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Background There is a general lack of research on children’s household experiences and child health outcomes in low- and middle-income countries (LMICs). This study examines the relationship between household composition, stunting and diarrhoea prevalence among children younger than 5 years of age in Botswana. Methods The analysis uses data from the 2007 Botswana Family Health Survey (BFHS) and multilevel logistic regression models. Results The findings indicate that stunting varies by whom the child lives with. Stunting is higher among children living with no parents compared to those living with both parents. Stunting is also high among children living with unrelated household members. Similarly, children in households with a mother-only and with a grandparent present, have a higher level of stunting compared to those living with both parents. Conversely, living with an aunt and living with other relatives, protects against stunting. The findings on diarrhoea prevalence show that children living in mother-only households and those living with no parents are less likely to have diarrhoea than those living with both parents. Also, across all households, those who are more affluent have lower rates of child stunting and diarrhoea than those which are more deprived. Finally, the findings show a clustering effect at the household level for both stunting and diarrhoea prevalence. Conclusions These findings suggest that policies and programs aimed at reducing stunting and diarrhoea may work best if they target households and other adults co-residing in homes with children besides biological parents. Further, children who live in poorer households deserve special attention.

BACKGROUND: Although couples HIV testing and counseling (CHTC) is effective for facilitating mutual disclosure and linkage to HIV care, uptake remains low. Using a randomized controlled design, we tested the efficacy of a behavioral couples-based intervention aimed to increase CHTC.SETTING: The Vulindlela district of KwaZulu-Natal, South Africa.METHODS: Couples were recruited from the community (eg, markets and community events). Couples were excluded if mutual HIV serostatus disclosure had occurred. Both partners had to report being each other's primary partner and relationship length was at least 6 months. Assessments occurred at baseline, and 3, 6, and 9 months after intervention. Eligible couples attended a group session (3-4 hours) after which randomization occurred. Intervention couples additionally received: one couples-based group session followed by 4 couples' counseling sessions (1-2 hours). Intervention topics included communication skills, intimate partner violence, and HIV prevention. Our primary outcomes were CHTC and sexual risk behavior.RESULTS: Overall, 334 couples were enrolled. Intervention couples were significantly more likely to have participated in CHTC [42% vs. 12% (P ≤ 0.001)]. In addition, their time to participate in CHTC was significantly shorter (logrank P ≤ 0.0001) (N = 332 couples). By group, 59% of those who tested HIV-positive in intervention and 40% of those who tested in control were new HIV diagnoses (P = 0.18). There were no group differences in unprotected sex.CONCLUSIONS: Our intervention improved CHTC uptake-a vehicle for mutual serostatus disclosure and entrée into HIV treatment, both of which exert a significant public health impact on communities substantially burdened by HIV.

BackgroundIn South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000–2014.MethodsUsing longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (ResultsThe proportion of children and adolescents (ConclusionsThe survival of parents with children and adolescents

Objective: The HIV literature has largely ignored the importance of alcohol use in the quality of intimate relationships in sub-Saharan Africa (SSA), despite evidence of alcohol’s role in relational behaviors that increase risk for HIV infection and other harms. The present study explored the association of alcohol use with relationship functioning among heterosexual couples from rural South Africa. Method: Dyadic analyses were conducted with 443 sexually active, heterosexual, South African couples (886 individuals) to examine the association between male partners’ alcohol use (abstinent, nonhazardous, and hazardous), and male and female partners’ reports of relationship intimacy, trust, mutually constructive communication, demand/withdraw communication, and satisfaction. Five structural equation models were fit using male partner alcohol use as a predictor of male and female reports of relationship quality. Results: Women with a hazardous-drinking male partner (compared to an abstainer) reported significantly higher levels of intimacy (p Conclusions: Hazardous alcohol use among South African couples is positively correlated with women’s relationship intimacy and maladaptive communication patterns, yet negatively correlated with men’s perceived trust.

BackgroundMortality risk is lower in married than in unmarried men and women. However, little is known about the association between mortality and relationship status in South Africa where marriage rates are low, migration is common, many couples are not co-resident and HIV prevalence is high.MethodUsing demographic surveillance data collected from 2001 to 2011, relationship status was categorised as conjugal (partners belong to the same household), non-conjugal (partners do not belong to the same household) or not partnered. Rates of relationship formation and dissolution were calculated by age and sex. Controlling for antiretroviral treatment (ART) introduction in 2005 as well as education, sex-specific and age-specific Cox proportional hazards models were used to investigate the association between relationship status and (1) all-cause mortality and (2) non-AIDS mortality.ResultsBefore 2005, individuals in conjugal relationships had a lower hazard of all-cause mortality in all age groups than not partnered men and women. Non-conjugal relationships lowered the risk of dying compared with not partnered men and women in fewer age groups. After ART introduction, the protective association of conjugal relationships was weaker but remained generally significant for men and women but not in non-conjugal relationships. In the later period, the association is reversed in young men (20–29?years) with mortality higher in conjugal and non-conjugal relationships compared with men not partnered. The analysis of non-AIDS deaths provided similar results.ConclusionsThe higher degree of social connections within a shared household environment that characterises conjugal relationships affords men and women greater protection against mortality.

