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To better understand the optimal frequency of parent-adolescent alcohol-specific communication, we conducted a secondary analysis of the National Center on Addiction and Substance Abuse Culture of High School Survey, a 2010 nationally representative online survey of 1000 high school students. Logistic regression models assessed the relationship between alcohol-specific communication and adolescent perceptions ( binge drinking is very dangerous, drinking is cool, and getting drunk is very dangerous), adjusting for grade, sex, race, personal and peer alcohol use, and parental monitoring. Among adolescents reporting personal and peer alcohol use, a dose-response relationship existed between frequency of alcohol-specific communication and thinking binge drinking is very dangerous (often [adjusted odds ratio [AOR] = 7.98; 95% confidence interval [CI] = 2.98-21.36], sometimes (AOR = 6.08; 95% CI = 2.36-15.69), rarely (AOR = 5.27; 95% CI = 1.95-14.26) vs never), and was also associated with decreased perceptions that drinking is cool (often [AOR = 0.22; 95% CI = 0.08-0.66), rarely vs never [AOR = 0.17; 95% CI = 0.06-0.51]); the inverse was true for never-drinkers without peer use.

Approximately 25% of the world's population consists of young people. The experience of violence peaks during adolescence and the early adult years. A link between personal experience of violence and mental health among young people has been demonstrated but rural-urban differences in these associations are less well known in low to middle income countries. The aim of this study was to investigate the associations between interpersonal violence and psychological distress among rural and urban young women.Data on experiences of violence and psychological distress were collected from a total of 926 non-pregnant young women aged between 18 and 22 years of age in rural and urban sites in South Africa. The General Health Questionnaire-28 was used to assess psychological distress as an indicator of mental health. Generalised structural equation models were employed to assess potential pathways of association between interpersonal violence and psychological distress.Thirty-four percent of the urban young women (n = 161) reported psychological distress compared to 18% of rural young women (n = 81). In unadjusted analysis, exposure to interpersonal violence doubled the odds of psychological distress in the urban adolescents and increased the odds 1.6 times in the rural adolescents. In adjusted models, the relationship remained significant in the urban area only (OR 1.84, 95% CI 1.13-3.00). Rural residence seemed protective against psychological distress (OR 0.41, 95% CI 0.24-0.69). Structural equation modelling did not reveal any direct association between exposure to interpersonal violence and psychological distress among rural young women. Stressful household events were indirectly associated with psychological distress, mediated by violence among young women in the urban area.The relationship between violence and psychological distress differs between urban and rural-residing young women in South Africa, and is influenced by individual, household and community (contextual) factors.

Forced displacement worldwide is at its highest in decades and millions of young children are living in conflict zones, in transitional or enduring refugee contexts, and in demographically diverse marginalized and informal settlements. There is a huge unmet need for delivering early childhood development interventions to ensure the safety and continued development of young children in these vulnerable contexts. In this paper, we discuss nurturing care as an important entry point for multisectoral collaborations to support families and reach young children. Nurturing care is a basic right of every child and encompasses health, nutrition, security and safety, responsive caregiving, and early learning. We review key elements of the biological and psychological development of children important to nurturing care and illustrate their application in case studies of war and displacement in Angola and Kenya. Building on long-term benefits of early interventions, scaled up support is essential to improve the health, development, and well-being of young children in contexts of conflict, violence, and insecurity. Not only do early childhood development interventions support the development of young children, but they also provide a potential pathway to violence reduction and a way to achieve more peaceful families, communities, and societies.

Background Temporally-harmonized asset-based measures of wealth can be used to study the association of life-course wealth exposures in the same scale with health outcomes in low- and middle-income countries (LMICs). The within-individual longitudinal stability of asset-based indices of wealth in LMICs is poorly understood. Methods Using data from five birth cohorts from three continents, we developed temporally-harmonized asset indices over the life course through polychoric principal component analysis of a common set of assets collected consistently over time (18 years in Brazil to 50 years in Guatemala). For each cohort, we compared the harmonized index to cross-sectional indices created using more comprehensive asset measures using rank correlations. We evaluated the rank correlation of the harmonized index in early life and adulthood with maternal schooling and own attained schooling, respectively. Results Temporally-harmonized asset indices developed from a consistently-collected set of assets (range: 10 in South Africa to 30 in Philippines) suggested that mean wealth improved over time for all birth cohorts. Cross-sectional indices created separately for each study wave were correlated with the harmonized index for all cohorts (Brazil: r = 0.78 to 0.96; Guatemala: r = 0.81 to 0.95; India: 0.75 to 0.93; Philippines: r = 0.92 to 0.99; South Africa: r = 0.84 to 0.96). Maternal schooling (r = 0.15 to 0.56) and attained schooling (r = 0.23 to 0.53) were positively correlated with the harmonized asset index in childhood and adulthood respectively. Conclusions Temporally-harmonized asset indices displayed coherence with cross-sectional indices as well as construct validity with schooling., Highlights • Temporally-harmonized asset indices are useful to assess relative importance of wealth at different life stages with health on the same scale. • Harmonized indices using a subset of assets were correlated with cross-sectional asset indices using all available assets in five LMIC birth cohorts. • Harmonized indices displayed construct validity, as demonstrated by its correlation with schooling. • Harmonized indices were robust to alternate specifications such as shorter lists of assets, study years, and factor extraction procedures.

Chronic lead exposure is associated with neurological ill-health including anti-social behavior such as aggressive behavior. The main aim of this study was to examine the association between lead exposure at 13years old and dimensions of aggressive behavior during mid-adolescence. The study sample included 508 males and 578 females in mid-adolescence (age 14 to 15years) from the Birth to Twenty Plus cohort in Johannesburg, South Africa. Blood samples collected at age 13years were used to measure blood lead levels. Seventeen items characterizing aggression from the Youth Self Report questionnaire were used to examine aggressive behavior. Principal Component Analysis was used to derive composite variables from the original data for aggressive behavior; and data were examined for an association between blood lead levels and dimensionality of direct and indirect aggression and disobedience during mid-adolescence. We also examined the dimensions of aggression during mid-adolescence in relation to gender and socio-demographic factors. Blood lead levels ranged from 1 to 28.1μg/dL. Seventy two percent of males and 47.7% of females in the study had blood lead levels ≥5μg/dL. There was a positive association between elevated blood lead levels and direct aggression (p

