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  • 101. Lippman, Sheri A.
    et al.
    Neilands, Torsten B.
    MacPhail, Catherine
    Peacock, Dean
    Maman, Suzanne
    Rebombo, Dumisani
    Twine, Rhian
    Selin, Amanda
    Leslie, Hannah H.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Pettifor, Audrey
    Community Mobilization for HIV Testing Uptake: Results From a Community Randomized Trial of a Theory-Based Intervention in Rural South Africa2017In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 74, p. S44-S51Article in journal (Refereed)
    Abstract [en]

    Background: HIV testing uptake in South Africa is below optimal levels. Community mobilization (CM) may increase and sustain demand for HIV testing, however, little rigorous evidence exists regarding the effect of CM interventions on HIV testing and the mechanisms of action.

    Methods: We implemented a theory-driven CM intervention in 11 of 22 randomly-selected villages in rural Mpumalanga Province. Cross-sectional surveys including a community mobilization measure were conducted before (n = 1181) and after (n = 1175) a 2-year intervention (2012–2014). We assessed community-level intervention effects on reported HIV testing using multilevel logistic models. We used structural equation models to explore individual-level effects, specifically whether intervention assignment and individual intervention exposure were associated with HIV testing through community mobilization.

    Results: Reported testing increased equally in both control and intervention sites: the intervention effect was null in primary analyses. However, the hypothesized pathway, CM, was associated with higher HIV testing in the intervention communities. Every standard deviation increase in village CM score was associated with increased odds of reported HIV testing in intervention village participants (odds ratio: 2.6, P = <0.001) but not control village participants (odds ratio: 1.2, P = 0.53). Structural equation models demonstrate that the intervention affected HIV testing uptake through the individual intervention exposure received and higher personal mobilization scores.

    Conclusions: There was no evidence of community-wide gains in HIV testing due to the intervention. However, a significant intervention effect on HIV testing was noted in residents who were personally exposed to the intervention and who evidenced higher community mobilization. Research is needed to understand whether CM interventions can be diffused within communities over time.

  • 102. Lippman, Sheri A.
    et al.
    Pettifor, Audrey Pettifor
    Neilands, Torsten B.
    MacPhail, Catherine
    Peacock, Dean
    Maman, Suzanne
    Twine, Rhian
    Selin, Amanda
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Communities can mobilize to test: findings from a community randomized trial of a theory-based community mobilization intervention in South Africa2015In: Journal of the International AIDS Society, ISSN 1758-2652, E-ISSN 1758-2652, Vol. 18Article in journal (Other academic)
  • 103. Lippman, Sheri A.
    et al.
    Pettifor, Audrey
    Rebombo, Dumisani
    Julien, Aimee
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Dufour, Mi-Suk Kang
    Kabudula, Chodziwadziwa Whiteson
    Neilands, Torsten B.
    Twine, Rhian
    Gottert, Ann
    Gomez-Olive, F. Xavier
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Sanne, Ian
    Peacock, Dean
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa.
    Evaluation of the Tsima community mobilization intervention to improve engagement in HIV testing and care in South Africa: study protocol for a cluster randomized trial2017In: Implementation Science, ISSN 1748-5908, E-ISSN 1748-5908, Vol. 12, no 9Article in journal (Refereed)
    Abstract [en]

    Background: HIV transmission can be decreased substantially by reducing the burden of undiagnosed HIV infection and expanding early and consistent use of antiretroviral therapy (ART). Treatment as prevention (TasP) has been proposed as key to ending the HIV epidemic. To activate TasP in high prevalence countries, like South Africa, communities must be motivated to know their status, engage in care, and remain in care. Community mobilization (CM) has the potential to significantly increase uptake testing, linkage to and retention in care by addressing the primary social barriers to engagement with HIV care-including poor understanding of HIV care; fear and stigma associated with infection, clinic attendance and disclosure; lack of social support; and gender norms that deter men from accessing care. Methods/design: Using a cluster randomized trial design, we are implementing a 3-year-theory-based CM intervention and comparing gains in HIV testing, linkage, and retention in care among individuals residing in 8 intervention communities to that of individuals residing in 7 control communities. Eligible communities include 15 villages within a health and demographic surveillance site (HDSS) in rural Mpumalanga, South Africa, that were not exposed to previous CM efforts. CM activities conducted in the 8 intervention villages map onto six mobilization domains that comprise the key components for community mobilization around HIV prevention. To evaluate the intervention, we will link a clinic-based electronic clinical tracking system in all area clinics to the HDSS longitudinal census data, thus creating an open, population-based cohort with over 30,000 18-49-year-old residents. We will estimate the marginal effect of the intervention on individual outcomes using generalized estimating equations. In addition, we will evaluate CM processes by conducting baseline and endline surveys among a random sample of 1200 community residents at each time point to monitor intervention exposure and community level change using validated measures of CM. Discussion: Given the known importance of community social factors with regard to uptake of testing and HIV care, and the lack of rigorously evaluated community-level interventions effective in improving testing uptake, linkage and retention, the proposed study will yield much needed data to understand the potential of CM to improve the prevention and care cascade. Further, our work in developing a CM framework and domain measures will permit validation of a CM conceptual framework and process, which should prove valuable for community programming in Africa.

  • 104. Manyema, M.
    et al.
    Norris, S. A.
    Said-Mohamed, R.
    Tollman, Stephen T.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences,University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Twine, R.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences,University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Richter, L. M.
    The associations between interpersonal violence and psychological distress among rural and urban young women in South Africa2018In: Health and Place, ISSN 1353-8292, E-ISSN 1873-2054, Vol. 51, p. 97-106Article in journal (Refereed)
    Abstract [en]

    Background: 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.

    Methods: Data on experiences of violence and psychological distress were collected from a total of 926 nonpregnant 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.

    Results: 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.

    Conclusion: 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.

  • 105. Maraba, Noriah
    et al.
    Karat, Aaron S.
    McCarthy, Kerrigan
    Churchyarda, Gavin J.
    Charalambous, Salome
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt); School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana .
    Grant, Alison D.
    Chihota, Violet
    Verbal autopsy-assigned causes of death among adults being investigated for TB in South Africa2016In: Transactions of the Royal Society of Tropical Medicine and Hygiene, ISSN 0035-9203, E-ISSN 1878-3503, Vol. 110, no 9, p. 510-516Article in journal (Refereed)
    Abstract [en]

    Background: Adults being investigated for TB in South Africa experience high mortality, yet causes of death (CoD) are not well defined. We determined CoD in this population using verbal autopsy (VA), and compared HIV- and TB-associated CoD using physician-certified verbal autopsy (PCVA) and InterVA-4 software. Methods: All contactable consenting caregivers of participants who died during a trial comparing Xpert MTB/RIF to smear microscopy were interviewed using the WHO VA tool. CoD were assigned using PCVA and InterVA-4. Kappa statistic (K) and concordance correlation coefficient (CCC) were calculated for comparison. Results: Among 231 deaths, relatives of 137 deceased were interviewed. Of the 137 deceased 76 (55.4%) were males, median age 41 years (IQR 33-50). PCVA assigned 70 (51.1%) TB immediate CoD (44 [62.8%] pulmonary TB; 26 [37.1%] extra-pulmonary TB); 21 (15.3%) HIV/AIDS-related; and 46 (33.5%) other CoD. InterVA-4 assigned 48 (35.0%) TB deaths; 49 (35.7%) HIV/AIDS-related deaths; and 40 (29.1%) other CoD. Agreement between PCVA and InterVA-4 CoD was slight at individual level (K=0.20; 95% CI 0.10-0.30) and poor at population level (CCC 0.67; 95% CI 0.38-0.99). Conclusions: TB and HIV are leading CoD among adults being investigated for TB. PCVA and InterVA agreement at individual level was slight and poor at population level. VA methodology needs further development where TB and HIV are common.

  • 106.
    Mee, Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Kanda, Accra, Ghana.
    Madhavan, Sangeetha
    Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Department of African–American Studies, University of Maryland, Maryland, USA.
    Dowling Root, Elisabeth
    Department of Geography and Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, USA.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Kanda, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Kanda, Accra, Ghana.
    Evidence for localised HIV related micro-epidemics associated with the decentralised provision of antiretroviral treatment in rural South Africa: a spatio-temporal analysis of changing mortality patterns (2007-2010)2014In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 4, no 1, article id 010403Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In this study we analysed the spatial and temporal changes in patterns of mortality over a period when antiretroviral therapy (ART) was rolled out in a rural region of north-eastern South Africa. Previous studies have identified localised concentrated HIV related sub-epidemics and recommended that micro-level analyses be carried out in order to direct focused interventions.

    METHODS: Data from an ongoing health and socio-demographic surveillance study was used in the analysis. The follow-up was divided into two periods, 2007-2008 and 2009-2010, representing the times immediately before and after the effects on mortality of the decentralised ART provision from a newly established local health centre would be expected to be evident. The study population at the start of the analysis was approximately 73 000 individuals. Data were aggregated by village and also using a 2 × 2 km grid. We identified villages, grid squares and regions in the site where mortality rates within each time period or rate ratios between the periods differed significantly from the overall trends. We used clustering techniques to identify cause-specific mortality hotspots.

    FINDINGS: Comparing the two periods, there was a 30% decrease in age and gender standardised adult HIV-related and TB (HIV/TB) mortality with no change in mortality due to other causes. There was considerable spatial heterogeneity in the mortality patterns. Areas separated by 2 to 4 km with very different epidemic trajectories were identified. There was evidence that the impact of ART in reducing HIV/TB mortality was greatest in communities with higher mortality rates in the earlier period.

    CONCLUSIONS: This study shows the value of conducting high resolution spatial analyses in order to understand how local micro-epidemics contribute to changes seen over a wider area. Such analyses can support targeted interventions.

