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Adverse pregnancy outcomes (APOs) are common occurrences that contribute to negative maternal and child health outcomes. Our aim was to test the hypothesis that trauma exposure and depression are drivers of the better-recognised risk factors for miscarriage, abortion and stillbirths. Our comparative cohort study based in Durban, South Africa recruited women who reported a recent rape (n = 852) and those who had never experienced rape (n = 853), with follow-up for 36 months. We explored APOs (miscarriage, abortion or stillbirth) among those having a pregnancy during follow-up (n = 453). Potential mediators were baseline depression, post-traumatic stress symptoms, substance abuse, HbA1C, BMI, hypertension and smoking. A structural equation model (SEM) was used to determine direct and indirect paths to APO. Overall, 26.6% of the women had a pregnancy in the follow-up period and 29.4% ended in an APO, with miscarriage (19.9%) the most common outcome, followed by abortion (6.6%) and stillbirths (2.9%). The SEM showed two direct pathways from exposure to childhood trauma, rape and other trauma, to APO which were ultimately mediated by hypertension and/or BMI, but all paths to BMI were mediated by depression and IPV-mediated pathways from childhood and other trauma to hypertension. Food insecurity mediated a pathway from experiences of trauma in childhood to depression. Our study confirms the important role of trauma exposure, including rape, and depression on APOs, through their impact on hypertension and BMI. It is critical that violence against women and mental health are more systematically addressed in antenatal, pregnancy and postnatal care. [ABSTRACT FROM AUTHOR]

A mixed-culture of bacteria collected from a wastewater treatment plant in Brits, North-West Province (South Africa) biocatalytically reduced Cr(VI) at much higher concentrations than previously observed in cultures isolated in North America. Complete Cr(VI) reduction in aerobic cultures was achieved at a high concentration of 200 mg/L after incubation for only 65 hours. Under anaerobic conditions up to 150 mg, Cr(VI)/L was completely removed after incubating for 130 to 155 hours, still higher than the Cr(VI) reduction achieved with previous cultures where complete removal was only observed in cultures with the added Cr(VI) concentration not greater than 30 mg/L. Cr(VI) reduction capability of the cultures was verified in purified cultures. Consortium cultures were characterised using 16S rRNA partial sequence analysis. Results showed that the gram-positive Bacillus genera predominated under aerobic conditions with a small composition of the gram-negative Microbacterium sp. There was more biodiversity observed in the anaerobic cultures with the marked appearance of Enterococcus, Arthrobacter, Paenibacillus and Oceanobacillus species. The results showed that Cr(VI) reduction rate in the new culture was up to eight times higher than that previously observed in other Cr(VI) reducing cultures isolated from Cr(VI) contaminated soil environments in Newark (New Jersey) and other sites in North America. [ABSTRACT FROM AUTHOR]

Background: Population-based statistics on deaths from child abuse and neglect are only routinely available in countries that have reliable national statistics on child murder. For low-income and middle-income countries, relatively little is known about prevalence trends of child murder. South Africa is an exception, having conducted dedicated national studies on child murders for 2009 and 2017 to provide data on child murders overall and on child abuse and neglect-related murders. We aimed to compare child abuse and neglect-related murders in South Africa across two surveys to determine any change between 2009 and 2017., Methods: We conducted two retrospective national mortuary-based surveys on murder of children aged 0-17 years for 2009 and 2017 from a proportionate random sample of medico-legal laboratories in South Africa. A sampling frame of medico-legal laboratories for each study year was prepared with stratification by medico-legal laboratory size. A minimum of 2 years after the crime was allowed before data collection to enable progression of the investigation process. Child abuse and neglect-related murders were identified using both medico-legal laboratory post-mortem autopsy reports and police data. To identify a child abuse and neglect-related murder, we primarily used the framework of abuse happening within the context of responsibility of care arrangements but broadened this to include all perpetrators and abuse identified from the data. We stratified age into 0-4, 5-9, 10-14, and 15-17 years and further stratified children younger than 5 years into early neonates (newborns killed within 6 days of birth), 7 days to 11 months, and 1-4 years. We calculated incidence rate ratios (IRR) with 95% CIs to compare rates between 2009 and 2017., Findings: An estimated 458 (95% CI 377-539) children in 2009 and 213 (179-247) children in 2017 were murdered in circumstances of child abuse and neglect. The percentage of all child murders that were child abuse and neglect-related declined from 2009 to 2017 (458 [45·0%] of 1018 in 2009 vs 213 [25·0%] of 851 in 2017), with the overall age-standardised rate decreasing from 2·6 to 1·1 per 100 000 children aged 0-17 years (IRR 0·43 [95% CI 0·35-0·54]). Girls represented 276 (60·3%) of 458 murders in 2009, which declined to 96 (45·1%) of 213 murders in 2017, and boys represented 178 (38·9%) of 458 murders in 2009 and 109 (51·4%) of 213 murders in 2017. The decrease was statistically significant for girls in the 0-4 year (IRR 0·33 [0·22-0·49]) and 5-9 year (0·33 [0·15-0·73]) age groups and for boys in the 0-4 year age group (0·49 [0·33-0·71]). Among early neonates (within 6 days of birth), the decrease in child abuse and neglect-related murders was more pronounced among girls than among boys (IRR 0·33 [95% CI 0·19-0·56] vs 0·46 [0·28-0·77])., Interpretation: Child abuse and neglect-related murders are common in South Africa but our study shows that they can be reduced. The high rate of these murders points to the need to continue research and monitoring to inform priority targeted interventions and to better understand the impact of child support policies., Funding: Ford Foundation and South African Medical Research Council., Competing Interests: Declaration of interests RM has received grants from Back of the Yards Algae Sciences. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs)., Methods and Findings: We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data., Conclusions: In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems., Competing Interests: The authors have declared that no competing interest interest exists., (Copyright: © 2024 Abrahams 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.)