Background Evidence has identified the detrimental effects that adverse childhood experiences (ACEs) have on outcomes across the life course. We assess associations between prospective and retrospective ACEs and mental health in young adulthood and the influence of recent stressors. Methods Secondary analysis of a sample of 1592 young adults from the Birth to Twenty Plus cohort, from 1990 to 2013, were assessed throughout their first 18 years for prospective ACEs. Retrospective ACEs and an assessment of mental health were collected at the 22–23-year data point. Findings Prospective physical and sexual abuse are associated with an increased risk of depression (OR 1·7 [95% CI 1·37–1·93, p = 0·034], and OR 1·8 [95% CI 1·27–2·07, p = 0·018], respectively). Retrospective emotional abuse/neglect is associated with increased anxiety (OR 1·8 [95% CI 1·32–2·36, p = 0·000]), depression (OR 1·6 [95% CI 1·08–2·25, p = 0·018]) and overall psychological distress (OR 1·6 [95% CI 1·18–2·17, p = 0·002]). Prospectively reporting four or more ACEs is associated with a twofold increase in risk for overall psychological distress (OR 2·2 [95% CI 1·58–3.12, p = 0·008]). Retrospectively reporting four or more ACEs is associated with increased likelihood of somatization (p = 0·004), anxiety (p = 0·002), depression (p = 0·021), and overall psychological distress (p = 0·005). Interpretation Both individual and combined retrospective and prospective ACEs are related to mental health in young adulthood. Recent stressors reinforce this relationship; the likelihood of those who report more ACEs experiencing psychological distress increases when adjusting for recent stressors. Funding Wellcome Trust (UK), South African Medical Research Council, Human Sciences Research Council, University of the Witwatersrand and supported by the DSI-NRF Centre of Excellence in Human Development.

Background An estimated 43% of children younger than 5 years of age are at elevated risk of failing to achieve their human potential. In response, the World Health Organization and UNICEF developed Care for Child Development (CCD), based on the science of child development, to improve sensitive and responsive caregiving and promote the psychosocial development of young children. Methods In 2015, the World Health Organization and UNICEF identified sites where CCD has been implemented and sustained. The sites were surveyed, and responses were followed up by phone interviews. Project reports provided information on additional sites, and a review of published studies was undertaken to document the effectiveness of CCD for improving child and family outcomes, as well as its feasibility for implementation in resource-constrained communities. Results The inventory found that CCD had been integrated into existing services in diverse sectors in 19 countries and 23 sites, including child survival, health, nutrition, infant day care, early education, family and child protection and services for children with disabilities. Published and unpublished evaluations have found that CCD interventions can improve child development, growth and health, as well as responsive caregiving. It has also been reported to reduce maternal depression, a known risk factor for poor pregnancy outcomes and poor child health, growth and development. Although CCD has expanded beyond initial implementation sites, only three countries reported having national policy support for integrating CCD into health or other services. Conclusions Strong interest exists in many countries to move beyond child survival to protect and support optimal child development. The United Nations Sustainable Development Goals depend on children realizing their potential to build healthy and emotionally, cognitively and socially competent future generations. More studies are needed to guide the integration of the CCD approach under different conditions. Nevertheless, the time is right to provide for the scale-up of CCD as part of services for families and children.

Background South Africa is the first sub-Saharan African country to legislate, fund and implement free preschool education. Human rights and restitution were at the forefront of the political struggle for democracy in South Africa. Levelling the playing fields by improving the school readiness of children disadvantaged by the racist policies of Apartheid is essential to the transformation of South African society. Methods A review of published and unpublished documents on Grade R was undertaken, and access and enrolment data come from the National Department of Basic Education's Education Management Information System (EMIS). Results A decade after initiation in 2005, 79% of 5-year-olds was enrolled in a preschool class; the vast majority of them in free public schools. Grade R is near universal and on track to becoming compulsory. It is part of the Foundation Phase (Grades 1-3) of schooling, falling under the Department of Basic Education, but also part of a broader national strategy to improve early child development under the direction of an Inter-Departmental Steering. Evaluations demonstrate wide access to Grade R and high uptake, especially in the poorest areas. However, the quality of Grade R provision in these areas is not up to standard because of low levels of funding; inadequate training, supervision, remuneration and retention of Grade R teachers; insufficient learner support materials; and inadequate monitoring and quality assurance. Conclusions Lack of quality, amongst other factors, contributes to a widening school performance gap between children from more and less privileged areas. Quality of Grade R as well as earlier learning and subsequent years of schooling must be improved to achieve South Africa's aim to reduce poverty and inequality through, amongst others, parent and family involvement, learning in the home and preschool preparation.

Epidemiological studies have shown the adverse neuro-behavioral health effects of lead exposure among children, in particular. However, there is lack evidence in this regard from developing countries. The main aim of this study was to assess the association between blood lead levels (BLLs) during early adolescence and violent behavior in late adolescence.Our study sample from the Birth to Twenty Plus cohort in Soweto-Johannesburg, South Africa included 1332 study participants (684 females). BLLs were measured using blood samples collected at age 13years. Violent behavior was evaluated using data collected at ages 15 to 16years using the Youth Self Report questionnaire. First, bivariate analysis was used to examine data for an association between lead exposure in early adolescence and violent behavior items during late adolescence. Principal Component Analysis (PCA) was used for dimensionality reduction and six violent behavior components were derived. Data were further analyzed for an association between BLLs at age 13years and violent behavior using PCA derived components; to determine the specific type(s) of violent behavior associated with lead exposure.Median whole BLLs were 5.6μg/dL (p

The South African government offers three main services to improve the developmental potential and overall well-being of the country's children: cash grants, health care, and education. There is research to suggest that receiving supports to the household in multiple domains simultaneously might improve children's development over and above improvements to development that are typically experienced when receiving a single developmental support, however, no research to date has empirically examined the patterns by which these services may be received, the associated quality of these services, the multilevel characteristics of children and their households that might predict receiving particular patterns of services, or the relationship between service receipt and children's academic and cognitive development in a natural (non-experimental) environment in South Africa. This paper uses three-step latent class analysis to explore patterns of receipt of the three primary government-provided services, the child-, caregiver-, household-, and community-level factors that predict receipt of these patterns, and the associations between service receipt patterns and the academic and cognitive outcomes of low-income 7–10 year old children living in peri-urban and rural regions of KwaZulu-Natal, South Africa, while accounting for potential sources of selection bias. Results revealed three service receipt patterns: primarily education, primarily cash grants and education, and all three services, showed that household level factors were most predictive of service receipt such that the most economically disadvantaged households were likely to receive the most services, and found that children receiving more services had poorer math outcomes as compared to children receiving fewer services.