  • 107.
    Mee, Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Madhavan, Sangeetha
    Kabudula, Chodziwadziwa
    Gómez-Olivé, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Hargreaves, James
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study2014In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, article id 24826Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.

    DESIGN: This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.

    RESULTS: Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.

    CONCLUSIONS: In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.

  • 108.
    Mee, Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Population Health, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Kabudula, Chodziwadziwa
    University of the Witwatersrand.
    Wagner, Ryan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Gómez-Olivé, F. Xavier
    University of the Witwatersrand.
    Madhavan, Sangeetha
    University of Maryland-College Park.
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    The development of a localised HIV epidemic and the associated excess mortality burden in a rural area of South Africa2016In: Global Health, Epidemiology and Genomics, E-ISSN 2054-4200, Vol. 1, no e7Article in journal (Refereed)
    Abstract [en]

    The human immunodeficiency virus (HIV) epidemic in South Africa rapidly developed into a major pandemic. Here we analyse the development of the epidemic in a rural area of the country. The data used were collected between 1992 and 2013 in a longitudinal population survey, the Agincourt Health and Demographic Surveillance Study, in the northeast of the country. Throughout the period of study mortality rates were similar in all villages, suggesting that there were multiple index cases evenly spread geographically. These were likely to have been returning migrant workers. For those aged below 39 years the HIV mortality rate was higher for women, above this age it was higher for men. This indicates the protective effect of greater access to HIV testing and treatment among older women. The recent convergence of mortality rates for Mozambicans and South Africans indicates that the former refugee population are being assimilated into the host community. More than 60% of the deaths occurring in this community between 1992 and 2013 could be attributed directly or indirectly to HIV. Recently there has been an increasing level of non-HIV mortality which has important implications for local healthcare provision. This study demonstrates how evidence from longitudinal analyses can support healthcare planning.

  • 109.
    Mee, Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; London School of Hygiene and Tropical Medicine, London, UK.
    Wagner, Ryan G
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Gómez-Olivé, Francesc Xavier
    Kabudula, Chodziwadziwa
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Madhavan, Sangeetha
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Changing use of traditional healthcare amongst those dying of HIV related disease and TB in rural South Africa from 2003 - 2011: a retrospective cohort study2014In: BMC Complementary and Alternative Medicine, ISSN 1472-6882, E-ISSN 1472-6882, Vol. 14, no 1, article id 504Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period.

    METHODS: Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use.

    RESULTS: There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated.

    CONCLUSIONS: There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.

  • 110. Micklesfield, Lisa K.
    et al.
    Munthali, Richard J.
    Prioreschi, Alessandra
    Said-Mohamed, Rihlat
    van Heerden, Alastair
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; INDEPTH Network, 38 & 40 Mensah Wood Street, East Legon, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; INDEPTH Network, 38 & 40 Mensah Wood Street, East Legon, Accra, Ghana.
    Dunger, David
    Norris, Shane A.
    Understanding the Relationship between Socio-Economic Status, Physical Activity and Sedentary Behaviour, and Adiposity in Young Adult South African Women Using Structural Equation Modelling2017In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 14, no 10, article id 1271Article in journal (Refereed)
    Abstract [en]

    Socio-economic status (SES) is an important predictor of obesity, but how it is associated with differences in physical activity and sedentary behaviour is less clear. This cross-sectional study examined the association between SES (sum of household assets), physical activity and sedentary time, and how they predict adiposity. Socio-demographic, anthropometric, and physical activity data on rural (n = 509) and urban (n = 510) South African women (18-23 years) were collected. Overweight and obesity prevalence, and sedentary time, were higher; and moderate-vigorous intensity physical activity (MVPA) was lower, in the urban sample. Structural equation models (SEMs) were constructed for BMI and waist circumference. In the urban sample SES had a direct inverse effect on MVPA (beta; 95% CI, -41.69; -73.40 to -9.98), while in the rural sample SES had a direct effect on BMI (beta; 95% CI, 0.306; 0.03 to 0.59). In the pooled sample, SES had a direct inverse effect on MVPA (beta; 95% CI, 144; -170.34 to -119.04), and MVPA was directly associated with BMI (beta; 95% CI, 0.04; 0.01 to 0.08). The influence of SES, and the role of physical activity and sedentary time on adiposity differs between the urban and rural samples, and the importance of other environmental and behavioural factors must be considered in the development of obesity and the design of effective interventions.

  • 111. Micklesfield, Lisa K
    et al.
    Pedro, Titilola M
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pettifor, John M
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norris, Shane A
    Physical activity and sedentary behavior among adolescents in rural South Africa: levels, patterns and correlates2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, p. 40-Article in journal (Refereed)
    Abstract [en]

    Background: Physical inactivity is increasing among children and adolescents and may be contributing to the increasing prevalence of overweight and obesity. This study examines physical activity and sedentary behavior patterns, and explores associations with individual, maternal, household, and community factors amongst rural South African adolescents.

    Methods: In 2009, 381 subjects, stratified by ages 11-12-years and 14-15-years, were randomly selected from 3511 children and adolescents who had participated in a growth survey two years previously. Weight and height were measured and self-reported Tanner pubertal stage was collected. A questionnaire quantifying frequency and duration of physical activity (PA) domains and sedentary time for the previous 12 months was administered. Moderate-vigorous physical activity (MVPA mins/wk) was calculated for time spent in school and club sport. Socio-demographic and other related data were included from the Agincourt health and socio-demographic system (HDSS). The Agincourt HDSS was established in 1992 and collects prospective data on the community living in the Agincourt sub-district of Mpumalanga Province in rural north-east South Africa.

    Results: Puberty, maternal education and socio-economic status (SES) contributed significantly to the mulitiple linear regression model for sedentary behavior (R-2=0.199; adjusted R-2=0.139; p < 0.000), and sex, SES and maternal education contributed to the tobit regression model for school and club sport MVPA (p < 0.000). MVPA, calculated from school and club sport, was higher in boys than girls (p < 0.001), and informal activity was lower (boys: p < 0.05 and girls: p < 0.01) while sedentary time was higher (girls: p < 0.01) in the older than the younger groups. Ninety-two percent (92%) of the sample reported walking for transport.

    Conclusions: In this study of rural South African adolescent boys and girls, SES at the maternal, household and community level independently predicted time spent in sedentary behaviors, and school and club MVPA. This study provides local data that can be used to develop health promotion strategies specific to this community, and other similar communities in developing countries.

  • 112. Moyes, Jocelyn
    et al.
    Cohen, Cheryl
    Pretorius, Marthi
    Groome, Michelle
    von Gottberg, Anne
    Wolter, Nicole
    Walaza, Sibongile
    Haffejee, Sumayya
    Chhagan, Meera
    Naby, Fathima
    Cohen, Adam L.
    Tempia, Stefano
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH network, Accra, Ghana.
    Dawood, Halima
    Venter, Marietjie
    Madhi, Shabir A.
    Epidemiology of Respiratory Syncytial Virus-Associated Acute Lower Respiratory Tract Infection Hospitalizations Among HIV-Infected and HIV-Uninfected South African Children, 2010-20112013In: Journal of Infectious Diseases, ISSN 0022-1899, E-ISSN 1537-6613, Vol. 208, no Supplement: 3, p. S217-S226Article in journal (Refereed)
    Abstract [en]

    Background. There are limited data on respiratory syncytial virus (RSV) infection among children in settings with a high prevalence of human immunodeficiency virus (HIV). We studied the epidemiology of RSV-associated acute lower respiratory tract infection (ALRTI) hospitalizations among HIV-infected and HIV-uninfected children in South Africa. Methods. Children aged <5 years admitted to sentinel surveillance hospitals with physician-diagnosed neonatal sepsis or ALRTI were enrolled. Nasopharyngeal aspirates were tested by multiplex real-time polymerase chain reaction assays for RSV and other viruses. Associations between possible risk factors and severe outcomes for RSV infection among HIV-infected and uninfected children were examined. The relative risk of hospitalization in HIV-infected and HIV-uninfected children was calculated in 1 site with population denominators. Results. Of 4489 participants, 4293 (96%) were tested for RSV, of whom 1157 (27%) tested positive. With adjustment for age, HIV-infected children had a 3-5-fold increased risk of hospitalization with RSV-associated ALRTI (2010 relative risk, 5.6; [95% confidence interval (CI), 4.5-6.4]; 2011 relative risk, 3.1 [ 95% CI, 2.6-3.6]). On multivariable analysis, HIV-infected children with RSV-associated ALRTI had higher odds of death (adjusted odds ratio. 31.1; 95% CI, 5.4-179.8) and hospitalization for >5 days (adjusted odds ratio, 4.0; 95% CI, 1.5-10.6) than HIV-uninfected children. Conclusion. HIV-infected children have a higher risk of hospitalization with RSV-associated ALRTI and a poorer outcome than HIV-uninfected children. These children should be targeted for interventions aimed at preventing severe RSV disease.