Background: The extremely high prevalence of sexual violence victimisation reported among female students in South African public higher education demands urgent action to develop, rigorously evaluate and scale effective prevention interventions. This article details findings from a pilot feasibility study of Ntombi Vimbela! a campus sexual violence risk reduction intervention developed to tackle the high burden of sexual violence in higher education institutions in South Africa., Methods: Ntombi Vimbela! (NV!) is a sexual violence risk reduction intervention that comprises sexuality empowerment, gender and social norm change, early-risk identification, self-defence, resistance and mental wellbeing components. NV! is comprised of ten workshop sessions running for 3.5 h each. Workshops are co-delivered by two trained peer facilitators per group of at most 20 first-year female students. One-year post-intervention quantitative outcome assessments were remotely completed by 98 participants who participated in the NV! pilot workshops. Qualitative assessments were conducted with 35 participants through in-depth telephone interviews (IDTIs)., Findings: One year after attending NV! workshops, most participants reported improved awareness of sexual rights, assertive communication, shifts in gender equitable beliefs, reductions in rape myth acceptance, improved expressed sexual relationship power sexual decision-making, and improved negotiation within their intimate relationships. Participants' depressive symptoms also significantly decreased. Many participants improved awareness of sexual assault risk and vigilance, including using self-protection strategies such as removing themselves from environments where alcohol intoxication posed sexual assault risks. Some participants used assertive communication to withstand peer pressure to engage in risky sexual behaviours. Most participants scored highly on the self-defence efficacy scale. Some participants were exposed to and successful in using verbal and physical resistance strategies in potential sexual assault risky situations., Conclusion: These findings indicate the potential beneficial effects of NV! as a campus sexual violence risk reduction intervention at one-year post-intervention, which must be evaluated in a future rigorous randomised control trial., Pilot Trial Registered at: ClinicalTrials.gov NCT04607564 on 29/10/2020., (© 2023. The Author(s).)

Background: The association of traumatic experiences with problematic alcohol use has been described, but data on possible mediation effects of mental distress are sparse. We examined whether mental ill-health mediated the association between trauma exposure across the lifespan and alcohol use., Method: We analysed cross-sectional data from a sample of rape-exposed and non-rape-exposed women, living in KwaZulu-Natal, with self-reported data on alcohol misuse (AUDIT-C cut-off ≥ 3) and exposure to childhood maltreatment (CM), intimate partner violence (IPV), non-partner sexual violence (NPSV), other traumatic events, and mental ill-health. Logistic regression and multiple mediation models were used to test the mediation effects of symptoms of depression and PTSS on the association between abuse/trauma and alcohol misuse., Results: Of 1615 women, 31% (n = 498) reported alcohol misuse. Exposure to any CM (adjusted odds ratio (aOR): 1.59, 95% confidence interval (CI): 1.27-1.99), as well as to sexual, physical and emotional CM, were independently associated with alcohol misuse. Lifetime exposure to any IPV (aOR:2.01, 95%CI:1.59-2.54), as well as to physical, emotional and economic IPV, NPSV (aOR: 1.75, 95%CI: 1.32-2.33), and other trauma (aOR:2.08, 95%CI:1.62-2.66), was associated with alcohol misuse. Exposure to an increasing number of abuse types, and other traumatic events, was independently associated with alcohol misuse. PTSS partially mediated the associations of CM, IPV, NPSV and other trauma exposures with alcohol misuse (ps ≤ 0.04 for indirect effects), but depression symptoms did not., Conclusions: These findings highlight the need for trauma-informed interventions to address alcohol misuse that are tailored to the needs of women who have experienced violence., (© 2023. The Author(s).)