Stunting is a measure of overall nutritional status and is a major public health concern because of its association with child mortality and morbidity and later adult performance. This study examined the effects of pregnancy events, birth characteristics and infant risk exposure on stunting at age 2 years. The study, established in 1990 in Soweto, an urban South African township, included 1098 mother–infant pairs enroled in the Birth to Twenty Plus longitudinal birth cohort study. In total, 22% of children were stunted at age 2 years, with males at greater risk than females [24.8 v. 19.4%, odds ratio (OR)=1.38; 95% confidence interval (CI): 1.03, 1.83]. In unadjusted analysis, male sex, household socio-economic status (SES), overcrowding, maternal age, maternal education, single motherhood, ethnicity, birth weight, gestational age and duration of infant breastfeeding were all significantly associated with stunting. In multivariable analysis, higher birth weight was protective against stunting for both sexes. Higher maternal education was protective for females only (adjusted odds ratio (AOR)=0.35; 95% CI: 0.14, 0.87), whereas wealthier household SES protected males (AOR for richest SES group=0.39; 95% CI: 0.16, 0.92). In this and other similar settings, current stunting prevention efforts focussing on primarily providing targeted proximal interventions, such as food supplements, risk undermining the critical importance of addressing key distal determinants of stunting such as SES and maternal education.

BackgroundInequalities in early childhood development (ECD) tend to persist into adulthood and amplify across the life course. To date, little research on inequalities in early childhood care and development in low/middle-income countries has been available to guide governments, donors and civil society in identifying which young children and families should be targeted by policies and programmes to improve nurturing care that could prevent them from being left behind.MethodsUsing data from 135 Demographic and Health Surveys and Multiple Indicator Cluster Surveys between 2010 and 2018, we assessed levels and trends of inequalities in exposure to risks of stunting or extreme poverty (under age 5; levels in 85 and trends in 40 countries), early attendance of early care and education programmes (36–59 months; 65 and 17 countries), home stimulation (36–59 months; 62 and 14 countries) and child development according to the Early Childhood Development Index (36–59 months; 60 and 13 countries). Inequalities within countries were measured as the absolute gap in three domains—child gender, household wealth and residential area—and compared across regions and country income groups.Results63% of children were not exposed to stunting or extreme poverty; 39% of 3–4-year olds attended early care and education; and 69% received a level of reported home stimulation defined as adequate. Sub-Saharan Africa had the lowest proportion of children not exposed to stunting or extreme poverty (45%), attending early care and education (24%) and receiving adequate home stimulation (47%). Substantial gaps in all indicators were found across country income groups, residential areas and household wealth categories. There were no significant reductions in gaps over time for a subset of countries with available data in two survey rounds.ConclusionsAvailable data indicate large inequalities in early experiences and outcomes. Efforts of reducing these inequalities must focus on the poorest families and those living in rural areas in the poorest countries. Improving and applying population-level measurements on ECD in more countries over time are important for ensuring equal opportunities for young children globally.

Measuring executive function (EF) among adults is important, as the cognitive processes involved in EF are critical to academic achievement, job success and mental health. Current evidence on measurement and structure of EF largely come from Western, Educated, Industrialized, Rich and Democratic (WEIRD) countries. However, measuring EF in low-and-middle-income countries (LMICs) is challenging, because of the dearth of EF measures validated across LMICs, particularly measures that do not require extensive training, expensive equipment, or professional administration. This paper uses data from three LMIC cohorts to test the feasibility, validity and reliability of EF assessment in adults using three sub-tests (representing key components of EF) of the NIH Toolbox Cognitive battery. For each cohort, all three EF measures (inhibition, flexibility and working memory) loaded well onto a unidimensional latent factor of EF. Factor scores related well to measures of fluid intelligence, processing speed and schooling. All measures showed good test-retest reliability across countries. This study provides evidence for a set of sound measures of EF that could be used across different cultural, language and socio-economic backgrounds in future LMIC research. Furthermore, our findings extend conclusions on the structure of EF beyond those drawn from WEIRD countries.

Die Dominanz der Physik in der Meteorologie ist nicht selbstverständlich, sondern Ergebnis eines historischen Prozesses. Bis Mitte des 19. Jahrhunderts konkurrierten Wissensformen mit unterschiedlichen Vorstellungen von der Beobachtung und Prognose des Wetters miteinander.

While adverse childhood experiences (ACEs), as described by the CDC-Kaiser Permanente Study, are reportedly common in both high and low-income settings, evidence on the epidemiology of ACEs in low-income settings is scarce. This study aimed to determine the prevalence of ACEs reported in young adulthood and assess their association with childhood maternal, household and community factors. We used data from the 22–23 year wave of the Birth to Twenty Plus (Bt20+) study in South Africa, the largest and longest running birth cohort in Africa. With ACEs as the main outcome measure, their association with childhood factors was assessed using regression models. As demonstrated in high-income settings, ACEs are highly prevalent in this young adult population in a middle income country. Both household and community socio-economic status in childhood was associated with the experience of ACEs and the likelihood of experiencing multiple ACEs. The attenuation of significance in adjusted models suggested that individual ACEs are correlated and may exert their effects through other ACEs. Interventions for the prevention of ACEs need to be directed not only at individuals but households as well as communities., Developmental biology; Epidemiology; Public health; Quality of life; Interrelated; Abuse; Clustering; Household dysfunction; ACE score; Adverse childhood experiences; Neglect; Adversity; Early childhood development.

BACKGROUND: Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence-based clinical decision-making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research. METHODS: A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis. RESULTS: The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved. CONCLUSIONS: The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals' clinical practice. The guidelines were poorly aligned with the health professionals' knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the development and implementation of guidelines in Child Mental Health Services settings are given.