  • 113. Moyes, Jocelyn
    et al.
    Walaza, Sibongile
    Pretorius, Marthi
    Groome, Michelle
    von Gottberg, Anne
    Wolter, Nicole
    Haffejee, Sumayya
    Variava, Ebrahim
    Cohen, Adam L.
    Tempia, Stefano
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network Accra, Ghana.
    Dawood, Halima
    Venter, Marietjie
    Cohen, Cheryl
    Madhi, Shabir A.
    Respiratory syncytial virus in adults with severe acute respiratory illness in a high HIV prevalence setting2017In: Journal of Infection, ISSN 0163-4453, E-ISSN 1532-2742, Vol. 75, no 4, p. 346-355Article in journal (Refereed)
    Abstract [en]

    Background: There are limited data on the epidemiology of respiratory syncytial virus (RSV) illness in HIV-infected adults or the elderly in Africa. We studied the epidemiology of RSV-associated severe acute respiratory illness (SARI) hospitalizations in adults in South Africa from 2009 through 2013. Methods: Individuals admitted to sentinel surveillance hospitals were investigated by respiratory tract swabs for RSV, using a multiplex real-time polymerase chain reaction assay. The incidence of RSV-associated SARI was calculated for the one site with population denominators. Results: Of 7796 participants investigated, 329 (4%) tested positive for RSV. On multivariable analysis, HIV-infected individuals with RSV-associated SARI had greater odds of being in the age groups 18-44 and 45-64 years (odd ratios (OR) 26.3; 95% confidence interval (CI) 6.2-112.1 and OR 11.4; 95% CI 2.6-50.0) compared with those >= 65 years and being female (OR 2.7; 95% CI 1.4-5.4). The relative risk of hospitalization with RSV-associated SARI was 12-18 times higher in HIV infected individual compared to that of HIV-uninfected. Conclusion: The incidence of RSV-associated SARI was higher in HIV-infected individuals and those aged 65 years and older. Further studies are warranted to describe the disease association of RSV detected in adults with SARI.

  • 114. Msimang, Veerle M. Y.
    et al.
    Page, Nicola
    Groome, Michelle J.
    Moyes, Jocelyn
    Cortese, Margaret M.
    Seheri, Mapaseka
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Chagan, Meera
    Madhi, Shabir A.
    Cohen, Cheryl
    Impact of Rotavirus Vaccine on Childhood Diarrheal Hospitalization After Introduction Into the South African Public Immunization Program2013In: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, no 12, p. 1359-1364Article in journal (Refereed)
    Abstract [en]

    Background: Oral rotavirus vaccine was introduced into the South African routine immunization program in August 2009 administered at 6 and 14 weeks with no catch-up. We described the change in rotavirus-associated diarrheal hospitalizations among children <5 years at 3 sentinel sites from 2009 through 2011. Methods: During 2009 through 2011, we compared the proportion of enrolled children aged <5 years hospitalized with acute gastroenteritis and testing rotavirus positive. We used hospital data to determine the change in diarrhea hospitalizations and estimated total numbers of rotavirus hospitalizations by adjusting for nonenrolled patients. Stool samples were tested for rotavirus using enzyme immunoassay. Results: In 2009 (May-December), 46% (404/883) of samples among children <5 years tested rotavirus positive, decreasing to 33% (192/580) (P < 0.001) in 2010 and 29% (113/396) (P < 0.001) in 2011. Compared with May-December 2009, total diarrhea hospitalizations among children aged <5 years was one-third lower in May-December of 2010 and 2011. Among infants, adjusted rotavirus hospitalizations were 61% (n = 267) and 69% (n = 214) lower, respectively, in 2010 and 2011 when compared with 2009 (n = 689), and 45 and 50 percentage points greater than the reduction in rotavirus-negative cases. Among children <5 years, rotavirus hospitalizations were 54% and 58% lower in 2010 and 2011, compared with 2009 (40 and 44 percentage points greater than reduction in rotavirus-negative cases). Rotavirus reductions occurred in rural and urban settings. Conclusion: Using published estimates of rotavirus hospitalization burden, we estimate that at least 13,000 to 20,000 hospitalizations in children <2 years were prevented in the 2 years after rotavirus vaccine introduction.

  • 115. Murray, Jillian
    et al.
    Cohen, Adam
    Walaza, Sibongile
    Groome, Michelle
    Madhi, Shabir
    Variava, Ebrahim
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dawood, Halima
    Tempia, Stefano
    Tshangela, Akhona
    Venter, Marietje
    Feikin, Daniel
    Cohen, Cheryl
    Determining the Provincial and National Burden of Influenza-Associated Severe Acute Respiratory Illness in South Africa Using a Rapid Assessment Methodology2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 7, article id e0132078Article in journal (Refereed)
    Abstract [en]

    Local disease burden data are necessary to set national influenza vaccination policy. In 2010 the population of South Africa was 50 million and the HIV prevalence was 11%. We used a previously developed methodology to determine severe influenza burden in South Africa. Hospitalized severe acute respiratory illness (SARI) incidence was calculated, stratified by HIV status, for four age groups using data from population-based surveillance in one site situated in Gauteng Province for 2009-2011. These rates were adjusted for each of the remaining 8 provinces based on their prevalence of risk factors for pneumonia and healthcare-seeking behavior. We estimated non-hospitalized influenza-associated SARI from healthcare utilization surveys at two sites and used the percent of SARI cases positive for influenza from sentinel surveillance to derive the influenza-associated SARI rate. We applied rates of hospitalized and non-hospitalized influenza-associated SARI to census data to calculate the national number of cases. The percent of SARI cases that tested positive for influenza ranged from 7-17% depending on age group, year, province and HIV status. In 2010, there were an estimated 21,555 total severe influenza cases in HIV-uninfected individuals and 13,876 in HIV-infected individuals. In 2011, there were an estimated 29,892 total severe influenza cases in HIV-uninfected individuals and 17,289 in HIV-infected individuals. The incidence of influenza-associated SARI was highest in children <5 years and was higher in HIV-infected than HIV-uninfected persons in all age groups. Influenza virus was associated with a substantial amount of severe disease, especially in young children and HIV-infected populations in South Africa.

  • 116. Musenge, Eustasius
    et al.
    Chirwa, Tobias Freeman
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vounatsou, Penelope
    Bayesian analysis of zero inflated spatiotemporal HIV/TB child mortality data through the INLA and SPDE approaches: applied to data observed between 1992 and 2010 in rural North East South Africa2013In: International Journal of Applied Earth Observation and Geoinformation, ISSN 0303-2434, Vol. 22, p. 86-98Article in journal (Refereed)
    Abstract [en]

    Longitudinal mortality data with few deaths usually have problems of zero-inflation. This paper presents and applies two Bayesian models which cater for zero-inflation, spatial and temporal random effects. To reduce the computational burden experienced when a large number of geo-locations are treated as a Gaussian field (GF) we transformed the field to a Gaussian Markov Random Fields (GMRF) by triangulation. We then modelled the spatial random effects using the Stochastic Partial Differential Equations (SPDEs). Inference was done using a computationally efficient alternative to Markov chain Monte Carlo (MCMC) called Integrated Nested Laplace Approximation (INLA) suited for GMRF. The models were applied to data from 71,057 children aged 0 to under 10 years from rural north-east South Africa living in 15,703 households over the years 1992-2010. We found protective effects on HIV/TB mortality due to greater birth weight, older age and more antenatal clinic visits during pregnancy (adjusted RR (95% CI)): 0.73(0.53;0.99), 0.18(0.14;0.22) and 0.96(0.94;0.97) respectively. Therefore childhood HIV/TB mortality could be reduced if mothers are better catered for during pregnancy as this can reduce mother-to-child transmissions and contribute to improved birth weights. The INLA and SPDE approaches are computationally good alternatives in modelling large multilevel spatiotemporal GMRF data structures.

  • 117. Musenge, Eustasius
    et al.
    Vounatsou, Penelope
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    The contribution of spatial analysis to understanding HIV/TB mortality in children: a structural equation modelling approach2013In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 6, no 1, p. 38-48, article id 19266Article in journal (Refereed)
    Abstract [en]

    Background: South Africa accounts for more than a sixth of the global population of people infected with HIV and TB, ranking her highest in HIV/TB co-infection worldwide. Remote areas often bear the greatest burden of morbidity and mortality, yet there are spatial differences within rural settings.

    Objectives: The primary aim was to investigate HIV/TB mortality determinants and their spatial distribution in the rural Agincourt sub-district for children aged 1-5 years in 2004. Our secondary aim was to model how the associated factors were interrelated as either underlying or proximate factors of child mortality using pathway analysis based on a Mosley-Chen conceptual framework.

    Methods: We conducted a secondary data analysis based on cross-sectional data collected in 2004 from the Agincourt sub-district in rural northeast South Africa. Child HIV/TB death was the outcome measure derived from physician assessed verbal autopsy. Modelling used multiple logit regression models with and without spatial household random effects. Structural equation models were used in modelling the complex relationships between multiple exposures and the outcome (child HIV/TB mortality) as relayed on a conceptual framework.

    Results: Fifty-four of 6,692 children aged 1-5 years died of HIV/TB, from a total of 5,084 households. Maternal death had the greatest effect on child HIV/TB mortality (adjusted odds ratio = 4.00; 95% confidence interval = 1.01-15.80). A protective effect was found in households with better socio-economic status and when the child was older. Spatial models disclosed that the areas which experienced the greatest child HIV/TB mortality were those without any health facility.

    Conclusion: Low socio-economic status and maternal deaths impacted indirectly and directly on child mortality, respectively. These factors are major concerns locally and should be used in formulating interventions to reduce child mortality. Spatial prediction maps can guide policy makers to target interventions where they are most needed.

  • 118.
    Ng, Nawi
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana and Purworejo HDSS, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia.
    Kowal, Paul
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Naidoo, Nirmala
    Abdullah, Salim
    Bawah, Ayaga
    Binka, Fred
    Chuc, Nguyen T K
    Debpuur, Cornelius
    Egondi, Thaddeus
    Xavier Gómez-Olivé, F
    Hakimi, Mohammad
    Hirve, Siddhivinayak
    Hodgson, Abraham
    Juvekar, Sanjay
    Kyobutungi, Catherine
    Van Minh, Hoang
    Mwanyangala, Mathew A
    Nathan, Rose
    Razzaque, Abdur
    Sankoh, Osman
    Kim Streatfield, P
    Thorogood, Margaret
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wilopo, Siswanto
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana and MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Chatterji, Somnath
    Health inequalities among older men and women in Africa and Asia: evidence from eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE Study2010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, no Supplement 2, p. 96-107Article in journal (Refereed)
    Abstract [en]

    Background: Declining rates of fertility and mortality are driving demographic transition in all regions of the world, leading to global population ageing and consequently changing patterns of global morbidity and mortality. Understanding sex-related health differences, recognising groups at risk of poor health and identifying determinants of poor health are therefore very important for both improving health trajectories and planning for the health needs of ageing populations.