Objective In view of expanding ‘test and treat’ initiatives, we sought to elicit how the experience of HIV testing influenced subsequent engagement in HIV care among people diagnosed with HIV. Methods As part of a multisite qualitative study, we conducted in-depth interviews in Uganda, South Africa, Tanzania, Kenya, Malawi and Zimbabwe with 5–10 health workers and 28–59 people living with HIV, per country. Topic guides covered patient and provider experiences of HIV testing and treatment services. Themes were derived through deductive and inductive coding. Results Various practices and techniques were employed by health workers to increase HIV testing uptake in line with national policies, some of which affected patients’ subsequent engagement with HIV services. Provider-initiated testing was generally appreciated, but rarely considered voluntary, with instances of coercion and testing without consent, which could lead to disengagement from care. Conflicting rationalities for HIV testing between health workers and their clients caused tensions that undermined engagement in HIV care among people living with HIV. Although many health workers helped clients to accept their diagnosis and engage in care, some delivered static, morally charged messages regarding sexual behaviours and expectations of clinic use which discouraged future care seeking. Repeat testing was commonly reported, reflecting patients’ doubts over the accuracy of prior results and beliefs that antiretroviral therapy may cure HIV. Repeat testing provided an opportunity to develop familiarity with clinical procedures, address concerns about HIV services and build trust with health workers. Conclusion The principles of consent and confidentiality that should underlie HIV testing and counselling practices may be modified or omitted by health workers to achieve perceived public health benefits and policy expectations. While such actions can increase HIV testing rates, they may also jeopardise efforts to connect people diagnosed with HIV to long-term care, and undermine the potential of test and treat interventions.

We assess depression rates and investigate whether depression among HIV-infected adults receiving antiretroviral treatment (ART) is associated with social support and HIV coping strategies in rural South Africa (SA). The study took place in a decentralised public-sector ART programme in a poor, rural area of KwaZulu-Natal, SA, with high-HIV prevalence and high-ART coverage. The 12-item General Health Questionnaire (GHQ12), validated in this setting, was used to assess depression in 272 adults recently initiated on ART. Estimates of depression prevalence ranged from 33% to 38%, depending on the method used to score the GHQ12. Instrumental social support (providing tangible factors for support, such as financial assistance, material goods or services), but not emotional social support (expressing feelings, such as empathy, love, trust or acceptance, to support a person), was significantly associated with lower likelihood of depression [adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) 0.52-0.81, P < 0.001], when controlling for sex, age, marital status, education, household wealth and CD4 cell count. In addition, using "avoidance of people" as a strategy to cope with HIV was associated with an almost three times higher odds of depression (aOR = 2.79, CI: 1.34-5.82, P = 0.006), whereas none of the other five coping strategies we assessed was significantly associated with depression. In addition to antidepressant drug treatment, interventions enhancing instrumental social support and behavioural therapy replacing withdrawal behaviours with active HIV coping strategies may be effective in reducing the burden of depression among patients on ART.

We used data from the Birth to Twenty Cohort study to understand children’s receipt of financial support from their fathers in a low income, Black community in urban South Africa. Specifically, we (1) described fathers’ financial support over the life course of children; (2) estimated survival probabilities of receiving support for all children and not receiving support for children who experienced a parental union dissolution; and (3) identified factors that explained variation in the receipt of support after a union dissolution. Results suggest that most children received full or partial support throughout the life course. Furthermore, a high proportion of children received support after a union dissolution with much of the variation driven by pre-dissolution support, father’s education and the presence of extended kin.

This paper examines how care-giving to adults and/or children and care-receiving is associated with the health and wellbeing of older people aged 50+ in rural South Africa. Data used are from a cross-sectional survey adapted from World Health Organization's Study on Global Ageing and Adult Health (SAGE) conducted in 2009/10 in rural South Africa. Bivariate statistics and multivariate logistical regression were used to assess the relationship between care-giving and/or care-receiving with functional disability, quality of life or emotional wellbeing, and self-rated health status, adjusted for socio-demographic factors. Sixty-three per cent of 422 older people were care-givers to at least one young adult or child; 27 per cent of older people were care-givers due to HIV-related reasons in young adults; 84 per cent of participants were care-recipients mainly from adult children, grandchildren and spouse. In logistic regressions adjusting for sex, age, marital status, education, receipt of grants, household headship, household wealth and HIV status, care-giving was statistically significantly associated with good functional ability as measured by ability to perform activities of daily living. This relationship was stronger for older people providing care-giving to adults than to children. In contrast, care-givers were less likely to report good emotional wellbeing; again the relationship was stronger for care-givers to adults than children. Simultaneous care-giving and -receiving was likewise associated with good functional ability, but about a 47 per cent lower chance of good emotional wellbeing. Participants who were HIV-infected were more likely to be in better health but less likely to be receiving care than those who were HIV-affected. Our findings suggest a strong relationship between care-giving and poor emotional wellbeing via an economic or psychological stressor pathway. Interventions that improve older people's socio-economic circumstances and reduce financial hardship as well as those that provide social support would go some way towards mitigating this relationship.