Background: Intimate partner violence impacts relationships across the socioeconomic spectrum, nonetheless its prevalence is reported to be highest in areas that are most socio-economically deprived. Poverty has direct and indirect impacts on intimate partner violence (IPV) risk, however, one of the postulated pathways is through food insecurity. The aim of this paper is to describe the association between food insecurity (household hunger) and women's experiences, and men's perpetration, of intimate partner violence and non-partner sexual violence in data from Africa and Asia., Methods: We conducted a pooled analysis of data from baseline interviews with men and women participating in six Violence Against Women prevention intervention evaluations and present a meta-analysis using mixed-effects Poisson regression models. Data were from South Africa (two studies), Ghana, Rwanda (two data sets), and Afghanistan and comprised interviews with 6545 adult women and 8104 adult men. We assessed food insecurity with the Household Hunger Scale., Results: Overall, 27.9% of women experienced moderate food insecurity (range from 11.1% to 44.4%), while 28.8% of women reported severe food insecurity (range from 7.1 to 54.7%). Overall food insecurity was associated with an increased likelihood of women experiencing physical intimate partner violence, adjusted incidence rate ratio (aIRR) = 1.40 (95% CI = 1.23 to 1.60) for moderate food insecurity and aIRR = 1.73 (95% CI = 1.41 to 2.12) for severe food insecurity. It was also associated with an increased likelihood of men reporting perpetration of physical IPV, with aIRR = 1.24 (95% CI = 1.11 to 1.39) for moderate food insecurity and aIRR = 1.18 (95% CI = 1.02 to 1.37) for severe food insecurity. Food insecurity was not significantly associated with women's experience of non-partner sexual violence, aIRR = 1.27 (95% CI = 0.93 to 1.74) for moderate or severe food insecurity vs none, nor men's perpetration of non-partner sexual violence aIRR = 1.02 (95% CI = 0.90 to 1.15)., Conclusions: Food insecurity is associated with increased physical intimate partner violence perpetration and experience reported by men and women. It was not associated with non-partner sexual violence perpetration, although there was some evidence to suggest an elevated risk of non-partner sexual violence among food-insecure women. Prevention programming needs to embrace food insecurity as a driver of intimate partner violence perpetration, however, non-partner sexual violence prevention needs to be shaped around a separate understanding of its drivers., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Prospective studies assessing women's experience of intimate partner violence (IPV) and alcohol use have shown mixed results and all are from high-income countries. Using longitudinal data from young women in South Africa we assess whether changes in physical IPV impact alcohol use, and whether changes in alcohol use impact physical IPV experience. Post-hoc analysis of women aged 18-30 living in informal settlements in eThekwini Municipality, South Africa, involved in the Stepping Stones and Creating Futures trial, between September 2015 and October 2019, with data collected at baseline ( n = 677) and endline at 24 months ( n = 545, 80.5% retention). At both timepoints, women were asked about their past year physical IPV experience and alcohol use. We estimated changes in physical IPV over time and whether this was associated with harmful alcohol use at endline. We then estimated changes in alcohol use over time, and whether this was associated with experience of past year physical IPV at endline. Women who experienced an increase in physical IPV over the study period were more likely to report harmful drinking at 24 months (aOR2.45, 95% CI 1.21-4.97). Similarly, women reporting increased alcohol use over time were more likely to report past year physical IPV at 24 months (aOR2.04, 95% CI 1.21-3.46). Among young women living in urban poverty those who experienced increasing physical violence from intimate partners were more likely to report increased and problematic alcohol use. Similarly, women reporting increasing alcohol use over 24 months were more likely to report physical IPV. However, there was no evidence that decreased alcohol use led to reductions in IPV, or that reduced IPV experience led to decreased alcohol use. Future research and interventions need to consider the reciprocal risks of physical IPV and alcohol use, with a focus on joint underlying drivers.