BackgroundThe 2016 World Health Organization Antenatal Guidelines and the 2015 South African Maternal and Child Health Guidelines recommend one early antenatal ultrasound scan to establish gestational age and to detect multiple pregnancies and fetal abnormalities. Prior research indicates that ultrasound scan can also increase parental–fetal attachment. We aim to establish whether, compared to routine care, messages to promote parental attachment and healthy child development, conducted during one or two pregnancy ultrasound scans, improve early child development and growth, exclusive breastfeeding, parental–child interactions and prenatal and postnatal clinic attendance.MethodsThe effect of messages to sensitise mothers and fathers to fetal development will be tested in a three-armed randomised trial with 100 mothers and their partners from Soweto, Johannesburg in each arm. The primary outcome is child development at 6 months postnatally. Secondary outcomes include infant feeding, parental attachment and interaction, parental mental health and infant growth, assessed at 6 weeks and 6 months. Parents in Arm 1 receive a fetal ultrasound scan DiscussionEvidence from high-income countries suggests that first-time prospective mothers and fathers enjoy seeing their fetus during ultrasound scan and that it is an emotional experience. A number of studies have found that ultrasound scan increases maternal attachment during pregnancy, a predictor of positive parent–infant interactions which, in turn, promotes healthy infant development. It is generally agreed that studies are needed which follow up parental–child behaviour and healthy child development postnatally, include fathers and examine the construct in a wider diversity of settings, especially in low and middle-income countries. Testing the added benefits of pregnancy ultrasound scan for child development is a gap that the proposed trial in South Africa seeks to address.Trial registrationPan African Clinical Trials Registry,PACTR201808107241133. Registered on 15 August 2018.

There is substantial evidence that early growth retardation, indicated by stunting, is associated with poorer cognitive function among children. There are, however, contradictory findings on the extent to which subsequent 'catch-up' growth among stunted children is associated with similar 'catch-up' cognitive functioning. In this paper we show that the apparent contradictions in the literature may be a result of differences in the definition of catch up used in the different studies. We explore two variations in definition: the age from which catch-up growth is measured, and the extent of growth required to be classified as 'caught up'. Using cohort data from South Africa with repeated measures of length in early childhood, we first show that varying the starting age from which catch up is measured from 1y to 2y greatly affects the conclusions drawn with respect to cognitive outcomes, as the prevalence of stunting tends to peak around 2y. Second, we show how the results differ when we vary what counts as catch up, and here we explore five definitions ranging from most lenient to strictest. The strictest definition requires children to have caught up sufficiently that their height-for-age falls within the 'normal' range at follow-up; very few children catch up to this extent. For all definitions of catch-up, except the strictest, we find that children who are stunted at 2 years of age who subsequently experience catch-up growth, on average, do worse on cognitive tests than children who were never stunted, and almost as poorly as children who remain stunted (with the coefficient ranging from -1.584; p 0.01 to -1.753; p 0.01). This suggests the timing of investments in early childhood is key, with intervention in the first two years to prevent deprivation that affects both linear growth and cognitive function.

BackgroundLittle is known about the patterns of development assistance (DA) for each component of reproductive, maternal, newborn, child and adolescent health (RMNCAH) in conflict-affected countries nor about the DA allocation in relation to the burden of disease.MethodsWe tracked DA to RMNCAH in general and to each of its four components: reproductive health (RH), maternal and newborn health (MNH), child health (CH) and adolescent health (AH), in 25 conflict-affected countries between 2003 and 2017. We compared DA and disability-adjusted life years (DALYs) for each component. Using keyword searching and funding allocation methods, we produced two sets of estimates: DA primarily targeting RMNCAH (lower bound) and DA both primarily and partially for RMNCAH or DA not explicitly targeting RMNCAH but benefiting it (upper bound).FindingsBetween 2003 and 2017, we identified 46 833 projects among the 25 countries that targeted RMNCAH. During the study period, DA to RMNCAH increased by seven-fold from $0.5 billion to $3.6 billion, with a slowdown since 2013. Cumulatively, RH received the largest proportion of DA to RMNCAH (50%) with 84% of its funding earmarked for HIV/AIDS, which contributed to less than 6% of the total RMNCAH-related DALYs. AH received 3% of the DA-RMNCAH but contributed 15% to the RMNCAH-related DALYs. Non-communicable diseases caused more than one-third of the DALYs among adolescents, but received only 3% of DA to AH. RMNCAH-inclusive estimates showed consistent results.ConclusionWhile there was a substantial increase in funding to RMNCAH in conflict-affected countries over the period of study, some health issues with high disease burden (eg, AH and non-communicable diseases) received a disproportionately small portion of aid for RMNCAH. We recommend that donors increase investment to RMNCAH in conflict-affected countries, particularly in areas where the burden of disease or the potential benefit of investment is likely to be high.

Many adults diagnosed with a life-threatening condition have children living at home; they and their partners face the dual challenge of coping with the diagnosis while trying to maintain a parenting role. Parents are often uncertain about how, when, and what to tell their children about the condition, and are fearful of the effect on their family. There is evidence that children are often aware that something is seriously wrong and want honest information. Health-care professionals have a key role in supporting and guiding parents and caregivers to communicate with their children about the diagnosis. However, the practical and emotional challenges of communicating with families are compounded by a scarcity of evidence-based guidelines. This Review considers children's awareness and understanding of their parents' condition, the effect of communication around parental life-threatening condition on their wellbeing, factors that influence communication, and the challenges to achieving effective communication. Children's and parents' preferences about communication are outlined. An expert workshop was convened to generate principles for health-care professionals, intended as practical guidance in the current absence of empirically derived guidelines.

When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.