Gender is increasingly recognised as fundamental to understanding migration processes, causes, and consequences. In South Africa, it is intrinsic to the social transformations fueling high levels of internal migration and complex forms of mobility. Although female migration in Africa has often been characterised as less prevalent than male migration and primarily related to marriage, in South Africa, a feminisation of internal migration is underway, fueled by women's increasing labour market participation. In this paper, we report sex differences in patterns, trends, and determinants of internal migration based on data collected in a demographic surveillance system between 2001 and 2006 in rural KwaZulu-Natal. We show that women were somewhat more likely than men to undertake any migration, but sex differences in migration trends differed by migration flow, with women more likely to migrate into the area than men and men more likely to out-migrate. Out-migration was suppressed by marriage, particularly for women, but most women were not married; both men's and women's out-migrations were undertaken mainly for purposes of employment. Over half of female out-migrations (vs 35% of male out-migrations) were to nearby rural areas. The findings highlight the high mobility of this population and the extent to which gender is intimately related to the processes determining migration. We consider the implications of these findings for the measurement of migration and mobility, in particular for health and social policy and research among highly mobile populations in southern Africa.

This paper explores the implications of the disability grant for household members’ well-being and adults’ success on ART (antiretroviral therapy). It uses case studies based on data from an in-depth qualitative study of 10 households in KwaZulu-Natal. Receipt of the disability grant ensured that the basic needs of the HIV-infected adult could be met by other household members, especially when the grant was received when the person first met the qualifying criteria and in conjunction with ART. Where treatment was effective, HIV-infected adults were able to make substantial contributions to the well-being of other members in addition to the financial support provided by the grant itself. Thus, early access to financial support in conjunction with commencing ART may lead to improved health outcomes and reduce poverty and vulnerability associated with illness in poor households. This synergistic relationship between social welfare and treatment may in turn contribute to greater cost-efficiency.

Summary Background Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world. Methods Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods. Findings Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 42 8 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15·2 years for men (95% CI 12·4–17·8) and 17·2 years for women (14·5–20·2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79·7% of the total life expectancy gains in men (8·4 adult life-years), and 90·7% in women (12·8 adult life-years). For men, 9·5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1·2 years for men (−2·9 to 5·8) and to 5·3 years for women (2·6–7·8). In 2011–14, pulmonary tuberculosis and HIV were responsible for 84·9% of the life expectancy deficit in men and 80·8% in women. Interpretation The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis. Funding Wellcome Trust, the Bill & Melinda Gates Foundation, and the National Institutes of Health.

In rural South Africa, high HIV prevalence has the potential to affect the care and support that kin are able to provide to those living with HIV. Despite this, families seem to be largely resilient and a key source of care and support to family affected by HIV. In this article, we explore the motivations for the provision of care and support by kin. We use the results of a small-scale in-depth qualitative study conducted in 10 households over 6 months in rural KwaZulu-Natal, South Africa, to show that family obligation and conditional reciprocity operate in varying degrees and build social capital. We highlight the complexity of kin relations where obligation is not guaranteed or is limited, requiring the consideration of policy measures that provide means of social support that are not reliant on the family.

Introduction: power imbalances within sexual relationships have significant implications for HIV prevention in sub-Saharan Africa. Little is known about how power influences the quality of a relationship, which could be an important pathway leading to healthy behavior around HIV/AIDS.Methods: this paper uses data from 448 heterosexual couples (896 individuals) in rural KwaZulu-Natal, South Africa who completed baseline surveys from 2012 to 2014 as part of a couples-based HIV intervention trial. Using an actor-partner interdependence perspective, we assessed: (1) how both partners' perceptions of power influences their own (i.e., actor effect) and their partner's reports of relationship quality (i.e., partner effect); and (2) whether these associations differed by gender. We examined three constructs related to power (female power, male equitable gender norms, and shared power) and four domains of relationship quality (intimacy, trust, mutually constructive communication, and conflict).Results: for actor effects, shared power was strongly and consistently associated with higher relationship quality across all four domains. The effect of shared power on trust, mutually constructive communication, and conflict were stronger for men than women. The findings for female power and male equitable gender norms were more mixed. Female power was positively associated with women's reports of trust and mutually constructive communication, but negatively associated with intimacy. Male equitable gender norms were positively associated with men's reports of mutually constructive communication. For partner effects, male equitable gender norms were positively associated with women's reports of intimacy and negatively associated with women's reports of conflict.Conclusions: research and health interventions aiming to improving HIV-related behaviors should consider sources of shared power within couples and potential leverage points for empowerment at the couple level. Efforts solely focused on empowering women should also take the dyadic environment and men's perspectives into account to ensure positive relationship outcomes