    Objectives: To determine the extent to which demographic and socio-economic factors impact upon measures of health in older populations in Africa and Asia; to examine sex differences in health and further explain how these differences can be attributed to demographic and socio-economic determinants.

    Methods: A total of 46,269 individuals aged 50 years and over in eight Health and Demographic Surveillance System (HDSS) sites within the INDEPTH Network were studied during 2006-2007 using an abbreviated version of the WHO Study on global AGEing and adult health (SAGE) Wave I instrument The survey data were then linked to longitudinal HDSS background information. A health score was calculated based on self-reported health derived from eight health domains. Multivariable regression and post-regression decomposition provide ways of measuring and explaining the health score gap between men and women.

    Results: Older men have better self-reported health than older women. Differences in household socioeconomic levels, age, education levels, marital status and living arrangements explained from about 82% and 71% of the gaps in health score observed between men and women in South Africa and Kenya, respectively, to almost nothing in Bangladesh. Different health domains contributed differently to the overall health scores for men and women in each country.

    Conclusion: This study confirmed the existence of sex differences in self-reported health in low- and middleincome countries even after adjustments for differences in demographic and socio-economic factors. A decomposition analysis suggested that sex differences in health differed across the HDSS sites, with the greatest level of inequality found in Bangladesh. The analysis showed considerable variation in how differences in socio-demographic and economic characteristics explained the gaps in self-reported health observed between older men and women in African and Asian settings. The overall health score was a robust indicator of health, with two domains, pain and sleep/energy, contributing consistently across the HDSS sites. Further studies are warranted to understand other significant individual and contextual determinants to which these sex differences in health can be attributed. This will lay a foundation for a more evidence-based approach to resource allocation, and to developing health promotion programmes for older men and women in these settings.

  • 119. Nzenze, S. A.
    et al.
    Shiri, T.
    Nunes, M. C.
    Klugman, K. P.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Twine, R.
    de Gouveia, L.
    von Gottberg, A.
    Madhi, S. A.
    Temporal association of infant immunisation with pneumococcal conjugate vaccine on the ecology of Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus nasopharyngeal colonisation in a rural South African community2014In: Vaccine, ISSN 0264-410X, E-ISSN 1873-2518, Vol. 32, no 42, p. 5520-5530Article in journal (Refereed)
    Abstract [en]

    Background: Immunisation of children with pneumococcal conjugate vaccines (PCV) may affect the bacterial-ecology of the nasopharynx, including colonisation by Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. The aim of this study was to evaluate the effect of infant PCVimmunisation on the nasopharyngeal ecology of these potentially pathogenic bacteria in a rural African setting. Methods: Two cross sectional surveys were undertaken from May to October in 2009 (Period-1) which coincided with the introduction of 7-valent PCV (PCV7) and in May-October 2011 (Period-2). Consenting household members, where there was a child <2 years of age in residence, had nasopharyngeal swabs undertaken for culture. Results: From Period-1 to Period-2 in children 0-2 years and 3-12 years, prevalence of overall S. pneumoniae colonisation decreased from 74.9% to 67.0% (p < 0.001) and H. influenzae declined among children 3-12 years (55.1-45.3%, p < 0.001) but not among those <2 years. The prevalence of S. aureus remained unchanged in all children. Competitive associations were found between S. pneumoniae and S. aureus and between H. influenzae and S. aureus among children. In individuals >12 years, the prevalence of colonisation decreased from 11.2% to 6.8%, 16.7% to 8.8% and 31.2% to 23.7% for S. pneumoniae, H. influenzae and S. aureus, respectively; p < 0.001 for all comparions. Synergistic relationships for S. aureus with H. influenzae and S. pneumoniae were observed in both periods among this group.

  • 120. Nzenze, Susan A
    et al.
    Shiri, Tinevimbo
    Nunes, Marta C
    Klugman, Keith P
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Twine, Rhian
    de Gouveia, Linda
    von Gottberg, Anne
    Madhi, Shabir A
    Temporal changes in pneumococcal colonization in a rural African community with high HIV prevalence following routine infant pneumococcal immunization2013In: The Pediatric Infectious Disease Journal, ISSN 0891-3668, E-ISSN 1532-0987, Vol. 32, no 11, p. 1270-1278Article in journal (Refereed)
    Abstract [en]

    Background: Pneumococcal conjugate vaccine (PCV) immunization of children decreases their risk of nasopharyngeal acquisition of vaccine serotypes. We studied the impact of routine infant PCV immunization alone on the epidemiology of nasopharyngeal pneumococcal colonization among a rural African community with high prevalence of HIV positivity.

    Methods: Two cross-sectional surveys were undertaken in a rural South African community from May to October 2009 (period 1) and 2011 (period 2). Seven-valent PCV was introduced into the public immunization program for infants in April 2009, without catch-up campaign for older children. Randomly selected households with at least 1 child <2 years of age were recruited. Nasopharyngeal swabs from all consenting household members were obtained for Streptococcus pneumoniae culture and serotyping by Quellung method.

    Results: The median ages (SD) of children enrolled were 4.32 (SD, 3.4) and 3.80 (SD, 3.4) years in periods 1 and 2, respectively. Overall, the prevalence of vaccine serotype colonization declined from 18.3% (368/2010) in period 1 to 11.4% (418/3659) by period 2 (P < 0.0001). This included reductions (adjusted risk ratio) of 50% [95% confidence interval (95% CI): 0.42-0.59], 34% (95% CI: 0.48-0.92) and 64% (95% CI: 0.18-0.74) in age groups < 2 years, 6-12 years and adults. The prevalence of vaccine serotype colonization among primary caregivers decreased from 10.2% to 5.4% (P <= 0.001) by period 2. The prevalence of nonvaccine serotype colonization increased by 35% (95% CI: 1.17-1.56) among <2-year-old children by period 2, while it declined by 45-54% among adolescents and adults.

    Conclusions: An indirect effect of PCV7 was realized in a high HIV prevalence setting within 2 years of PCV introduction. The unexpected decline in nonvaccine serotypes colonization among adolescents/adults may indicate lag in replacement colonization by nonvaccine serotypes in this group.

  • 121. Payne, Collin F.
    et al.
    Davies, Justine I.
    Gomez-Olive, F. Xavier
    Hands, Katherine J.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kobayashi, Lindsay C.
    Tipping, Brent
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Wade, Alisha
    Witham, Miles D.
    Cross-sectional relationship between haemoglobin concentration and measures of physical and cognitive function in an older rural South African population2018In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 72, no 9, p. 796-802Article in journal (Refereed)
    Abstract [en]

    Background: Age cohort differences in haemoglobin concentrations and associations with physical and cognitive performance among populations of lower income and middle-income countries have not previously been described. We examined the association between these factors among older men and women in rural South Africa.

    Methods: We analysed cross-sectional data from a population-based study of rural South African men and women aged 40 and over (n=4499), with data drawn from questionnaire responses, a cognitive battery, objective physical function tests and blood tests. Anaemia was defined as a haemoglobin concentration <12 g/dL for women and <13 g/dL for men. We related haemoglobin concentrations to each of age, grip strength, walk speed and a latent cognitive function z-score for men and women separately. We used unadjusted correlations and linear models to adjust for comorbidities and inflammation.

    Results: In total, 1042 (43.0%) women and 833 (40.1%) men were anaemic. Haemoglobin concentrations were inversely correlated with age for men but not for women; in adjusted analyses, haemoglobin was 0.3 g/dL lower per decade older for men (95% CI 0.2 to 0.4 g/dL). In adjusted analyses, haemoglobin concentration was independently associated with grip strength in women (B=0.391, 95% CI 0.177 to 0.605), but this did not reach significance in men (B=0.266, 95% CI -0.019 to 0.552); no associations were observed between haemoglobin levels and walk speed or cognitive score.

    Conclusions: Anaemia was prevalent in this study population of middle-aged and older, rural South African adults, but in contrast to high-income countries, it was not associated with poor physical or cognitive function. Our findings need to be replicated in other populations.

  • 122. Payne, Collin F.
    et al.
    Gomez-Olive, Francesc Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Berkman, Lisa
    Physical Function in an Aging Population in Rural South Africa: Findings From HAALSI and Cross-National Comparisons With HRS Sister Studies2017In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368, Vol. 72, no 4, p. 665-679Article in journal (Refereed)
    Abstract [en]

    We use recently-collected data from the Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort from Agincourt, South Africa, to describe physical functioning in this aging population, and place the overall level and age-trajectories of physical health in the context of other Health and Retirement Study (HRS) sister studies in low- and middle-income countries (LMICs). We conduct multiple regression to estimate associations of physical functioning assessed from both self-report (activities of daily living [ADL] limitation, self-reported health) and performance (grip strength, gait speed) with socio-demographic and health characteristics in HAALSI, and use fully-interacted regression models to compare age-patterns of physical functioning outcomes cross-nationally. Gender differences in self-reported health are minimal, and men had 30% higher odds of being ADL limited controlling for socio-demographic and health characteristics. Measured physical performance is closely tied with socioeconomic conditions, but self-reported measures have a much smaller or weaker socioeconomic gradient. In international age-adjusted comparisons, the HAALSI sample had lower physical performance outcomes than most comparison populations. As the first HRS sister study undertaken in Africa, HAALSI adds vital information on population aging and health in the region. Continuing waves of HAALSI data will be a key resource for understanding differences in the complex processes of disability across LMIC contexts.