Background: Low birthweight (LBW) as well as early childhood stunting are risk factors for increased childhood morbidity in low-and middle-income countries (LMIC). The Covid 19 pandemic has exacerbated food insecurity and unemployment globally, prompting concerns for maternal and child health., Objectives: We used data from the great recession of 2008 to examine the relationship between household food security and other risk factors with LBW and stunting using a longitudinal sample of South African women and their offspring., Methods: Food security indicators, alcohol use, blood pressure and other characteristics were examined in relation to LBW (≤ 2500 g), stunting (height for age ≤ 2SD) and severe stunting (height for age ≤ 3SD). Regression modelling with clustering at maternal ID level were employed to adjust for maternal characteristics and women who gave birth more than once during the reference period., Results: Birthweight data were available for 1173 children and height for age 1216 children. The prevalence of LBW was 14.7% while stunting and severe stunting was 17.8% and 14.5%. Child hunger in the household, maternal hypertension and alcohol use were associated with low birthweight. Food expenditure below the Stats SA poverty line and low dietary diversity was associated with stunting and severe stunting respectively. Maternal height and low birthweight were associated with both stunting and severe stunting., Conclusions for Practice: Interventions that can improve household food security and nutritional status during the periconceptional and antenatal period may reduce the prevalence of low birthweight and subsequent stunting in low- and middle-income countries., (© 2022. The Author(s).)

Childhood stunting remains a global public health problem. Many stunted children live in the same household as overweight or obese adults (the so-called double burden of malnutrition), evidence that quality as well as quantity of food is important. In recent years, food security measurement has shifted away from anthropometry (e.g., stunting) to experiential measures (e.g., self-reported hunger). However, given the continued problem of stunting, it is important that national surveys identify malnutrition., Objectives: To examine the associations between a variety of food security indicators, including dietary diversity, with adult, child (0-4 years) (5-9 years) and adolescent (10-17 years) anthropometry. To estimate the prevalence of double burden households., Methods: The study utilized cross-sectional data from the South African National Income Dynamics Survey NIDS (2008). We examined the associations between five food security indicators and anthropometry outcomes. The indicators were adult and child hunger in the household, self-reported household food sufficiency, food expenditure>60% of monthly expenditure and household dietary diversity. Multinomial and logistic regression models were employed to examine the associations with adult BMI categories and children's stunting and BMI., Results: The prevalence of stunting was 18.4% and the prevalence of wasting and overweight was 6.8 and 10.4%, respectively. Children <5 and adolescents with medium dietary diversity were significantly more likely to be stunted than children with high dietary diversity. Among children <5, child hunger and medium dietary diversity were significantly associated with wasting. None of the food security indicators were associated with stunting in children aged 5-9. Among stunted children, 70.2% lived with an overweight or obese adult. Among adults, increased dietary diversity increased the risk of overweight and obesity., Conclusion: Dietary diversity can be used as a proxy for poor nutritional status among children <5 years and adolescents but the relationship between dietary diversity and adult obesity is more complex. Given the double burden of malnutrition in many low- and middle-income countries, indicators of dietary quality remain important. These tools can be further refined to include an extra category for processed foods. Given the relative simplicity to collect this data, national surveys would be improved by its inclusion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Harper, Goudge, Chirwa, Rothberg, Sambu and Mall.)

While ample evidence from high-income country settings indicates the prevalence and risk factors for multiple mental ill-health symptoms in student populations, evidence from low- and middle-income higher education settings remains limited. We determined the frequency, associations, and structural pathways between mental health outcomes and possible risk factors among a sample of 1292 predominantly Black African and female students ages 18-30 years, enrolled at nine purposefully selected public universities and Technical Vocational Education and Training (TVET) campuses. We measured and created a mental ill-health latent outcome consisting of depressive symptoms, post-traumatic stress disorder (PTSD), and suicidal thoughts. We also measured traumatic exposures including childhood trauma, recent intimate partner violence (IPV), non-partner rape, and other life traumatic events. We used structural equation modelling to analyse data. We found that 50% of the surveyed students binge drank, 43% reported depressive symptoms, 9% reported PTSD symptoms, and 21% had suicidal thoughts. Students' experiences of childhood trauma, food insecurity, other traumatic events, non-partner rape, and IPV impacted the mental ill-health latent. IPV experiences mediated the relationships between experiences of childhood trauma or other trauma and the mental ill-health latent, and the relationship between binge drinking and other life traumatic events. Non-partner rape mediated the relationship between food insecurity and the mental ill-health latent. Binge drinking directly impacted non-partner rape experience. The findings substantiate the need for campus-based mental health promotion, psychosocial services and treatments, and implementation of combined interventions that address the intersections of violence against women and mental health among students in South Africa.