Background There are few readily available, relatively easy to use and culturally adaptable developmental assessment tools for young children in southern Africa. The overarching aim of this study is to test the psychometric properties, contextual appropriateness and cut-off scores across 21 age groups of the Ages and Stages Questionnaire Third Edition (Squires & Bricker, 2009) among a group of typically developing children in South Africa and Zambia through a combination of both caregiver-report and direct observations, and to compare children's performance across sociodemographic variables. Methods The sample consisted of 853 children (50.5% Zambia, with 50.1% girls for Zambia and 50% girls for South Africa) aged 2 months to 60 months. Information on caregiver employment, education and household assets were also obtained. Results The psychometric properties of the ASQ-3 in southern Africa are consistent with those found in the extant literature. Analysis of item difficulty at each age reveals adequate levels of difficulty for majority of the items, with exception of the problem solving domain where half of the items at 54 and 60 months have poor pass rates. Sociodemographic variables were significantly associated with children's performance: higher caregiver levels of education are associated with higher toddler scores on the personal–social domain and higher preschooler scores on the problem solving domain; children whose caregivers earn a salary have higher fine motor scores during toddlerhood and higher problem solving scores during preschool and children who attend preschools have higher gross motor scores during toddlerhood and higher fine motor scores during the preschool years. Conclusions Findings provide evidence to support the psychometric properties and feasibility of using the ASQ-3 in both South Africa and Zambia through a combination of caregiver-report and direct observations.

Background Birth weight is an important determinant of an infant's immediate and future health. Aim This study examined associations between selected maternal psychosocial and environmental risk factors during pregnancy and subsequent infant birth weight, utilising data from the South African Birth to Twenty Plus (Bt20 +) birth cohort study. Subjects Exposure to nine maternal risks were assessed in 1228 women who completed an antenatal questionnaire and whose infants were delivered within a seven-week period. Outcome measures The outcome of interest was infant birth weight. Birth weight z-scores (BWZ) were calculated using the World Health Organization Child Growth Standards. Bivariate analyses and multiple regression models were used to identify significant risk factors. Results The mean infant birth weight was 3139 g (SD 486 g), with a significant advantage in mean birth weight for male infants of 73 g (p = 0.008). Being unsure or not wanting the pregnancy was associated with a ~ 156 g reduction in infant birth weight (β = − 0.32; 95% CI − 0.51; − 0.14). Tobacco use during pregnancy was also negatively associated with BWZ (β = − 0.32; 95% CI − 0.59; − 0.05). Exposure to both significant risk factors (tobacco use and pregnancy wantedness) was associated with cumulative reductions in birth weight, particularly among boys. Conclusions This study reinforces the importance of risks related to maternal attitudes and behaviours during pregnancy, namely unwanted pregnancy and tobacco use, which significantly lowered birth weight. Both identified risks are amenable to public health policy and programme intervention.

Background: Height and adiposity track over childhood, but few studies, to our knowledge, have longitudinally examined the mediating relation of the timing and progression of puberty. Objective: We assessed interrelations between prepubertal height and body mass index, the progression through puberty, and young adult height and adiposity. Methods: We analyzed data from the Birth to Twenty Plus study (females, n = 823; males, n = 765). Serial measures of anthropometry and pubertal development were obtained between ages 9 and 16 y. We used latent class growth analysis to categorize pubertal development with respect to pubic hair (females and males), breasts (females), and genitalia (males) development. Adult height and weight were obtained at ages 18 to 20 y. Results: Among females, higher latent class (earlier initiation and faster progression through puberty) was associated with an increased risk of obesity [pubic hair class 3 compared with class 1: RR, 3.41 (95% CI: 1.57, 7.44)] and inconsistent associations with height. Among males, higher latent class was associated with increased adult height [pubic hair development class 3 compared with class 1: 2.43 cm (95% CI: 0.88, 4.00)] and increased risk of overweight/obesity [pubic hair development class 3 compared with class 1: OR, 3.44 (95% CI: 1.44, 8.20)]. In females, the association with adult height became inverse after adjusting for prepubertal height [pubic hair development class 3 compared with class 1: females, 21.31 cm (95% CI: 22.32, 20.31)]; in males, the association with height was attenuated with this adjustment [20.56 cm (95% CI: 21.63, 0.52)]. Associations with adiposity were attenuated after adjusting for prepubertal adiposity. Conclusions: Progression throughpubertymodifies the relation between prepubertal and adult anthropometry. Screening for early or rapid progression of puberty might identify children at an increased risk of becoming overweight or obese adults. J Nutr doi: 10.3945/jn.116.231076.

We analyzed data from the Birth-to-Twenty study, a birth cohort initiated in 1990 in Soweto, the largest urban township in South Africa, adjacent to Johannesburg. Detailed information on this cohort has been published elsewhere (29). The study was designed to track the growth, health, and well-being of children. The cohort enrolled 3273 children who were born during a 6-wk period in early 1990. Participants were predominantly Black, and from families with a low socioeconomic status. Ethical approval was obtained from the University of the Witwatersrand Committee for Research on Human Subjects (approval identification no. M010556), and participants or their caregivers provided written informed consent throughout the study. Weight at birth, and weight and length/height at subsequent annual rounds were measured with the use of standard procedures (30). BMI was calculated as weight (kilograms) divided by height squared (meters squared). Height and BMI measures were converted to height-for-age z scores (HAZs)8 and BMI-for-age z scores (BMIZs) with the use of the WHO standards (31, 32). At birth or soon thereafter, data on demographic and socioeconomic variables, including the child’s ethnicity and maternal monthly income, were collected. Income was categorized into quintiles. At 9–16 y of age, pubertal development was assessed with the Tanner sexual maturation scale (SMS), a commonly used standard for evaluating pubertal stage in both clinical and research settings (33). The SMS consists of drawings of progressive stages in the development of secondary sexual characteristics—breasts in girls, genitals in boys, and pubic hair in both sexs (34, 35). The drawings are accompanied by written descriptions of each stage. The stages range from 1 (prepubertal) to 5 (postpubertal), with stage 2 considered to be the onset of puberty. From 9 to 11 y of age, a trained health care provider administered the SMS in a subset of Birth-to-Twenty participants. In a comparable group of South African adolescents, self-assessment was validated against expert assessment, both with the use of the SMS, and a substantial degree of concordance was found between the 2 ratings (36). Based on these findings, pubertal self-rating with the use of SMS was carried out at 12–16 y of age in the entire cohort. Participants were included in the present analysis if they had at least one SMS measurement, which resulted in an analytical sample of 2195 participants. Missing data were accounted for with the use of the Full Information Maximum Likelihood technique (37). Data management. We used latent class growth analysis (LCGA) in order to group participants into distinct classes based on common developmental trajectories for the SMS indicators of pubertal stage (Supplemental Figure 1). LCGA is an extension of latent growth curve modeling, which estimates a latent intercept (initial level of the outcome variable) and latent slope (rate of outcome change over time) for the entire population. However, instead of assuming that one growth trajectory adequately describes the entire population, LCGA identifies multiple growth trajectories and groups observations into distinct classes based on similarities in their growth patterns. We conducted separate analyses for girls (breast and pubic hair development), and for boys (genital and pubic hair development). We determined the optimal model in terms of the number of classes based on model fit statistics, with a focus on minimizing the value for the Bayesian Information Criteria, as well as parsimony of the model and identifying classes that had distinct differences in their developmental trajectories (37). We used ANOVA to assess the significance of differences in HAZ and BMIZ at ages 5 and 8 y between classes. We used multinomial logistic regression to determine whether HAZ and BMIZ at ages 5 and 8 y were associated with class membership. To address the strong correlation between repeated measures of HAZ and BMIZ in the same individuals, we computed sex-specific conditional measures of HAZ and BMIZ at age 8 y, as described elsewhere (38). These conditional measures represent the change in each of these measures that is not explained by the prior measure. A positive value represents a child who is growing faster than expected and a negative value characterizes a child growing slower than expected from their measure at age 5 y and the mean pattern in the sample. The results of the multinomial regression analyses are presented as relative risk ratios (RRRs), which are interpretable as ORs. To facilitate more direct comparisons with the existing literature, we created an indicator to represent the timing of pubertal development by comparing the children’s level of development in early adolescence to that of their peers. SMS scores at age 12 y were used, because the full cohort began providing pubertal data at this wave. Children who were at the median score at 12 y of age for pubic hair, breast, and genital development were considered to be the reference category. Those with a lower score were classified as slower developers, and those with a higher score were considered to be more rapid developers. With these 3 categories, we used multinomial logistic regression to assess the association between HAZ and BMIZ at ages 5 and 8 y with stage of pubertal development at age 12 y. We adjusted all models for ethnicity (Black, White, Indian, and Coloured) and quintiles of income. We used Mplus 7.3 (Muthen & Muthen) to perform the LGCA and to handle the missing data, and STATA 13.0 for all other analyses. P < 0.05 was considered to be statistically significant.