  • 123. Payne, Collin F.
    et al.
    Wade, Alisha
    Kabudula, Chodziwadziwa W.
    Davies, Justine I.
    Chang, Angela Y.
    Gomez-Olive, F. Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Berkman, Lisa F.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Salomon, Joshua A.
    Witham, Miles D.
    Prevalence and correlates of frailty in an older rural African population: findings from the HAALSI cohort study2017In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 17, article id 293Article in journal (Refereed)
    Abstract [en]

    Background: Frailty is a key predictor of death and dependency, yet little is known about frailty in sub-Saharan Africa despite rapid population ageing. We describe the prevalence and correlates of phenotypic frailty using data from the Health and Aging in Africa: Longitudinal Studies of an INDEPTH Community cohort.

    Methods: We analysed data from rural South Africans aged 40 and over. We used low grip strength, slow gait speed, low body mass index, and combinations of self-reported exhaustion, decline in health, low physical activity and high self-reported sedentariness to derive nine variants of a phenotypic frailty score. Each frailty category was compared with self-reported health, subjective wellbeing, impairment in activities of daily living and the presence of multimorbidity. Cox regression analyses were used to compare subsequent all-cause mortality for non-frail (score 0), pre-frail (score 1–2) and frail participants (score 3+).

    Results: Five thousand fifty nine individuals (mean age 61.7 years, 2714 female) were included in the analyses. The nine frailty score variants yielded a range of frailty prevalences (5.4% to 13.2%). For all variants, rates were higher in women than in men, and rose steeply with age. Frailty was associated with worse subjective wellbeing, and worse self-reported health. Both prefrailty and frailty were associated with a higher risk of death during a mean 17 month follow up for all score variants (hazard ratios 1.29 to 2.41 for pre-frail vs non-frail; hazard ratios 2.65 to 8.91 for frail vs non-frail).

    Conclusions: Phenotypic frailty could be measured in this older South African population, and was associated with worse health, wellbeing and earlier death.

  • 124. Pettifor, Audrey
    et al.
    Lippman, Sheri A.
    Gottert, Ann
    Suchindran, Chirayath M.
    Selin, Amanda
    Peacock, Dean
    Maman, Suzanne
    Rebombo, Dumisani
    Twine, Rhian
    Gómez-Olivé, Francesc Xavier
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    MacPhail, Catherine
    Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa2018In: Journal of the International AIDS Society, ISSN 1758-2652, E-ISSN 1758-2652, Vol. 21, no 7, article id e25134Article in journal (Refereed)
    Abstract [en]

    Introduction: Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk.

    Methods: Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (pos-tintervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes.

    Results: Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16).

    Conclusion: Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly.

  • 125. Pisa, Pedro T.
    et al.
    Pedro, Titilola M.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; INDEPTH Network: Network of Demographic Surveillance Sites-www.indepth-network.org, Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; INDEPTH Network: Network of Demographic Surveillance Sites-www.indepth-network.org, Accra, Ghana.
    Pettifor, John M.
    Norris, Shane A.
    Nutrient Patterns and Their Association with Socio-Demographic, Lifestyle Factors and Obesity Risk in Rural South African Adolescents2015In: Nutrients, ISSN 2072-6643, E-ISSN 2072-6643, Vol. 7, no 5, p. 3464-3482Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to identify and describe the diversity of nutrient patterns and how they associate with socio-demographic and lifestyle factors including body mass index in rural black South African adolescents. Nutrient patterns were identified from quantified food frequency questionnaires (QFFQ) in 388 rural South African adolescents between the ages of 11-15 years from the Agincourt Health and Socio-demographic Surveillance System (AHDSS). Principle Component Analysis (PCA) was applied to 25 nutrients derived from QFFQs. Multiple linear regression and partial R-2 models were fitted and computed respectively for each of the retained principal component (PC) scores on socio-demographic and lifestyle characteristics including body mass index (BMI) for age Z scores. Four nutrient patterns explaining 79% of the total variance were identified: PCI (26%) was characterized by animal derived nutrients; PC2 (21%) by vitamins, fibre and vegetable oil nutrients; PC3 (19%) by both animal and plant derived nutrients (mixed diet driven nutrients); and PC4 (13%) by starch and folate. A positive and significant association was observed with BMI for age Z scores per 1 standard deviation (SD) increase in PC1 (0.13 (0.02; 0.24); p = 0.02) and PC4 (0.10 (-0.01; 0.21); p = 0.05) scores only. We confirmed variability in nutrient patterns that were significantly associated with various lifestyle factors including obesity.

  • 126. Price, Jessica
    et al.
    Pettifor, Audrey
    Selin, Amanda
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    MacPhail, Catherine
    Agyei, Yaw
    Gomez-Olive, F. Xavier
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    The association between perceived household educational support and HIV risk in young women in a rural South African community (HPTN 068): A cross sectional study2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 1, article id e0210632Article in journal (Refereed)
    Abstract [en]

    Objective: To characterise perceived household support for female education and the associations between educational support and HIV prevalence, HSV-2 prevalence and sexual risk behaviours.

    Methods: This cross-sectional study used baseline survey data from the Swa Koteka HPTN 068 trial undertaken in Mpumalanga, South Africa. The study included 2533 young women aged 13-20, in grades 8-11 at baseline. HIV and HSV-2 status were determined at baseline. Information about patterns of sexual behaviour and household support for education was collected during the baseline survey. Linear regression and binary logistic regression were used to determine associations between household support for education and both biological and behavioural outcomes.

    Results: High levels of educational support were reported across all measures. HIV prevalence was 3.2% and HSV-2 prevalence was 4.7%, both increasing significantly with age. Over a quarter (26.6%) of young women reported vaginal sex, with 60% reporting condom use at last sex. The median age of sexual debut was 16 years. Household educational support was not significantly associated with HIV or HSV-2; however, the odds of having had vaginal sex were significantly lower in those who reported greater homework supervision (OR 0.82, 95% CI: 0.72-0.94), those who engaged in regular discussion of school marks with a caregiver (OR 0.82, 95% CI: 0.71-0.95) and when caregivers had greater educational goals for the young woman (OR 0.82, 95% CI: 0.71-0.96). In contrast, greater caregiver disappointment at dropout was significantly associated with reported vaginal sex (OR 1.29, 95% CI: 1.14-1.46).

    Conclusion: Young women in rural South Africa report experiencing high levels of household educational support. This study suggests that greater household educational support is associated with lower odds of having vaginal sex and engaging in risky sexual behaviour, though not with HIV or HSV-2 prevalence.

  • 127. Prioreschi, Alessandra
    et al.
    Wrottesley, Stephanie V.
    Cohen, Emmanuel
    Reddy, Ankita
    Said-Mohamed, Rihlat
    Twine, Rhian
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Dunger, David B.
    Norris, Shane A.
    Examining the relationships between body image, eating attitudes, BMI, and physical activity in rural and urban South African young adult females using structural equation modeling2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 11, article id e0187508Article in journal (Refereed)
    Abstract [en]

    The persistence of food insecurity, malnutrition, increasing adiposity, and decreasing physical activity, heightens the need to understand relationships between body image satisfaction, eating attitudes, BMI and physical activity levels in South Africa. Females aged 18-23 years were recruited from rural (n = 509) and urban (n = 510) settings. Body image satisfaction was measured using Stunkard's silhouettes, and the 26-item Eating Attitudes questionnaire (EAT-26) was used to evaluate participants' risk of disordered eating. Minutes per week of moderate to vigorous physical activity (MVPA) was assessed using the Global Physical Activity Questionnaire (GPAQ). Significant linear correlates were included in a series of regressions run separately for urban and rural participants. Structural equation modeling (SEM) was used to test the relationships between variables. Urban females were more likely to be overweight and obese than rural females (p = 0.02), and had a greater desire to be thinner (p = 0.02). In both groups, being overweight or obese was positively associated with a desire to be thinner (p<0.01), and negatively associated with a desire to be fatter (p<0.01). Having a disordered eating attitude was associated with body image dissatisfaction in the urban group (beta = 1.27, p<0.01, CI: 0.38; 2.16), but only with a desire to be fatter in the rural group (beta = 0.63, p = 0.04, CI: 0.03; 1.23). In the SEM model, body image dissatisfaction was associated with disordered eating (beta = 0.63), as well as higher MVPA participation (p<0.01). These factors were directly associated with a decreased risk of disordered eating attitude, and with a decreased desire to be thinner. Findings indicate a shift in both settings towards more Westernised ideals. Physical activity may provide a means to promote a healthy body image, while reducing the risk of disordered eating. Given the high prevalence of overweight and obesity in both rural and urban women, this study provides insights for future interventions aimed at decreasing adiposity in a healthy way.

  • 128. Ranganathan, Meghna
    et al.
    Heise, Lori
    MacPhail, Catherine
    Stockl, Heidi
    Silverwood, Richard J.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Selin, Amanda
    Gomez-Olive, F. Xavier
    Watts, Charlotte
    Pettifor, Audrey
    'It's because I like things. . . it's a status and he buys me airtime': exploring the role of transactional sex in young women's consumption patterns in rural South Africa (secondary findings from HPTN 068)2018In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 15, article id 102Article in journal (Refereed)
    Abstract [en]

    Background: 'Transactional sex', defined as a non-marital, non-commercial sexual relationship in which money or material goods are exchanged for sex, is associated with young women's increased vulnerability to HIV infection. Existing research illustrates that the motivations for transactional sex are complex. The fulfilment of psycho-social needs such as the need to belong to a peer group are important factors underlying young women's desires to obtain certain consumption items and thus engage in transactional sex.