This study describes associations of intimate partner violence (IPV), non-partner sexual violence (NPSV) and sexual harassment (SH) exposures with hypertension in South African women aged 18-40 years. Baseline data ( n = 1742) from the Rape Impact Cohort Evaluation study, including a history of sexual, physical, emotional and economic IPV, NPSV and SH were examined. Hypertension was based on blood pressure ≥140/90 mmHg or a previous diagnosis. Logistic regressions were adjusted for traditional hypertension risk factors and previous trauma (e.g., recent rape). Hypertension was more prevalent in women with a history of all forms of IPV, NPSV, and SH, all p ≤ 0.001, compared to women without. Frequent NPSV (adjusted odds ratio: 1.63; 95% CI: 1.27-2.67) any SH (2.56; 1.60-4.03), frequent physical (1.44; 1.06-1.95) and emotional IPV (1.45; 1.06-1.98), and greater severity of emotional IPV (1.05; 1.02-1.08) were associated with hypertension. Current depression, post-traumatic stress symptoms and/or alcohol binge-drinking completely or partially mediated these associations. This study shows that exposure to gender-based violence is associated with hypertension in young women. Understanding the role of psychological stress arising from abuse may enable the development of prevention and management strategies for hypertension among women with histories of abuse.

Background: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries., Methods and Findings: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs., Conclusions: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: CW was the Chief Scientific Adviser at the Department for International Development (UKAid) at the time of writing. This work was conducted as part of her academic role as professor in epidemiology at the London School of Hygiene & Tropical Medicine.

Rape stigma, both external and self-stigmatization (self-blame), is associated with adverse health outcomes. Understanding its origins and resilience factors is critical for reducing and preventing it. We describe the prevalence of rape stigma, the characteristics of women experiencing it and the pathways to experiencing greater stigma. The Rape Impact Cohort Evaluation study enrolled 852 women aged 16-40 years who had been raped from post-rape care centres in Durban, South Africa. We present a descriptive analysis of the baseline data, a multinomial logistic regression model of factors associated with different levels of stigma and a structural equation model (SEM). Most women reported stigmatizing thoughts or experiences, with self-stigmatizing thoughts being more prevalent than external stigmatization. The multinomial model showed that experiences of childhood or other trauma, emotional intimate partner violence (IPV), having less gender equitable attitudes and food insecurity were significantly associated with medium or high versus low levels of stigma. Internal and external stigma were significantly associated with each other. Women who had been previously raped reported less stigma. The SEM showed a direct path between food insecurity and rape stigma, with poorer women experiencing more stigma. Indirect paths were mediated by more traditional gender attitudes and childhood trauma experience and other trauma exposure. Our findings confirm the intersectionality of rape stigma, with its structural drivers of food insecurity and gender inequality, as well as its strong association with prior trauma exposure. Rape survivors may benefit from gender-empowering psychological support that addresses blame and shame., (© 2021 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.)

Female sex workers (FSWs) are at increased risk of mental health problems, including mood disorders and substance abuse, and we need to understand the origins of these to treat and prevent them, and particularly understand how the context in which they sell sex impacts their mental health. We conducted a multi-stage, community-centric, cross-sectional survey of 3005 FSWs linked to SW programmes in twelve sites across all nine provinces of South Africa. We interviewed adult women who had sold sex in the preceding six months, who were recruited via SW networks. We found that FSWs have very poor mental health as 52.7% had depression and 53.6% has post-traumatic stress disorder (PTSD). The structural equation model showed direct pathways from childhood trauma and having HIV+ status to mental ill-health. Indirect pathways were mediated by food insecurity, controlling partners, non-partner rape, harmful alcohol use, substance use to cope with SW, indicators of the circumstances of SW, i.e., selling location (on streets, in taverns and brothels), frequency of selling and experiencing SW stigma. All paths from childhood trauma had final common pathways from exposure to gender-based violence (non-partner rape or intimate partner violence) to mental ill-health, except for one that was mediated by food insecurity. Thus, FSWs' poor mental health risk was often mediated by their work location and vulnerability to violence, substance abuse and stigma. The potential contribution of legal reform to mitigate the risks of violence and mental ill-health are inescapable. Treatment of mental ill-health and substance abuse should be an essential element of FSW programmes.