Sexuality is an important determinant of health and wellbeing for all ages. The capacity and desire for emotional and sexual intimacy and pleasure is important for people throughout their lives. The issue of older people and sexuality has largely been ignored with the focus being almost entirely on fertility and reproductive aspects of sexuality, thus favouring the young and reproductive individuals. Various historical and cultural contexts shape the practices and perception of older people's sexuality in Africa. What is evident is the existence of myths and prejudices that sexuality is unimportant for older people, and this concern draws our attention to the presence of ageism in this sphere of life. Further, it is crucial to underscore the double jeopardy faced by older women where they not only face prejudice due to age, but are confronted with sexism as well where sexuality of older men is more tolerated than for their female age counterparts. The ageist and sexist attitude towards older peop...

Calls for research on men’s roles in families in sub-Saharan Africa, especially as fathers, and for greater efforts to engage men in family-based interventions and policy requires detailed data on family functioning, parenting and parenthood. However, in resource poor countries within the region few family or birth cohort studies have been conducted and household and population-based studies continue to be the main sources of empirical data about families. In this brief report, we review the data on fathers and father involvement collected in South Africa (e.g., national household surveys, household panel surveys, demographic surveillance systems, birth cohort) and suggest ways to improve ongoing empirical data collection efforts.

and to identify socio-demographic risk factors associated with adult injury-related deaths. methods The study used population-based mortality data collected by a demographic surveillance system on all resident and non-resident members of 11 000 households. Deaths and person-years of observation (pyo) were aggregated for individuals between 01 January 2000 and 31 December 2007. Cause of death was determined by verbal autopsy, coded using ICD-10 and further categorised using global burden of disease categories. Socio-demographic risk factors associated with injuries were examined using regression analyses. results We analysed data on 133 483 individuals with 717 584.6 person-years of observation (pyo) and 11 467 deaths. Of deaths, 8.9% were because of injury-related causes; 11% occurred in children

This paper examines the way gender shaped the health behaviours, health care experiences and narratives of HIV-positive men initiating antiretroviral treatment in South Africa. We conducted participant observation and in-depth, semi-structured interviews with eight men enrolled in a public HIV treatment programme in a rural health district in KwaZulu-Natal. We also interviewed their family members and programme staff. The study found that men's narratives and experiences of antiretroviral therapy (ART) were complex. Descriptions of control and coping juxtaposed with low self-esteem and guilt. Improvements in health following treatment increased optimism about the future but were readily undermined by men's concerns about being unable to meet strongly gendered expectations in relation to family and work. Alcohol use and abuse by men themselves or by family members was found to be an important issue influencing disclosure, uptake and adherence. Given messages discouraging alcohol use during treatment, men reported self-imposed delays to enrolment while they tried to stop or reduce alcohol use, although none had sought advice or professional help in doing so. Men also felt very threatened by alcohol abuse by family members fearing accidental disclose, insults and violence. With regards to health providers, men held strong views as to appropriate and professional behaviour by programme staff, particularly regarding confidentiality. As ART programmes in Africa become established and evolve, we not only need to identify barriers to men's access and adherence but monitor their health and treatment experiences. These findings suggest that the issue of alcohol and ART warrants further investigation. Additional training for primary health care providers and counsellors on health promotion with men may be useful.

HIV is no longer a new or emerging disease in southern Africa. In the era of HIV and AIDS, families and households have continued to form, build, migrate and dissolve. Children born in the 1980s with the risk of mother-to-child HIV transmission have already gone on to start the next generation of families and households. Isolating the impact of HIV and AIDS on families and households is complex given that the epidemic has become part of the direction and force of contemporary demographic, social and economic processes and trends. Cycles of family and household life have occurred in a changing HIV and AIDS public-health environment, one in which HIV treatment access has increased rapidly. As part of an on-going process to assess the relevance and effectiveness of policies and programmes designed to protect and support children affected by HIV and AIDS, it is necessary to update our knowledge about the family and household circumstances in which children live. This paper summarises findings from a review on the "Demographic Evidence of Family and Household Changes in Response to the Effects of HIV/AIDS in Southern Africa: Implications for Efforts to Strengthen Families". The review examined published literature presenting data from empirical studies, primarily large, cross-sectional or longitudinal population-based or sample surveys. The family or household life-cycle is used as a conceptual and organisational framework. The implications of the demographic evidence are discussed in relation to policy and programme responses to strengthen families and households in the region.

This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDS's Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of children's potential through early child development efforts.