    Methods: We use a mixed-methods approach to explore the relationship between transactional sex and consumption patterns among young women in rural Mpumalanga province, South Africa. In the secondary analysis of 693 sexually active young women, we use factor analysis to group the different consumption items and we use multivariable logistic regression to demonstrate the relationship between transactional sex and consumption patterns. The qualitative study uses five focus group discussions and 19 in-depth interviews to explore further young women's motivations for acquiring different consumption items.

    Results: The quantitative results show that young women that engage in transactional sex have higher odds of consuming items for entertainment (e.g., movie tickets) than on practical items (e.g., food and groceries). The qualitative findings also revealed that young women's perceptions of items that were considered a 'need' were strongly influenced by peer pressure and a desire for improved status. Further, there was a perception that emerged from the qualitative data that relationships with sugar daddies offered a way to acquire consumer goods associated with a 'modern lifestyle', such as items for personal enhancement and entertainment. However, young women seem aware of the risks associated with such relationships. More importantly, they also develop relationship with partners of similar age, albeit with the continued expectation of material exchange, despite engaging in the relationship for love.

    Conclusion: This study shows that young women are willing to take certain risks in order to have a degree of financial independence. Interventions that provide alternative methods of attaining this independence, such as the provision of cash transfers may have potential in preventing them from engaging in transactional relationships. Further, the psycho-social reasons that drive young women's motivations for consumption items resulting in risky sexual behaviours need to be better understood.

  • 129. Ranganathan, Meghna
    et al.
    Heise, Lori
    Pettifor, Audrey
    Silverwood, Richard J.
    Selin, Amanda
    MacPhail, Catherine
    Delany-Moretlwe, Sinead
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gomez-Olive, F. Xavier
    Hughes, James P.
    Piwowar-Manning, Estelle
    Laeyendecker, Oliver
    Watts, Charlotte
    Transactional sex among young women in rural South Africa: prevalence, mediators and association with HIV infection2016In: Journal of the International AIDS Society, ISSN 1758-2652, E-ISSN 1758-2652, Vol. 19, article id 20749Article in journal (Refereed)
    Abstract [en]

    Introduction: Young adolescent women in sub-Saharan Africa are three to four times more likely to be HIV-positive than boys or men. One of the relationship dynamics that is likely to be associated with young women's increased vulnerability to HIV is transactional sex. There are a range of HIV-related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in subSaharan Africa. Our paper presents data on the prevalence of self-reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV-related risk behaviours.

    Methods: We analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school-going young women aged 13-20 years in rural South Africa. We examined the association between young women's engagement in transactional sex and HIV infection. Transactional sex is defined as a non-commercial, non-marital sexual relationship whereby sex is exchanged for money and/or gifts. We explored whether this relationship is mediated by certain HIVrelated risk behaviours. We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI.

    Results: Overall, 14% (n = 97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV-positive (aOR: 2.5, CI: 95% 1.19-5.25, p = 0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship.

    Conclusions: This study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a "high risk" for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women's HIV risk.

  • 130. Ranganathan, Meghna
    et al.
    MacPhail, Catherine
    Pettifor, Audrey
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
    Khoza, Nomhle
    Twine, Rhian
    Watts, Charlotte
    Heise, Lori
    Young women's perceptions of transactional sex and sexual agency: a qualitative study in the context of rural South Africa2017In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 17, article id 666Article in journal (Refereed)
    Abstract [en]

    Background: Evidence shows that HIV prevalence among young women in sub-Saharan Africa increases almost five-fold between ages 15 and 24, with almost a quarter of young women infected by their early-to mid-20s. Transactional sex or material exchange for sex is a relationship dynamic that has been shown to have an association with HIV infection.

    Methods: Using five focus group discussions and 19 in-depth interviews with young women enrolled in the HPTN 068 conditional cash transfer trial (2011–2015), this qualitative study explores young women’s perceptions of transactional sex within the structural and cultural context of rural South Africa. The analysis also considers the degree to which young women perceive themselves as active agents in such relationships and whether they recognise a link between transactional sex and HIV risk.

    Results: Young women believe that securing their own financial resources will ultimately improve their bargaining position in their sexual relationships, and open doors to a more financially independent future. Findings suggest there is a nuanced relationship between sex, love and gifts: money has symbolic meaning, and money transfers, when framed as gifts, indicates a young woman’s value and commitment from the man. This illustrates the complexity of transactional sex; the way it is positioned in the HIV literature ignores that “exchanges” serve as fulcrums around which romantic relationships are organised. Finally, young women express agency in their choice of partner, but their agency weakens once they are in a relationship characterised by exchange, which may undermine their ability to translate perceived agency into STI and HIV risk reduction efforts.

    Conclusions: This research underscores the need to recognise that transactional sex is embedded in adolescent romantic relationships, but that certain aspects make young women particularly vulnerable to HIV. This is especially true in situations of restricted choice and circumscribed employment opportunities. HIV prevention educational programmes could be coupled with income generation trainings, in order to leverage youth resilience and protective skills within the confines of difficult economic and social circumstances. This would provide young women with the knowledge and means to more successfully navigate safer sexual relationships.

  • 131. Reniers, Georges
    et al.
    Wamukoya, Marylene
    Urassa, Mark
    Nyaguara, Amek
    Nakiyingi-Miiro, Jessica
    Lutalo, Tom
    Hosegood, Vicky
    Gregson, Simon
    Gomez-Olive, Xavier
    Geubbels, Eveline
    Crampin, Amelia C.
    Wringe, Alison
    Waswa, Laban
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Todd, Jim
    Slaymaker, Emma
    Serwadda, David
    Price, Alison
    Oti, Samuel
    Nyirenda, Moffat J.
    Nabukalu, Dorean
    Nyamukapa, Constance
    Nalugoda, Fred
    Mugurungi, Owen
    Mtenga, Baltazar
    Mills, Lisa
    Michael, Denna
    McLean, Estelle
    McGrath, Nuala
    Martin, Emmanuel
    Marston, Milly
    Maquins, Sewe
    Levira, Francis
    Kyobutungi, Catherine
    Kwaro, Daniel
    Kasamba, Ivan
    Kanjala, Chifundo
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kabudula, Chodziwadziwa
    Herbst, Kobus
    Gareta, Dickman
    Eaton, Jeffrey W.
    Clark, Samuel J.
    Church, Kathryn
    Chihana, Menard
    Calvert, Clara
    Beguy, Donatien
    Asiki, Gershim
    Amri, Shamte
    Abdul, Ramadhani
    Zaba, Basia
    Data Resource Profile: Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA Network)2016In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 45, no 1, p. 83-93Article in journal (Refereed)
  • 132. Rohr, Julia K.
    et al.
    Gomez-Olive, F. Xavier
    Rosenberg, Molly
    Manne-Goehler, Jennifer
    Geldsetzer, Pascal
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Houle, Brian
    Salomon, Joshua A.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Berkman, Lisa
    Baernighausen, Till
    Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study2017In: Journal of the International AIDS Society, ISSN 1758-2652, E-ISSN 1758-2652, Vol. 20, article id 691Article in journal (Refereed)
    Abstract [en]

    Introduction: In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home-based interventions where testing is not always feasible. We evaluate the accuracy of self-reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing.

    Methods: Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self-reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at-home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self-reported status compared to “gold standard” biomarker results. Log-binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self-report.

    Results: Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self-report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV-positive status, and participants reporting false-negatives were more likely to have older HIV tests.

    Conclusions: The majority of participants were willing to share their HIV status. False-negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self-reported status should be considered as a routine first step to establish HIV status.

  • 133. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Duta, Mihaela
    Demeyere, Nele
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Selin, Amanda
    MacPhail, Catherine
    Laeyendecker, Oliver
    Hughes, James P.
    Stein, Alan
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Executive function associated with sexual risk in young South African women: Findings from the HPTN 068 cohort2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 4, article id e0195217Article in journal (Refereed)
    Abstract [en]

    Purpose Heightened sexual risk in adolescence and young adulthood may be partially explained by deficits in executive functioning, the set of cognitive processes used to make reasoned decisions. However, the association between executive function and sexual risk is understudied among adolescent girls and young women, particularly in low- and middle-income countries. Methods In a cohort of 853 young women age 18-25 in rural Mpumalanga province, South Africa, we evaluated executive function with three non-verbal cognitive tests: I. a rule-finding test, II. a trail-making test, and III. a figure drawing test. Using log-binomial regression models, we estimated the association between lower executive function test scores and indicators of sexual risk (unprotected sex acts, concurrent partnerships, transactional sex, and recent HSV-2 infection). Results In general, young women with lower executive function scores reported higher frequencies of sexual risk outcomes, though associations tended to be small with wide confidence intervals. Testing in the lowest quintile of Test I was associated with more unprotected sex [aPR (95% CI): 1.4 (1.0, 1.8)]. Testing in the lowest quintile of Test II was associated with more concurrent relationships and transactional sex [aPR (95% CI): 1.6 (1.1, 2.5) and 1.7 (1.3, 2.4), respectively], and testing in the lowest four quintiles of Test III was associated with more concurrent relationships [aPR (95% CI): 1.7 (1.0, 2.7)]. Conclusions These results demonstrate an association between low executive function and sexual risk in South African young women. Future work should seek to understand the nature of this association and whether there is promise in developing interventions to enhance executive function to reduce sexual risk.