Background: Corporal punishment (CP) is still a common practice in schools globally. Although illegal, studies in South Africa report its continued use, but only a few have explored factors associated with school CP. Moreover, extant studies have not shown the interrelationships between explanatory factors. This study aimed to determine the prevalence and factors associated with learners' experiences, and to examine pathways to the learners' experiences of CP at school., Method: 3743 grade 8 learners (2118 girls and 1625 boys) from 24 selected public schools in Tshwane, South Africa, enrolled in a cluster randomised controlled trial evaluating a multi-component school-based intervention to prevent intimate partner violence, and completed self-administered questionnaires. We carried out descriptive analysis, simple linear and structural equation modelling to examine factors and pathways to the learners' experience of CP at school., Results: About 52% of learners had experienced CP at school in the last 6 months. It was higher among boys compared to girls. Experience of CP at school amongst learners was associated with learner behavior, home environment, and school environment. Learners from households with low-socio economic status (SES) had an increased risk of CP experience at school. Amongst boys, low family SES status was associated with a negative home environment and had a direct negative impact on a learner's mental health, directly associated with misbehavior., Conclusion: CP in public schools in South Africa continues despite legislation prohibiting its use. While addressing learner behaviour is critical, evidence-based interventions addressing home and school environment are needed to change the culture among teachers of using corporal punishment to discipline adolescents and inculcate one that promotes positive discipline., Competing Interests: The authors are not aware of any competing interests.

Objective: To determine the incidence of HIV acquisition in women postrape compared with a cohort of women who had not been raped., Design: A prospective cohort study., Methods: The Rape Impact Cohort Evaluation study based in Durban, South Africa, enrolled women aged 16-40 years from postrape care services, and a control group of women from Primary Healthcare services. Women who were HIV negative at baseline (441 in the rape-exposed group and 578 in the control group) were followed for 12-36 months with assessments every 3 months in the first year and every 6 months thereafter. Multivariable Cox regression models adjusted for baseline and time varying covariates were used to investigate the effect of rape exposure on HIV incidence over follow-up., Results: Eighty-six women acquired HIV during 1605.5 total person-years of follow-up, with an incident rate of 6.6 per 100 person-years [95% confidence interval (CI): 4.8-9.1] among the rape exposed group and 4.7 per 100 person-years (95% CI: 3.5-6.2) among control group. After controlling for confounders (age, previous trauma, social support, perceived stress, multiple partners and transactional sex with a casual partner), women exposed to rape had a 60% increased risk of acquiring HIV [adjusted hazard ratio: 1.59 (95% CI: 1.01-2.48)] compared with those not exposed. Survival analysis showed difference in HIV incident occurred after month 9., Conclusion: Rape is a long-term risk factor for HIV acquisition. Rape survivors need both immediate and long-term HIV prevention and care., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Little is known about women who have experienced a recent rape, and how they differ from women without this exposure. Identifying factors linked to rape is important for preventing rape and developing effective responses in countries like South Africa with high levels of sexual violence., Objective: To describe the socio-demographic and health profile of women recently exposed to rape and to compare them with a non-rape-exposed group., Methods: The Rape Impact Cohort Evaluation Study (RICE) enrolled 852 women age 16-40 years exposed to rape from post-rape care centres in Durban (South Africa) and a control group of 853 women of the same age range who have never been exposed to rape recruited from public health services. Descriptive analyses include logistic regression modelling of socio-demographic characteristics associated with recent rape exposure., Results: Women with recent rape reported poorer health and more intimate partner violence than those who were not raped. They had a lower likelihood of having completed school (Odds Ratio [OR] 0.46 95% Confidence Interval (CI): 0.24-0.87) and dependence on a government grant as a main source of income (OR 0.61: 95%CI 0.49-0.77). They were more likely to live in informal housing (OR 1.88 95%CI: 1.43-2.46) or rural areas (OR 2.24: 95%CI 1.61-3.07) than formal housing areas - however they were also more likely to report full-time employment (OR 4.24: 95%CI 2.73-6.57)., Conclusion: The study shows that structural factors, such as lower levels of education, poverty, and living in areas of poor infrastructure are associated with women's vulnerability to rape. It also shows possible protection from rape afforded by the national financial safety net. It highlights the importance of safe transportation in commuting to work. Preventing rape is critical for enabling women's full social and economic development, and structural interventions are key for reducing women's vulnerability.