Objective: To compare reported numbers of sexual partners in Eastern and Southern Africa. Methods: Sexual partnership data from four longitudinal population-based surveys (1998–2007) in Zimbabwe, Uganda and South Africa were aggregated and overall proportions reporting more than one lifetime sexual partner calculated. A lexis-style table was used to illustrate the average lifetime sexual partners by site, sex, age group and birth cohort. The male-to-female ratio of mean number of partnerships in the last 12 months was calculated by site and survey. For each single year of age, the proportion sexually active in the past year, the mean number of partners in the past year and the proportion with more than one partner in the past year were calculated. Results: Over 90% of men and women between 25 and 45 years of age reported being sexually active during the past 12 months, with most reporting at least one sexual partner. Overall, men reported higher numbers of lifetime sexual partners and partners in the last year than women. The male-to-female ratio of mean partnerships in the last year ranged from 1.41 to 1.86. In southern African cohorts, individuals in later birth cohorts reported fewer sexual partners and a lower proportion reported multiple partnerships compared with earlier birth cohorts, whereas these behavioural changes were not observed in the Ugandan cohorts. Across the four sites, reports of sexual partnerships followed a similar pattern for each sex. Conclusions: The longitudinal results show that reductions in the number of partnerships were more evident in southern Africa than in Uganda.

This paper describes marriage and partnership patterns and trends in rural KwaZulu-Natal, South Africa from 2000-2006. The study is based on longitudinal, population-based data collected by the Africa Centre demographic surveillance system. We consider whether the high rates of non-marriage among Africans in South Africa reported in the 1980s were reversed following the political transformation underway by the 1990s. Our findings show that marriage has continued to decline with a small increase in cohabitation among unmarried couples, particularly in more urbanised areas. Comparing surveillance and census data, we highlight problems with the use of the ‘living together’ marital status category in a highly mobile population.

In many parts of the developing world, rural areas exhibit high rates of unemployment and underemployment. Understanding what prevents people from migrating to find better jobs is central to the development process. In this paper, we examine whether binding credit constraints and childcare constraints limit the ability of households to send labor migrants, and whether the arrival of a large, stable source of income – here, the South African old-age pension – helps households to overcome these constraints. Specifically, we quantify the labor supply responses of prime-aged individuals to changes in the presence of pensioners, using longitudinal data collected in KwaZulu-Natal. Our ability to compare households and individuals before and after pension receipt, and pension loss, allows us to control for a host of unobservable household and individual characteristics that may determine labor market behavior. We find that large cash transfers to elderly South Africans lead to increased employment among prime-aged members of their households, a result that is masked in cross-sectional analysis by differences between pension and non-pension households. Pension receipt also influences where this employment takes place. We find large, significant effects on labor migration upon pension arrival. The pension’s impact is attributable both to the increase in household resources it represents, which can be used to stake migrants until they become self-sufficient, and to the presence of pensioners who can care for small children, which allows prime-aged adults to look for work elsewhere.

The objectives of this study were to describe the care and living arrangements of children in rural South Africa, focusing on differences between maternal, paternal and double orphans and non-orphans and to assess the prevalence and characteristics of ‘child-only’ households and ‘child- and elderly-only’ households in this setting. We analysed data from a longitudinal demographic information system using Mantel–Haenszel adjusted odds ratios and logistic regression. The prevalence of orphanhood almost doubled over the period 2000–2005. Maternal and double orphanhood prevalence increased more rapidly than paternal orphanhood, although most orphans are paternal orphans. Responsibility for paternal orphans' school fees and households is taken disproportionately by mothers. There is no evidence that it falls disproportionately to the young or elderly. Responsibility for maternal and double orphans' care is spread between different individuals with different ages, although the elderly have increased od...

OBJECTIVE: To examine mortality differentials in HIV-infected and uninfected adults by demographic characteristics and the effect of non-testing on the level and pattern of age-sex specific mortality. METHODS: Three annual prospective population-based HIV surveys between 2003 and 2006 provide information regarding individual adult HIV status; households were visited twice a year to collect information about births, deaths, migrations and other demographic, health and socioeconomic data. Deaths and person-years of exposure were aggregated for each calendar year between 2004 and 2006, from which mortality rates were derived. The association between risk factors and mortality was assessed using a Cox proportional hazards model. RESULTS: The observed rate of mortality in individuals who did not consent to HIV testing was four to seven times higher, and that in HIV-infected adults 11-19 times higher than mortality in HIV-negative individuals. After adjusting for age, sex and socioeconomic status, HIV-infected individuals had a ninefold greater hazard of dying than uninfected individuals. Mortality rates increased with age and peak in the 45-54 years age group, irrespective of HIV status. Multivariably, age and sex were significantly associated with the hazard of dying, but place of residency and socioeconomic status were not. Overall mortality declined from 71 to 48 deaths per 1000 person-years between 2005 and 2006. CONCLUSION: The substantial decline in mortality after 2004 is likely to be largely attributable to the increasing availability of antiretroviral therapy. Detailed investigation of the characteristics of the not-tested individuals is needed to understand their impact on mortality patterns.

Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988-2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa - where the HIV epidemic started later, has been very severe, and has not yet stabilized - the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas.

The health and well-being of female adolescents is considered crucial to the continued development of low-income countries. (1) Among the most widely used indicators of health and well-being for female adolescents are age at sexual debut (also described as age at first sex), age at first marriage or first union and age at first birth. Demographic and Health Survey (DHS) data are widely used to estimate these indicators, and DHS country reports routinely present the percentage of women aged 15-49 who experience sexual debut, marry or give birth before age 15, grouped into five-year cohorts, and the percentage of women aged 15-19 at time of survey who have started childbearing, by individual year of age. Despite evidence suggesting that social desirability bias and recall bias may exert a strong influence on reports of childbearing, sexual debut and marriage by adolescents, (2-4) the accuracy of DHS-based estimates of these widely reported indicators is poorly understood. Even less is known about the reliability of data when these events occur in very early adolescence. There is widespread recognition of the vulnerability of and risks faced by sexually active young adolescents (both in or outside of marriage), (5) and growing understanding of the need for appropriate sexual health education and services for this age-group. (6) To support improvements in education and services, age-disaggregated indicators are required to identify need and monitor progress. However, inaccurate data may lead to erroneous interpretations of both the proportions of adolescents experiencing sexual health events and of trends over time. In particular, underestimations of the proportions affected or overestimation of positive trends could lead to complacency about the scale of the problem or false optimism over progress. In this article, we first examine the consistency of DHS data from two consecutive surveys in each of nine countries on adolescent age at sexual debut, marriage or first union, and first birth across cohorts, disaggregated by age in years. We then carry out further analysis to determine which age-group of respondents (ages 15-19 vs. 20-24) is most likely to provide the most accurate estimates. In the discussion, we consider possible underlying causes for the inconsistencies we have identified and the implications the inconsistencies have for policymakers and researchers who use these data. Sources of Errors The DHS relies on retrospective reporting of events and asks all responding women of reproductive age to report on the same events, e.g., age at sexual debut, age at first marriage or union, and age at first birth. Errors in reporting on reproductive and sexual health events can be divided into three categories: recall error, survey completion issues and social desirability bias. While some of these sources of error are universal, others may be more prevalent in particular age-groups. Recall bias, an unintentional error in which an event is omitted or mistimed, is more common among older women than among younger women because more time has elapsed between the survey and the event of interest. (7) Perceptions of an event such as first marriage or union may be another source of unintentional error because the cultural, social and legal conditions defining such an event may vary. (8,9) Marriage and union formation may be fluid and, in many countries, are processes rather than single events, often spread out over many years. (10-13) Responses to questions on the occurrence and timing of marriage or union formation will reflect the current perceptions of respondents when thinking back over the course of their lives, and these perceptions may change as women get older. Survey completion issues may be a source of intentional bias. In the DHS, the backdating of births is a common problem because respondents who have given birth within five years of the survey are required to complete an additional questionnaire for the child. …

BackgroundIncreased sexual risk behaviour and HIV prevalence have been reported in migrants compared with non-migrants in sub-Saharan Africa. We investigated the association of residential and migration patterns with sexual HIV risk behaviours and HIV prevalence in an open, general population cohort in rural KwaZulu-Natal, South Africa.MethodsIn a mainly rural demographic surveillance area in northern KwaZulu-Natal, South Africa, we collected longitudinal demographic, migration, sexual behaviour, and HIV status data through household surveillance twice per year and individual surveillance once per year. All resident household members and a sample of non-resident household members (stratified by sex and migration patterns) were eligible for participation. Participants reported sexual risk behaviours, including data for multiple, concurrent, and casual sexual partners and condom use, and gave a dried blood spot sample via fingerprick for HIV testing. We investigated population-level differences in sexual HIV risk behaviours and HIV prevalence with respect to migration indicators using logistic regression models.FindingsBetween Jan 1, 2005, and Dec 31, 2011, the total eligible population at each surveillance round ranged between 21?129 and 22?726 women (aged 17–49 years) and between 20?399 and 22?100 men (aged 17–54 years). The number of eligible residents in any round ranged from 24?395 to 26?664 and the number of eligible non-residents ranged from 17?002 to 18?891 between rounds. The stratified sample of non-residents included between 2350 and 3366 individuals each year. Sexual risk behaviours were significantly more common in non-residents than in residents for both men and women. Estimated differences in sexual risk behaviours, but not HIV prevalence, varied between the migration indicators: recent migration, mobility, and migration type. HIV prevalence was significantly increased in current residents with a recent history of migration compared with other residents in the study area in men (adjusted odds ratio 1·19, 95% CI 1·07–1·33) and in women (1·18, 1·10–1·26).InterpretationLocal information about migrants and highly mobile individuals could help to target intervention strategies that are based on the identification of transmission hotspots.FundingWellcome Trust.