  • 134. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Lippman, Sheri A.
    Thirumurthy, Harsha
    Emch, Michael
    Miller, William C.
    Selin, Amanda
    Gomez-Olive, Francesc Xavier
    Hughes, James P.
    Laeyendecker, Oliver
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;.
    Relationship Between Community-Level Alcohol Outlet Accessibility and Individual-Level Herpes Simplex Virus Type 2 Infection Among Young Women in South Africa2015In: Sexually Transmitted Diseases, ISSN 0148-5717, E-ISSN 1537-4521, Vol. 42, no 5, p. 259-265Article in journal (Refereed)
    Abstract [en]

    Background: Exposure to alcohol outlets may influence sexual health outcomes at the individual and community levels. Visiting alcohol outlets facilitates alcohol consumption and exposes patrons to a risky environment and network of potential partners, whereas the presence of alcohol outlets in the community may shift social acceptance of riskier behavior. We hypothesize that living in communities with more alcohol outlets is associated with increased sexual risk. Methods: We performed a cross-sectional analysis in a sample of 2174 South African schoolgirls (ages 13-21 years) living across 24 villages in the rural Agincourt subdistrict, underpinned by long-term health and sociodemographic surveillance. To examine the association between number of alcohol outlets in village of residence and individual-level prevalent herpes simplex virus type 2 (HSV-2) infection, we used generalized estimating equations with logit links, adjusting for individual-and villagelevel covariates. Results: The median number of alcohol outlets per village was 3 (range, 0-7). Herpes simplex virus type 2 prevalence increased from villages with no outlets (1.4%[95% confidence interval, 0.2-12.1]), to villages with 1 to 4 outlets (4.5% [3.7-5.5]), and to villages with more than 4 outlets (6.3% [5.6, 7.1]). An increase of 1 alcohol outlet per village was associated with an 11% increase in the odds of HSV-2 infection (adjusted odds ratio [95% confidence interval], 1.11 [0.98-1.25]). Conclusions: Living in villages with more alcohol outlets was associated with increased prevalence of HSV-2 infection in young women. Structural interventions and sexual health screenings targeting villages with extensive alcohol outlet environments could help prevent the spread of sexually transmitted infections.

  • 135. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Miller, William C.
    Thirumurthy, Harsha
    Emch, Michael
    Afolabi, Sulaimon A.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Collinson, Mark
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Relationship between school dropout and teen pregnancy among rural South African young women2015In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 44, no 3, p. 928-936Article in journal (Refereed)
    Abstract [en]

    Background: Sexual activity may be less likely to occur during periods of school enrolment because of the structured and supervised environment provided, the education obtained and the safer peer networks encountered while enrolled. We examined whether school enrolment was associated with teen pregnancy in South Africa. Methods: Using longitudinal demographic surveillance data from the rural Agincourt sub-district, we reconstructed the school enrolment status from 2000 through 2011 for 15 457 young women aged 12-18 years and linked them to the estimated conception date for each pregnancy during this time. We examined the effect of time-varying school enrolment on teen pregnancy using a Cox proportional hazard model, adjusting for: age; calendar year; household socioeconomic status; household size; and gender, educational attainment and employment of household head. A secondary analysis compared the incidence of pregnancy among school enrolees by calendar time: school term vs school holiday. Results: School enrolment was associated with lower teen pregnancy rates [adjusted hazard ratio (95% confidence interval): 0.57 (0.50, 0.65)]. This association was robust to potential misclassification of school enrolment. For those enrolled in school, pregnancy occurred less commonly during school term than during school holidays [incidence rate ratio (95% confidence interval): 0.90 (0.78, 1.04)]. Conclusions: Young women who drop out of school may be at higher risk for teen pregnancy and could likely benefit from receipt of accessible and high quality sexual health services. Preventive interventions designed to keep young women in school or addressing the underlying causes of dropout may also help reduce the incidence of teen pregnancy.

  • 136. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Nguyen, Nadia
    Westreich, Daniel
    Bor, Jacob
    Baernighausen, Till
    Mee, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa; London Sch Hyg & Trop Med, Dept Global Hlth & Dev, Fac Publ Hlth & Policy, London WC1, England.
    Twine, Rhian
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Univ Witwatersrand, Fac Hlth Sci, Sch Publ Hlth, MRC Wits Rural Publ Hlth & Hlth Transit Res Unit, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Relationship between Receipt of a Social Protection Grant for a Child and Second Pregnancy Rates among South African Women: A Cohort Study2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 9, article id e0137352Article in journal (Refereed)
    Abstract [en]

    Background Social protection programs issuing cash grants to caregivers of young children may influence fertility. Grant-related income could foster economic independence and/or increase access to job prospects, education, and health services, resulting in lower pregnancy rates. In the other direction, these programs may motivate family expansion in order to receive larger grants. Here, we estimate the net effect of these countervailing mechanisms among rural South African women. Methods We constructed a retrospective cohort of 4845 women who first became eligible for the Child Support Grant with the birth of their first child between 1998 and 2008, with data originally collected by the Agincourt Health and Socio- Demographic Surveillance System in Mpumalanga province, South Africa. We fit Cox regression models to estimate the hazard of second pregnancy in women who reported grant receipt after birth of first child, relative to non- recipients. As a secondary analysis to explore the potential for grant loss to incentivize second pregnancy, we exploited a natural experiment created by a 2003 expansion of the program's age eligibility criterion from age seven to nine. We compared second pregnancy rates between (i) women with children age seven or eight in 2002 (recently aged out of grant eligibility) to (ii) women with children age seven or eight in 2003 (remained grant-eligible). Results The adjusted hazard ratio for the association between grant exposure and second pregnancy was 0.66 (95% CI: 0.58, 0.75). Women with first children who aged out of grant eligibility in 2002 had similar second pregnancy rates to women with first children who remained grant-eligible in 2003 [IRR (95% CI): 0.9 (0.5, 1.4)]. Conclusions Across both primary and secondary analyses, we found no evidence that the Child Support Grant incentivizes pregnancy. In harmony with South African population policy, receipt of the Child Support Grant may result in longer spacing between pregnancies.

  • 137. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Twine, Rhian
    Hughes, James P.
    Gomez-Olive, F. Xavier
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Sulaimon, Afolabi
    Tollman, Stephen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Selin, Amanda
    MacPhail, Catherine
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Evidence for sample selection effect and Hawthorne effect in behavioural HIV prevention trial among young women in a rural South African community2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 1, article id e019167Article in journal (Refereed)
    Abstract [en]

    Objectives: We examined the potential influence of both sample selection effects and Hawthorne effects in the behavioural HIV Prevention Trial Network 068 study, designed to examine whether cash transfers conditional on school attendance reduce HIV acquisition in young South African women. We explored whether school enrolment among study participants differed from the underlying population, and whether differences existed at baseline (sample selection effect) or arose during study participation (Hawthorne effect).

    Methods: We constructed a cohort of 3889 young women aged 11-20 years using data from the Agincourt Health and socio-Demographic Surveillance System. We compared school enrolment in 2011 (trial start) and 2015 (trial end) between those who did (n=1720) and did not (11=2169) enrol in the trial. To isolate the Hawthorne effect, we restricted the cohort to those enrolled in school in 2011.

    Results: In 2011, trial participants were already more likely to be enrolled in school (99%) compared with non-participants (93%). However, this association was attenuated with covariate adjustment (adjusted risk difference (aRD) (95% Cl): 2.9 (0.7 to 6.5)). Restricting to those enrolled in school in 2011, trial participants were also more likely to be enrolled in school in 2015 (aRD (95% Cl): 4.9 (1.5 to 8.3)). The strength of associations increased with age.

    Conclusions: Trial participants across both study arms were more likely to be enrolled in school than nonparticipants. Our findings suggest that both sample selection and Hawthorne effects may have diminished the differences in school enrolment between study arms, a plausible explanation for the null trial findings. The Hawthorne-specific findings generate hypotheses for how to structure school retention interventions to prevent HIV.

  • 138. Rosenberg, Molly
    et al.
    Pettifor, Audrey
    Van Rie, Annelies
    Thirumurthy, Harsha
    Emch, Michael
    Miller, William C.
    Gomez-Olive, F. Xavier
    Twine, Rhian
    Hughes, James P.
    Laeyendecker, Oliver
    Selin, Amanda
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    The Relationship between Alcohol Outlets, HIV Risk Behavior, and HSV-2 Infection among South African Young Women: A Cross-Sectional Study2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 5, article id e0125510Article in journal (Refereed)
    Abstract [en]

    Background: Alcohol consumption has a disinhibiting effect that may make sexual risk behaviors and disease transmission more likely. The characteristics of alcohol- serving outlets (e.g. music, dim lights, lack of condoms) may further encourage risky sexual activity. We hypothesize that frequenting alcohol outlets will be associated with HIV risk.

    Methods: In a sample of 2,533 school- attending young women in rural South Africa, we performed a cross- sectional analysis to examine the association between frequency of alcohol outlet visits in the last six months and four outcomes related to HIV risk: number of sex partners in the last three months, unprotected sex acts in the last three months, transactional sex with most recent partner, and HSV- 2 infection. We also tested for interaction by alcohol consumption.

    Results: Visiting alcohol outlets was associated with having more sex partners [adjusted odds ratio (aOR), one versus zero partners (95% confidence interval (CI)): 1.51 (1.21, 1.88)], more unprotected sex acts [aOR, one versus zero acts ( 95% CI): 2.28 ( 1.52, 3.42)], higher levels of transactional sex [aOR ( 95% CI): 1.63 ( 1.03, 2.59)], and HSV-2 infection [aOR ( 95% CI): 1.30 ( 0.88, 1.91)]. In combination with exposure to alcohol consumption, visits to alcohol outlets were more strongly associated with all four outcomes than with either risk factor alone. Statistical evidence of interaction between alcohol outlet visits and alcohol consumption was observed for all outcomes except transactional sex.