Background: Approximately 250 million (43%) children under five years in low- and middle-income countries are at risk of sub-optimal development. Of these, 67% are found in sub-Saharan Africa due to exposure to multiple risks, including inadequate stimulation at home. In order to promote early childhood development (ECD), an intervention integrating ECD content into routine facility-based health services and supporting ECD policy and advocacy is currently being implemented in Siaya County. In addition, parental counseling on early stimulation is integrated into home-based visits by community health volunteers. We aim to evaluate the intervention’s operational feasibility, effectiveness and cost-effectiveness.Methods: The study is a cluster-randomized controlled trial using a mixed-methods approach. The study is being conducted in Bondo sub-county in Siaya County. The study has three arms. Arm 1 will receive a health facility-based ECD intervention. Arm 2 will receive the health facility-based ECD intervention combined with home-based ECD counselling. Arm 3 (control) will receive standard care. Six health facilities in each study arm (18 in total) will be randomly selected from wards within the sub-county. We aim to recruit and follow-up 699 mother/caregiver-child dyads, 233 in each arm. Pregnant women are recruited when they visit health facilities during the third trimester. Analysis will involve estimating the effect of the intervention using mixed linear models and the Difference-in-Differences estimator.Conclusions: The data generated from this study will provide much-needed information for program design and implementation of interventions aimed at promoting ECD in Kenya and other sub-Saharan African countries.Trial Registration: Current Control Trial is ISRCTN11561283.

The authors examined the dimensionality and psychometric properties of the Multigroup Ethnic Identity Measure (MEIM) among Black South African adolescents (ages = 13–14; 52% female) representing several ethnic groups (Ndebele, Pedi, Sotho, Swati, Tsonga, Tswana, Venda, Xhosa, Zulu) and evaluated the measure for differential item functioning primarily among four ethnic groups (Sotho, Tswana, Xhosa, and Zulu). Results indicated that a two-dimensional model best represented the data, reflecting ethnic search/clarity and ethnic affirmations. Subsequently, we evaluated the equivalence of the MEIM among the four South African ethnic groups and a sample of African American adolescents (M(age) = 15.57 years; SD = 1.22; 51% female). Further analyses revealed that configural and metric models were excellent across the four South African ethnic groups and the African American group. However, scalar invariance (i.e., intercept) was not found; the item intercepts were different for the South African ethnic groups and African Americans. Findings are discussed with consideration for conducting research on ethnic identity among youth in South Africa.

The history of stigma around addiction and its treatment is long and pervasive. Stigma permeates the public’s perceptions of people with substance use disorders, the self-perceptions of those who have the disease, and the way in which it is addressed on a structural level. Instead of offering evidence-based clinical treatments within a medical setting, addiction typically is addressed outside mainstream health care by providers who are not trained to offer the comprehensive clinical care needed by those who have this complex, chronic condition. Even worse, because of stigma, addiction frequently is criminalized and those who have it often are penalized and denied effective treatment. Stigma even surrounds treatment itself, especially medication-based treatment, which is offered to only a fraction of the people who need it and only under the weight of onerous regulations and restrictions, despite the mounds of scientific evidence attesting to its safety and effectiveness. As drug overdose deaths continue to climb, we cannot afford to wait until stigma is eradicated through widespread public acceptance to treat addiction as a disease. The government, the health care system, the criminal justice system, and employers—the systems in power—must override stigma’s influence by ensuring that addiction is addressed with compassion, by trained health care professionals, using proven clinical treatments. As addiction begins to be viewed as the treatable disease that it is, stigma will recede and we will more effectively be able to contain our nation’s addiction crisis.

Prior work on data obtained from the urban Johannesburg-Soweto based Birth to Twenty Plus (Bt20+) cohort has documented extensive levels of travel to school in the early post-apartheid era (1997–2003), with fewer than 20% of children attending the age-appropriate school closest to their home ( de Kadt et al., 2014 ). These extremely high levels of schooling mobility impose costs on children and families, as well as the educational system more broadly, and have contributed to the evolution of contemporary enrolment patterns. This paper analyses the relationship between travel to school and potentially related variables at the individual, family and community level. Our analysis indicates that Black children, children attending higher quality schools, and those living in relatively poor areas were most likely to travel to school. However, while travel to school has a strong and positive univariate relationship with both maternal education and family socio-economic status (SES), this fades out in a multivariate analysis. Our findings highlight the significant costs incurred in the pursuit of high quality education by many Black children and families, as well as those living in poorer areas, in the early post-apartheid era. This is despite post-apartheid educational policy with an explicit aim of redress. The paper contributes to understanding the challenges of apartheid’s inequitable geographical legacy in ensuring equitable access to high quality education for all in South Africa, as well as to the growing literatures on the geography of education and school choice in low and middle income countries.