This study examines the social context of men’s health and health behaviors in rural KwaZulu-Natal, South Africa, particularly in relationship to fathering and fatherhood. Individual interviews and focus groups were conducted with 51 Zulu-speaking men. Three themes related to men’s health emerged from the analysis of transcripts: (a) the interweaving of health status and health behaviors in descriptions of “good” and “bad” fathers, (b) the dominance of positive accounts of health and health status in men’s own accounts, and (c) fathers’ narratives of transformations and positive reinforcement in health behaviors. The study reveals the pervasiveness of an ideal of healthy fathers, one in which the health of men has practical and symbolic importance not only for men themselves but also for others in the family and community. The study also suggests that men hold in esteem fathers who manage to be involved with their biological children who are not coresident or who are playing a fathering role for nonbiological children (social fathers). In South Africa, men’s health interventions have predominantly focused on issues related to HIV and sexual health. The new insights obtained from the perspective of men indicate that there is likely to be a positive response to health interventions that incorporate acknowledgment of, and support for, men’s aspirations and lived experiences of social and biological fatherhood. Furthermore, the findings indicate the value of data on men’s involvement in families for men’s health research in sub-Saharan Africa.

There is growing policy and academic interest in the conditions, experiences, and well-being of migrant families stretched across origin and destination households. In South Africa, the dispersal of children and migrant parents across multiple households is a commonplace childhood experience. However, in common with the broader international context, quantitative analyses of the social and residential connections between children and migrant parents in South Africa have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper describes a new data collection effort in the origin and destination households of migrants from rural KwaZulu-Natal and explains the methodology for using this data to examine multiple household contexts for children and parents. In order to illustrate the contribution that this form of data collection effort could make to family migration studies, the paper also presents results on the living arrangements of children ‘left behind’ by migrant parents; a potentially vulnerable group whose arrangements are challenging to examine with existing data sources. The empirical results show the majority (75%) of left behind children have previously migrated and a significant proportion of migrants' children (25%) were not living in their parent's origin or destination household. The findings highlight the need for careful measurement of the circumstances of left behind children and demonstrate the contribution of linked data for providing insights into the residential arrangements of migrants' children. © 2014 The Authors. Population, Space and Place published by John Wiley & Sons Ltd

This paper examines the reach and impact of the South African Child Support Grant, using longitudinal data collected through the Africa Centre for Health and Population Studies. The grant is being taken up for a third of all age-eligible resident children, and appears to be reaching those children living in the poorer households of the demographic surveillance area (DSA). Children who received the grant are significantly more likely to be enrolled in school in the years following grant receipt than are equally poor children of the same age. However, older brothers and sisters of grant recipients, when they were observed at younger ages, were less likely than other children to be enrolled in school – perhaps reflecting the greater poverty in grant-receiving households. Thus the grant appears to help overcome the impact of poverty on school enrolment.

Studies in Western populations report a J- or U-shaped relation between body mass index (BMI; in kg/m(2)) and mortality, in which persons with extremes of BMI experience increased mortality. In contrast, little is known about populations in developing countries, where nutritional status is lower.The objective was to examine the association between BMI and mortality in Bangladeshi women.A cohort of 1888 rural Bangladeshi women (mean age: 27.9 y) was followed over 19 y. Height, weight, arm circumference, fertility, and socioeconomic data were obtained between 1975 and 1979. Mortality, loss-to-follow-up, and additional socioeconomic data were identified by the demographic surveillance system of the International Centre for Health and Population Research, Bangladesh. Proportional hazards regression was used to examine the relation between BMI and all-cause mortality.The association between BMI and mortality was reverse J-shaped. After adjustment for socioeconomic indicators, the risk of dying was highest in women with BMIs in the lowest 10% of the decile distribution (16.39) and lowest in women with intermediate (11-89% range of the decile distribution) BMIs (16.39-20.71). Women with BMIs in the highest 10% of the distribution (20.71) had slightly elevated mortality (NS) compared with those with intermediate BMIs. Age and education were strongly associated with mortality. Women without schooling had a risk of mortality 4 times that of women withor = 1 y of schooling.A woman's BMI relative to the BMI distribution in the local population may be a better predictor of mortality than is absolute BMI. The contribution of education in reducing mortality supports development programs aimed at increasing women's education.

People have argued that the benefits of human immunodefi-ciency virus (HIV) testing and counselling are so important that participants in HIV surveys must be given their HIV test results and that individuals who decline to receive their test re -sults should be excluded from participation in such surveys.

