences of being orphaned, living with chronically ill parents, or living in a severely affected community impact child health. Our study responds by examining which HIV/AIDS-related experiences place children at greatest risk for poor health. Data from the 2004-2005 Malawi Integrated Household Survey were analyzed using logistic multilevel modeling to examine whether HIV/AIDS-related experiences within the family and community predicted reported health status among children age 6-17 years. We found higher burdens of acute and chronic morbidity for children whose parents have an AIDS-related illness. No other AIDS-related exposure, including orphanhood and recent household deaths, demonstrated a clear relationship with health status. Children living with sick parents may be at increased risk due to the spread of infectious disease and receiving limited adult care. Community home-based care programs are best situated to identify children in these difficult circumstances and to mitigate their disadvantage., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by children's households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process.

Families play central roles in the HIV/AIDS pandemic, caring for both orphaned children and the ill. This extra caregiving depletes two family resources essential for supporting children: time and money. We use recent data from published studies in sub-Saharan Africa to illustrate deficits and document community responses. In Botswana, parents caring for the chronically ill had less time for their preschool children (74 versus 96 hours per month) and were almost twice as likely to leave children home alone (53% versus 27%); these children experienced greater health and academic problems. Caregiving often prevented adults from working full time or earning their previous level of income; 47% of orphan caregivers and 64% of HIV/AIDS caregivers reported financial difficulties due to caregiving. Communities can play an important role in helping families provide adequate childcare and financial support. Unfortunately, while communities commonly offer informal assistance, the value of such support is not adequate to match the magnitude of need: 75% of children's families in Malawi received assistance from their social network, but averaging only US$81 annually. We suggest communities can strengthen the capacity of families by implementing affordable quality childcare for 0-6 year olds, after-school programming for older children and youth, supportive care for ill children and parents, microlending to enhance earnings, training to increase access to quality jobs, decent working conditions, social insurance for the informal sector, and income and food transfers when families are unable to make ends meet.

We examined over 20,000 arraignment records to define criminal typologies and post-treatment driving under the influence of alcohol (DUI) convictions for a select cohort of 1,281 repeat DUI offenders who were offered and elected treatment as an alternative to incarceration; we compared this information with a similar data analysis collected 20 years previously. Analyses of 8,600 prior-to-treatment convictions defined four basic crime profiles: only DUI and other substance-related offenses (60%), plus crimes against property (18%), plus crimes against people (8%), plus crimes against both property and people (13%). During the six years after inpatient treatment, 15.5% of the cohort was convicted of another DUI. The reoffense rate was significantly different across criminal types and was not related to the time post treatment years at risk. The findings show there has been no significant improvement in treatment outcome over the last 20 years. New and innovative DUI offender policies and practices are needed to better engage the heterogeneous offender population, and reduce the incidence of repeat DUI., (2007 John Wiley & Sons, Ltd)

The Iowa Gambling Treatment Program (IGTP) amassed participant data for gamblers and concerned others of gamblers over 4 years (1997-2001). Data collection opportunities included: (1) crisis contacts, (2) placement screening, (3) admission, (4) treatment services, (5) discharge, and (6) follow-up. Among followed gamblers, 74% of treatment completers, 49% of substantial treatment completers, and 36% of dropouts and referrals were abstaining from gambling at 6-month follow-up. The reduction in dollars lost to gambling was similar; 85% of treatment completers, 88% of substantial treatment completers, and 65% of others reduced their dollars lost per week. Although more extensive follow-up efforts are needed to properly evaluate the effectiveness of the IGTP, these results suggest that the IGTP shows promise.

BACKGROUND: This article reports the first national assessment of patterns of drinking and gambling-related rulemaking on college campuses (e.g., punitive versus recovery oriented). Analyses relating school policies to known school rates of drinking or gambling identified potentially influential policies. These results can inform and encourage the development of guidelines, or "best practices," upon which schools can base future policy. METHODS: The college policy information was collected from handbooks, Web sites and supplemental materials of 119 scientifically selected colleges included in the fourth (2001) Harvard School of Public Health College Alcohol Study (CAS). A coding instrument of 40 items measured the scope and focus of school alcohol and gambling policies. This instrument included items to measure the presence of specific policies and establish whether the policies were punitive or rehabilitative. A total of 11 coders followed a process of information extraction, coding and arbitration used successfully in other published studies to codify policy information. RESULTS: Although all schools had a student alcohol use policy, only 26 schools (22%) had a gambling policy. Punitive and restrictive alcohol policies were most prevalent; recovery-oriented policies were present at fewer than 30% of schools. Certain alcohol and gambling policies had significant relationships with student binge drinking rates. CONCLUSIONS: The relative lack of college recovery-oriented policies suggests that schools might be overlooking the value of rehabilitative measures in reducing addictive behaviors among students. Since there are few college gambling-related policies, schools might be missing an opportunity to inform students about the dangers of excessive gambling.