Nicotine use and addiction frequently co-occur with alcohol and other drug use and addiction in both young people and adults. Studies of the neurobiology of such co-occurrence shed light on the ways in which nicotine primes or sensitizes the brain to be more receptive to the use of other substances and to their addictive effects and the ways in which nicotine and other addictive substance use mutually perpetuate one another through cross reinforcement and cross-tolerance processes. These effects are especially pronounced during youth, when key regions of the brain associated with cognition, emotion, substance use, and addiction are undergoing rapid change and development. The substantial co-occurrence of all forms of nicotine use and other substance use and addiction underscores the need to control the growing use of noncigarette nicotine products, especially among youth, and to incorporate all forms of nicotine product use into substance use and addiction prevention and clinical practice.

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children’s development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

Males generally drink alcohol more than females do and have higher rates of alcohol use disorder and other health consequences associated with high-risk drinking; yet the gender gap is closing. In the past decade, women have shown dramatically steeper increases in alcohol use, risky drinking, and alcohol use disorder relative to men. This is highly concerning since the evidence is indisputable that women who drink alcohol experience its adverse effects, including addiction, more rapidly and intensely compared to men who drink similar amounts. While there are common biological and environmental factors associated with alcohol misuse and addiction across males and females, there also are notable differences. Despite this, alcohol-related policies, programs, and interventions do not adequately address these important differences. A comprehensive approach is needed that takes into account sex differences in motivations for alcohol use, consequences of alcohol use, barriers to treatment, and treatment and recovery needs.

Background Adverse childhood experiences (ACES) have been linked to poor health and well-being outcomes, including poor mental health such as psychological distress. Both ACEs and psychological distress pose a significant public health burden, particularly in low to middle income countries. Contemporaneous stress events in adulthood may also impact psychological distress. The aims of this study were to describe the prevalence of ACEs and psychological distress and to assess the separate and cumulative effect of ACEs on psychological distress, while accounting for the effect of adult stress. Methods In this cross-sectional study, we used retrospectively measured ACEs from a sample of 1223 young adults aged between 22 and 23 years (52% female) from the Birth to Twenty Plus Study. Psychological distress and adult life stress were measured with a six-month recall period. Hierarchical logistic regression was employed to assess the associations between the exposures and outcome. Results Nearly 90% of the sample reported at least one ACE and 28% reported psychological distress. The median number of ACEs reported was three (range 0–11). After accounting for demographic and socio-economic factors, all ACEs were individually associated with psychological distress except for parental divorce and unemployment. The individual ACEs increased the odds of PD by between 1.42 and 2.79 times. Compared to participants experiencing no ACEs, those experiencing one to five ACEs were three times more likely to report psychological distress (AOR 3.2 95% CI: 1.83–5.63), while participants who experienced six or more ACEs had nearly eight times greater odds of reporting psychological distress (AOR 7.98 95% CI: 4.28–14.91). Interaction analysis showed that in the absence of adult life stress, the effect of low ACEs compared to high ACEs on PD was not significantly different. Discussion and conclusion The prevalence of ACEs in this young adult population is high, similar to other studies in young adult populations. A significant direct association exists between ACEs and psychological distress. Adult life stress seems to be a mediator of this relationship. Interventions targeted at psychological distress should address both early life adversity and contemporary stress. Electronic supplementary material The online version of this article (10.1186/s12889-018-5767-0) contains supplementary material, which is available to authorized users.

BACKGROUND: The role that childhood stunting plays in the development of overweight and obesity later in life is not well understood, particularly in adolescence and young adulthood, because most studies have only followed up through midchildhood. OBJECTIVE: The objective of this study was to examine the relation between stunting and age-specific patterns of overweight and obesity incidence from early childhood to young adulthood in the context of a country in the process of the nutrition transition while these children were growing up. METHODS: We analyzed data from 895 participants in the Birth-to-Twenty Plus Cohort (Bt20(+)), an urban South African birth cohort initiated in 1990. Anthropometric data were collected at multiple ages and participants were included if they provided height at age 24 mo and ≥1 measure of body mass index [BMI; weight (kg)/height (m)(2)] in each of the following time periods: 4–8 y, 11–12 y, 13–15 y, 16–18 y, and 22–24 y. We defined stunting at age 24 mo as height-for-age z score 1 in childhood (4–8 y) and adolescence (11–12 y, 13–15 y, and 16–18 y) and BMI ≥25 in young adulthood (22–24 y). We compared BMI, BMIZ, and the prevalence of overweight by stunting status, stratified by sex. RESULTS: Our sample was 93% black and 51% female. The prevalence of stunting at 24 mo was 26% in males and 19% in females. In young adulthood, the prevalence of overweight and obesity was 15.5% (men) and 47.5% (women). Among both males and females, neither mean BMI nor a combined measure of overweight and obesity in any subsequent period differed by stunting status at 24 mo (P ≥ 0.05). CONCLUSION: Stunting at 24 mo was not related to the risk of overweight or obesity in this cohort. Stunting may not be an important contributor to the increasing obesity rates in urban South Africa.

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18–24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61–0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05–1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85–2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08–1.36), and marriage (aOR 1.55; 95% CI 1.37–1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18–24 vs. 25–32 years). Electronic supplementary material The online version of this article (doi:10.1007/s10461-017-1807-5) contains supplementary material, which is available to authorized users.