Birth weight is an indicator of prenatal development associated with health in infancy and childhood, and may be affected by the family environment experienced by the mother during pregnancy. Using data from KwaZulu-Natal, South Africa, we explore the importance of the mother's access to the father and grandparents of the child during pregnancy. Controlling for household socio-economic indicators and maternal characteristics, the survival and residence of the biological father with the mother are positively associated with birth weight. The type of relationship seems to matter: married women have the heaviest newborns, but co-residence with a non-marital partner is also associated with higher birth weight. Access to the maternal grandmother may also be important: women whose mothers are alive have heavier newborns, but no additional benefit is observed from residing together. Co-residence with any grandparent is not associated with birth weight after controlling for the mother's partnership.

The majority of the black African population in South Africa utilize both traditional and public sector Western systems of healing for mental health care. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems. The aim of this study was to explore perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved in the provision of community mental health services. Qualitative individual and focus group interviews were conducted with key health care providers and service users in one typical rural South African health sub-district. The majority of service users held traditional explanatory models of illness and used dual systems of care, with shifting between treatment modalities reportedly causing problems with treatment adherence. Traditional healers expressed a lack of appreciation from Western health care practitioners but were open to training in Western biomedical approaches and establishing a collaborative relationship in the interests of improving patient care. Western biomedically trained practitioners were less interested in such an arrangement. Interventions to acquaint traditional practitioners with Western approaches to the treatment of mental illness, orientation of Western practitioners towards a culture-centred approach to mental health care, as well as the establishment of fora to facilitate the negotiation of respectful collaborative relationships between the two systems of healing are required at district level to promote an equitable collaboration in the interests of improved patient care.

Objectives: research on migration and HIV has largely focused on male migration, often failing to measure HIV risks associated with migration for women. We aimed to establish whether associations between migration and HIV infection differ for women and men, and identify possible mechanisms by which women's migration contributes to their high infection risk.Design: data on socio-demographic characteristics, patterns of migration, sexual behavior and HIV infection status were obtained for a population of 11,677 women aged 15–49 and men aged 15–54, resident members of households within a demographic surveillance area participating in HIV surveillance in 2003–04.Methods: logistic regression was conducted to examine whether sex and migration were independently associated with HIV infection in three additive effects models, using measures of recent migration, household presence and migration frequency. Multiplicative effects models were fitted to explore whether the risk of HIV associated with migration differed for males and females. Further modeling and simulations explored whether composition or behavioral differences accounted for observed associations.Results: relative to non-migrant males, non-migrant females had higher odds of being HIV-positive (adjusted odds ratio [aOR] = 1.72; 95% confidence interval [1.49–1.99]), but odds were higher for female migrants (aOR = 2.55 [2.07–3.13]). Female migrants also had higher odds of infection relative to female non-migrants (aOR = 1.48 [1.23–1.77]). The association between number of sexual partners over the lifetime and HIV infection was modified by both sex and migrant status: For male non-migrants, each additional partner was associated with 3% higher odds of HIV infection (aOR = 1.03 [1.02–1.05]); for male migrants the association between number of partners and HIV infection was non-significant. Each additional partner increased odds of HIV infection by 22% for female non-migrants (aOR = 1.22 [1.12–1.32]) and 46% for female migrants (aOR = 1.46 [1.25–1.69]).Conclusions: higher risk sexual behavior in the context of migration increased women's likelihood of HIV infection

Couples should be included in HIV prevention research, but their recruitment in southern Africa is challenging given high levels of migration and non-cohabitation. We describe the recruitment strategies and experiences of a pilot study in rural South Africa. With the aim of recruiting 20 couples at mobile voluntary counselling and testing (VCT) caravans and community venues, 75 index partners were screened with an average of 4 additional contacts required to schedule interviews. Recruiting and interviewing couples is feasible, but requires substantial resources.

There is increasing consensus on the importance of strengthening global health research to meet health and development goals. Three key global health research aims are to ensure that research (i) addresses priority health needs, (ii) contributes to policy development, and (iii) adds value to investments in developing countries through South-South collaboration and capacity-strengthening in the South. The ALPHA network (Analysing Longitudinal Population-based HIV/AIDS data on Africa) is an illustrative example of how these global health research aims can be translated into action. The network facilitates additional collaborative HIV epidemiological research among six independent research projects in Africa studying population-based cohorts. Under the first of the earlier mentioned aims, the network addresses key epidemiology research issues in HIV/AIDS which are crucial to making progress and monitoring progress in the response against HIV/AIDS. Under the second aim, the network's scientific programme of research has contributed to strengthening the evidence base on HIV epidemiology in Africa and has informed policy development in areas such as targeted HIV prevention, social support, monitoring epidemic response and epidemic forecasting. Under the third aim, investment in the network has added value to the research investment in the individual projects through capacity development among African researchers as well as through the collaborative research outputs of the individual projects. Lessons from the network are relevant to collaborations facing similar challenges in other areas of global health research. These include the importance of establishing transparent and efficient governance for research collaborations, developing advance consensus on data sharing, ensuring effective communication for networking and demonstrating the added value of research investment in South-South collaborations.