Introduction: Women with disabilities experience higher rates of intimate partner violence (IPV) than women without disabilities. There remains limited evidence about whether IPV prevention interventions for the general population have benefits for women with disabilities that compare to those for women without disabilities. Using data from IPV prevention randomised controlled trials in diverse locations (Rwanda, South Africa and Afghanistan), we assess whether outcomes differed by disability status., Methods: We assessed disability at baseline in three IPV prevention trials. We performed post-hoc analysis of intervention impacts at endline (22 or 24 months post-baseline) stratified by disability status at study baseline and tested an interaction term for disability at baseline by intervention arm for three sets of outcomes: (1) past year experiences of physical, sexual and severe IPV; (2) economic and livelihood outcomes; and (3) health, mental health and substance use outcomes., Results: At baseline between 17.7% and 26.2% of women reported being disabled. For IPV prevention, in seven out of eight tests across three studies, women with and without disabilities had similar outcomes. For economic, health and substance use outcomes, there was more variation, with women with disabilities reporting both better and worse outcomes than women without disabilities; however there was no clear pattern in these differential results., Conclusion: IPV prevention programmes targeting general populations can prevent IPV among women with disabilities participants with benefits that mirror those for women without disabilities. Benefits for participants with and without disabilities on secondary programme outcomes related to economic empowerment and health may be more varied and should be explicitly monitored., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Working with men to prevent their perpetration of intimate partner violence and non-partner sexual violence is increasingly recognised as effective. However, in any given context there are a multiplicity of masculinities, each of which has a different association with violence perpetration. There remains lack of clarity about whether such interventions impact all men and masculinities equally. We undertook a post-hoc analysis of men involved in the successful Stepping Stones and Creating Futures cluster randomized control trial in Durban, South Africa, to assess: i) whether there were different groups of men, ii) the factors associated with group allocation, and iii) whether the intervention had a differential impact on these groups in terms of violence perpetration. We used Latent Class Analysis (LCA) to identify masculinity classes, based on fit statistics and theoretical plausibility, and then used descriptive statistics (numbers, percentages, means) and p-values and multinomial models (95% confidence intervals, p-values) to assess factors associated with allocation to each class. To assess intervention impact by group, we used an intention-to-treat analysis, comparing men in each masculinity class, by intervention and control arm, using generalized estimating equations reporting unadjusted and adjusted odds ratios (aORs). In total 674 were recruited at baseline, and the LCA identified three classes of men: high violence (29% of men), medium violence (50% of men) and low violence (21% of men). Multinomial models showed those in more violent classes were more supportive of violence, had more adverse experiences, more depression and had worked more. By masculinity class, the impact of SS-CF showed reductions among the most violent men, with significant reductions in past year physical IPV (aOR0.59, p = 0.014), emotional IPV (aOR0.44, p = 0.044) and economic IPV (aOR0.35, p = 0.004), with non-significant reductions among other classes of men. This analysis suggests intensive group-based interventions can have significant impacts on the most violent men in communities., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Emerging evidence suggests working with men to prevent intimate partner violence (IPV) perpetration can be effective. However, it is unknown whether all men benefit equally, or whether different groups of men respond differentially to interventions., Methods: We conducted trajectory modelling using longitudinal data from men enrolled in intervention arms of three IPV trials in South Africa and Rwanda to identify trajectories of IPV perpetration. We then use multinomial regression to describe baseline characteristics associated with group allocation., Results: In South Africa, the Stepping Stones and Creating Futures (SS-CF) trial had 289 men and the CHANGE trial had 803 men, and in Rwanda, Indashyikirwa had 821 men. We identified three trajectories of IPV perpetration: a low-flat (60%-67% of men), high with large reduction (19%-24%) and high with slight increase (10%-21%). Baseline factors associated men in high-start IPV trajectories, compared with low-flat trajectory, varied by study, but included higher poverty, poorer mental health, greater substance use, younger age and more childhood traumas. Attitudes supportive of IPV were consistently associated with high-start trajectories. In separate models comparing high-reducing to high-increasing trajectories, baseline factors associated with reduced IPV perpetration were depressive symptoms (relative risk ratio, RRR=3.06, p=0.01 SS-CF); living separately from their partner (RRR=2.14, p=0.01 CHANGE); recent employment (RRR=1.85, p=0.04 CHANGE) and lower acceptability of IPV (RRR=0.60, p=0.08 Indashyikirwa). Older aged men had a trend towards reducing IPV perpetration in CHANGE (p=0.06) and younger men in Indashyikirwa (p=0.07)., Conclusions: Three distinct groups of men differed in their response to IPV prevention interventions. Baseline characteristics of past traumas and current poverty, mental health and gender beliefs predicted trajectory group allocation. The analysis may inform targeting of interventions towards those who have propensity to change or guide how contextual factors may alter intervention effects., Trial Registration Numbers: NCT03022370; NCT02823288; NCT03477877., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Young people, not in formal employment or education, face exceedingly high levels of intimate partner violence (IPV). We evaluated whether Stepping Stones and Creating Futures, compared with a wait-list control, can reduce IPV and strengthen livelihoods., Methods: A cluster randomized controlled trial with 34 clusters in urban informal settlements in eThekwini Municipality, South Africa. Participant inclusion criteria were aged 18-30 years, resident in the informal settlement, and not working or in education. A total of 676 women and 646 men were recruited from September 2015 to September 2016. At recruitment, participants were not blinded to study arm. Endline data were collected from March to October 2018 (24 months postenrollment). Analyses were by intention-to-treat and separate for men and women. No clusters withdrew; endline retention was 74.9% (n = 505) men and 80.6% (n = 545) women., Results: At endline in the intervention arm, men's self-reported past year IPV perpetration was lower (physical IPV [adjusted odds ratio [aOR]: .71, 95% confidence interval [CI]: .51-.97], severe IPV [aOR: .70, 95% CI: .52-.94], and sexual IPV [aOR: .74, 95% CI: .54-1.03]). There was no difference in men's controlling behaviors (β = .06, 95% CI: -.51 to .63) or past month earnings (β = .21, 95% CI: -.42 to .83). For women, earnings were significantly higher in the intervention arm (β = .97, 95% CI: .43-1.51), but there were no differences for past year IPV experience (physical IPV [aOR: .92, 95% CI: .62-1.37]; sexual IPV [aOR: .90, 95% CI: .64-1.28], severe IPV [aOR: .93, 95% CI: .66-1.31]) or controlling behaviors (β = -.01, 95% CI: -.88 to .86)., Conclusion: Stepping Stones and Creating Futures is effective in reducing men's self-reported perpetration of IPV and strengthening women's livelihoods, but not women's experiences of IPV., Trial Registration: NCT03022370. Registered January 13, 2017., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Trial Registration: ClinicalTrials.gov NCT02349321., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To compare growth velocity of two African child cohorts and examine the relationship between postnatal growth velocity in infancy/early childhood and the risk of overweight/stunting in early adolescence., Methods: The study used data from two child cohorts from urban (Birth to Twenty Cohort, South Africa) and rural (Lungwena Child Survival Study, Malawi) African settings. Mixed effect modelling was used to derive growth and peak growth velocities. T-tests were used to compare growth parameters and velocities between the two cohorts. Linear and logistic regression models were used to determine the relationship between growth velocity and early adolescent (ages 9-11 years) body mass index and odds of being overweight., Results: Children in the BH cohort were significantly taller and heavier than those in the Lungwena cohort, and exhibited faster weight and height growth velocity especially in the first year of life (P < 0.05). No significant association was shown between baseline weight (αw ) and overweight in early adolescence (OR = 1.25, CI = 0.67, 2.34). The weight growth velocity parameter βw was highly associated with odds of being overweight. Association between overweight in adolescence and weight velocity was stronger in infancy than in early childhood (OR at 3 months = 4.80, CI = 2.49, 9.26; OR at 5 years = 2.39, CI = 1.65, 3.47)., Conclusion: High weight and height growth velocity in infancy, independent of size at birth, is highly associated with overweight in early adolescence. However, the long term effects of rapid growth in infancy may be dependent on a particular population's socio-economic status and level of urbanization., (© 2014 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc.)

The Cr(VI) reducing capability of an acclimated indigenous culture cultivated from primary sludge was evaluated in batch and packed-bed bioreactor systems. Performance evaluation was carried out in unmodified cultures, cultures modified by substituting terminal organisms in the consortium by a known Cr(VI)-reducing organism (Escherichia coli ATCC 33456), and pure cultures of Cr(VI)-reducing organisms. A high Cr(VI) reduction rate was observed in modified cultures and in the pure culture of the Cr(VI)-reducing bacteria (Bacillus sp.). Furthermore, the Bacillus sp. pure culture outperformed both the unmodified and modified consortium cultures in reducing Cr(VI). Abiotic Cr(VI) reduction activity was evaluated in heat-killed and azide (N3) inactivated control cultures. No significant Cr(VI) reduction was observed in the controls. This study is part of the continuing research to identify synergistic culture systems for treating toxic compounds from polluted environments.