Involved and caring fatherhood contributes to the health and wellbeing of children, women and men. The corollary is also true - men, women and children are affected when fathers are not involved or supportive of their children. Many factors affect fathers' involvement, including women's attitudes, the history and nature of the relationship between mother and father, and the cultural context. This study explores gatekeeping and its impact on father involvement among Black South Africans in rural KwaZulu-Natal. Among married couples, gatekeeping occurs with respect to childcare and housework through women's attempts to validate their maternal identity according to socially and culturally constructed gender roles. Among unmarried, non-resident parents, women control father-child contact and involvement, with mothers and/or their families either facilitating or inhibiting father involvement. In this context, we found that cultural gatekeeping had a huge impact on father involvement, with the non-payment of inhlawulo or lobola regulating father-child involvement. In a country like South Africa, where there is high non-marital fertility and father-child non-residence, future research, parenting and family programmes should focus on strategies that encourage positive paternal involvement as well as maternal and cultural support for father involvement, regardless of parental relationship and residence status.

The use of psychometric assessments during early childhood to predict children’s later outcomes is vital for early intervention. This study evaluates the predictive power of eight psychometric assessments administered during early childhood as screening measures for identifying those in need of early interventions to prevent late school entry and grade repetition. The measures are the Bayley Scales of Infant Development and the Griffiths Mental Development Scales at 6 months and 1 year; the Vineland Social Maturity Scale and the Behaviour Screening Questionnaire at 2 years and 4 years; the Revised Denver Prescreening Developmental Questionnaire at 5 years; and the Conners’ Teacher Rating Scale, the Draw-a-Person, and the Raven’s Coloured Progressive Matrices at 7 years. We used receiver operating characteristic curve analysis to examine predictive values of the measures, and the area under the curve to assess sensitivity and specificity. Findings suggest that with a moderate degree of diagnostic accuracy, the Bayley Scales of Infant Development at Year 1 with receiver operating characteristic curve (area under the curve = 0.61; 95% confidence interval: 0.51, 0.71) and the Conners’ Teacher Rating Scale at Year 7 with receiver operating characteristic curve (area under the curve = 0.64; 95% confidence interval: 0.58, 0.70) can be used as screening measures to identify children at risk of late school entry. The Conners’ Teacher Rating Scale at Year 7 predicted grade repetition with a moderate degree of accuracy (area under the curve = 0.62; 95% confidence interval: 0.57, 0.67). The only statistically significant covariate-adjusted model showed that young maternal age ( β = –5.25; 95% confidence interval: –9.62, –0.88) and low socioeconomic status ( β = –2.04; 95% confidence interval: –3.76, –0.33) had a negative influence on the age at school entry as predicted by Bayley Scales of Infant Development at Year 1. This study is the first of its kind in South Africa, and contributes to the conceptual and empirical literature on children’s developmental assessment.

BACKGROUND In resource-limited settings, HIV infection is often diagnosed using 2 rapid tests. If the results are discordant, a third tie-breaker test is often used to determine HIV status. This study characterized samples with discordant rapid tests and compared different testing strategies for determining HIV status in these cases. METHODS Samples were previously collected from 173 African adults in a population-based survey who had discordant rapid test results. Samples were classified as HIV positive or HIV negative using a rigorous testing algorithm that included two fourth-generation tests, a discriminatory test, and 2 HIV RNA tests. Tie-breaker tests were evaluated, including rapid tests (1 performed in-country), a third-generation enzyme immunoassay, and two fourth-generation tests. Selected samples were further characterized using additional assays. RESULTS Twenty-nine samples (16.8%) were classified as HIV positive and 24 of those samples (82.8%) had undetectable HIV RNA. Antiretroviral drugs were detected in 1 sample. Sensitivity was 8.3%-43% for the rapid tests; 24.1% for the third-generation enzyme immunoassay; 95.8% and 96.6% for the fourth-generation tests. Specificity was lower for the fourth-generation tests than the other tests. Accuracy ranged from 79.5% to 91.3%. CONCLUSIONS In this population-based survey, most HIV-infected adults with discordant rapid tests were virally suppressed without antiretroviral drugs. Use of individual assays as tie-breaker tests was not a reliable method for determining HIV status in these individuals. More extensive testing algorithms that use a fourth-generation screening test with a discriminatory test and HIV RNA test are preferable for determining HIV status in these cases.

Many programs to support young children and families affected by HIV and AIDS depend substantially on a model of cascaded training from international nongovernmental organizations, through in-country groups and organizations to services on the ground. In this paper, we describe the training and capacity building – as described in proposals, progress reports, and individualized questionnaires – offered by 10 international organizations funded by the Conrad N. Hilton Foundation to provide supportive services for young children and their families in five southern and eastern African countries. We related the findings to effective features of training described in the literature. Training and capacity development were found to be the most substantial activities in rendering services to children and families, both in terms of effort and human and financial resources. A total of 67 trainings were conducted over a period of 18 months. Almost all trainings combine lecture-based instruction, group work/discussions, and role play, but only half of the trainings report some form of mentoring, supervision or coaching following the training. Drawing on the literature, it is likely that more purposeful planning is required in terms of the selection of trainees, local adaptation and development of materials, participatory training approaches, and techniques to develop and sustain skills as well as knowledge. Demonstration and mentorship in the field together with quality assurance procedures, pre-and post-assessment to evaluate training, processes to transfer learning into subsequent practice, as well as certification, are all fundamental steps to ensure that training plays a supportive role in the behavior changes necessary to support young children affected by HIV and AIDS and their families.

There is recognition that social protection policies such as raising the minimum wage can favourably impact health, but little evidence links minimum wage increases to child health outcomes. We used multi-year data (2003-2012) on national minimum wages linked to individual-level data from the Demographic and Health Surveys (DHS) from 23 low- and middle-income countries (LMICs) that had least two DHS surveys to establish pre- and post-observation periods. Over a pre- and post-interval ranging from 4 to 8 years, we examined minimum wage growth and four nutritional status outcomes among children under 5 years: stunting, wasting, underweight, and anthropometric failure. Using a differences-in-differences framework with country and time-fixed effects, a 10% increase in minimum wage growth over time was associated with a 0.5 percentage point decline in stunting (-0.054, 95% CI (-0.084,-0.025)), and a 0.3 percentage point decline in failure (-0.031, 95% CI (-0.057,-0.005)). We did not observe statistically significant associations between minimum wage growth and underweight or wasting. We found similar results for the poorest households working in non-agricultural and non-professional jobs, where minimum wage growth may have the most leverage. Modest increases in minimum wage over a 4- to 8-year period might be effective in reducing child undernutrition in LMICs.