    Conclusions: Frequenting alcohol outlets was associated with increased sexual risk in rural South African young women, especially when they consumed alcohol. Sexual health interventions targeted at alcohol outlets may effectively reach adolescents at high risk for sexually transmitted infections like HIV and HSV-2.

  • 139. Rosenberg, Molly S.
    et al.
    Gomez-Olive, Francesc X.
    Rohr, Julia K.
    Houle, Brian C.
    Kabudula, Chodziwadziwa W.
    Wagner, Ryan G.
    Salomon, Joshua A.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Berkman, Lisa F.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Baernighausen, Till
    Sexual Behaviors and HIV Status: A Population-Based Study Among Older Adults in Rural South Africa2017In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 74, no 1, p. E9-E17Article in journal (Refereed)
    Abstract [en]

    Objective: To identify the unmet needs for HIV prevention among older adults in rural South Africa.

    Methods: We analyzed data from a population-based sample of 5059 men and women aged 40 years and older from the study Health and Aging in Africa: Longitudinal Studies of INDEPTH Communities (HAALSI), which was carried out in the Agincourt health and sociodemographic surveillance system in the Mpumalanga province of South Africa. We estimated the prevalence of HIV (laboratory-confirmed and self-reported) and key sexual behaviors by age and sex. We compared sexual behavior profiles across HIV status categories with and without age–sex standardization.

    Results: HIV prevalence was very high among HAALSI participants (23%, 95% confidence interval [CI]: 21 to 24), with no sex differences. Recent sexual activity was common (56%, 95% CI: 55 to 58) across all HIV status categories. Condom use was low among HIV-negative adults (15%, 95% CI: 14 to 17), higher among HIV-positive adults who were unaware of their HIV status (27%, 95% CI: 22 to 33), and dramatically higher among HIV-positive adults who were aware of their status (75%, 95% CI: 70 to 80). Casual sex and multiple partnerships were reported at moderate levels, with slightly higher estimates among HIV-positive compared to HIV-negative adults. Differences by HIV status remained after age–sex standardization.

    Conclusions: Older HIV-positive adults in an HIV hyperendemic community of rural South Africa report sexual behaviors consistent with high HIV transmission risk. Older HIV-negative adults report sexual behaviors consistent with high HIV acquisition risk. Prevention initiatives tailored to the particular prevention needs of older adults are urgently needed to reduce HIV risk in this and similar communities in sub-Saharan Africa.

  • 140. Rosenberg, Molly S.
    et al.
    Gomez-Olive, Francesc X.
    Rohr, Julia K.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Baernighausen, Till W.
    Are circumcised men safer sex partners?: Findings from the HAALSI cohort in rural South Africa2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 8, article id e0201445Article in journal (Refereed)
    Abstract [en]

    Introduction: The real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access.

    Methods: We analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models.

    Results: One quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)] while those who reported initiation-based circumcision were less likely to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were attenuated, but not reversed after adjustment for key covariates.

    Conclusions: Medically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.

  • 141. Said-Mohamed, Rihlat
    et al.
    Prioreschi, Alessandra
    Nyati, Lukhanyo H.
    van Heerden, Alastair
    Munthali, Richard J.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg Parktown, South Africa; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg Parktown, South Africa; INDEPTH Network, Accra, Ghana.
    Gomez-Olive, Francesc Xavier
    Houle, Brian
    Dunger, David B.
    Norris, Shane A.
    Rural-urban variations in age at menarche, adult height, leg-length and abdominal adiposity in black South African women in transitioning South Africa2018In: Annals of Human Biology, ISSN 0301-4460, E-ISSN 1464-5033, Vol. 45, no 2, p. 123-132Article in journal (Refereed)
    Abstract [en]

    Background: The pre-pubertal socioeconomic environment may be an important determinant of age at menarche, adult height, body proportions and adiposity: traits closely linked to adolescent and adult health.

    Aims: This study explored differences in age at menarche, adult height, relative leg-length and waist circumference between rural and urban black South African young adult women, who are at different stages of the nutrition and epidemiologic transitions.

    Subjects and methods: We compared 18-23 year-old black South African women, 482 urban-dwelling from Soweto and 509 from the rural Mpumalanga province. Age at menarche, obstetric history and household socio-demographic and economic information were recorded using interview-administered questionnaires. Height, sitting-height, hip and waist circumference were measured using standardised techniques.

    Results: Urban and rural black South African women differed in their age at menarche (at ages 12.7 and 14.5 years, respectively). In urban women, a one-year increase in age at menarche was associated with a 0.65 cm and 0.16% increase in height and relative leg-length ratio, respectively. In both settings, earlier age at menarche and shorter relative leg-length were independently associated with an increase in waist circumference.

    Conclusions: In black South African women, the earlier onset of puberty, and consequently an earlier growth cessation process, may lead to central fat mass accumulation in adulthood.

  • 142. Sartorius, Benn K D
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vounatsou, Penelope
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Young and vulnerable: spatial-temporal trends and risk factors for infant mortality in rural South Africa (Agincourt), 1992-20072010In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 10, p. 645-Article in journal (Refereed)
    Abstract [en]

    This study demonstrates the use of Bayesian geostatistical models in assessing risk factors and producing smooth maps of infant mortality risk in a health and socio-demographic surveillance system. Results showed marked geographical differences in mortality risk across a relatively small area. Prevention of vertical transmission of HIV and survival of mothers during the infants' first year in high prevalence villages needs to be urgently addressed, including expanded antenatal testing, prevention of mother-to-child transmission, and improved access to antiretroviral therapy. There is also need to assess and improve the capacity of district hospitals for emergency obstetric and newborn care. Persisting risk factors, including inadequate provision of clean water and sanitation, are yet to be fully addressed.

  • 143. Sartorius, Benn
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Sartorius, Kurt
    Tollman, Stephen M.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Dying in their prime: determinants and space-time risk of adult mortality in rural South Africa2013In: Geospatial Health, ISSN 1827-1987, Vol. 7, no 2, p. 237-249Article in journal (Refereed)
    Abstract [en]

    A longitudinal dataset was used to investigate adult mortality in rural South Africa in order to determine location, trends, high impact determinants and policy implications. Adult (15-59 years) mortality data for the period 1993-2010 were extracted from the health and demographic surveillance system in the rural sub-district of Agincourt. A Bayesian geostatistical frailty survival model was used to quantify significant associations between adult mortality and various multilevel (individual, household and community) variables. It was found that adult mortality significantly increased over time with a reduction observed late in the study period. Non-communicable disease mortality appeared to increase and decrease in parallel with communicable mortality, whilst deaths due to external causes remained constant. Male gender, unemployment, circular (labour) migrant status, age and gender of household heads, partner and/or other household death, low education and low household socio-economic status were identified as significant and highly attributable determinants of adult mortality. Health facility remoteness was a risk for adult mortality and households falling outside a critical buffering zone were identified. Spatial foci of higher adult mortality risk were observed, indicating a strong non-random pattern. Communicable diseases differed from non-communicable diseases with respect to spatial distribution of mortality. Areas with significant excess mortality risk (hot spots) were found to be part of a complex interaction of highly attributable factors that continues to drive differential space-time risk patterns of communicable (HIV/AIDS and tuberculosis) mortality in Agincourt. The impact of HIV mortality and its subsequent lowering due to the introduction of antiretroviral therapy was found to be clearly evident in this rural population.

  • 144. Sartorius, Benn
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vounatsou, Penelope
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Survived infancy but still vulnerable: spatial-temporal trends and risk factors for child mortality in the Agincourt rural sub-district, South Africa, 1992-20072011In: Geospatial health, ISSN 1970-7096, Vol. 5, no 2, p. 285-295Article in journal (Refereed)
    Abstract [en]

    Targeting of health interventions to poor children at highest risk of mortality are promising approaches for enhancing equity. Methods have emerged to accurately quantify excess risk and identify space-time disparities. This provides useful and detailed information for guiding policy. A spatio-temporal analysis was performed to identify risk factors associated with child (1-4 years) mortality in the Agincourt sub-district, South Africa, to assess temporal changes in child mortality patterns within the study site between 1992 and 2007, and to produce all-cause and cause-specific mortality maps to identify high risk areas. Demographic, maternal, paternal and fertility-related factors, household mortality experience, distance to health care facility and socio-economic status were among the examined risk factors. The analysis was carried out by fitting a Bayesian discrete time Bernoulli survival geostatistical model using Markov chain Monte Carlo simulation. Bayesian kriging was used to produce mortality risk maps. Significant temporal increase in child mortality was observed due to the HIV epidemic. A distinct spatial risk pattern was observed with higher risk areas being concentrated in poorer settlements on the eastern part of the study area, largely inhabited by former Mozambican refugees. The major risk factors for childhood mortality, following multivariate adjustment, were mother's death (especially when due to HIV and tuberculosis), greater number of children under 5 years living in the same household and winter season. This study demonstrates the use of Bayesian geostatistical models for accurately quantifying risk factors and producing maps of child mortality risk in a health and demographic surveillance system. According to the space-time analysis, the southeast and upper central regions of the site appear to have the highest mortality risk. The results inform policies to address health inequalities in the Agincourt sub-district and to improve access to health services. Targeted efforts to prevent vertical transmission of HIV in specific settings need to be undertaken as well as ensuring the survival of the mother and father in childhood.

  • 145.
    Sartorius, Benn
    et al.
    MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Vounatsou, Penelope
    Swiss Tropical Institute, Basel, Switzerland.
    Collinson, Mark A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Accra, Ghana.
    Space and time clustering of mortality in rural South Africa (Agincourt HDSS), 1992-20072010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. 50-58Article in journal (Refereed)
    Abstract [en]

    This study has highlighted distinct clusters of all-cause and cause-specific mortality within the Agincourt subdistrict. It is a first step in prioritizing areas for further, more detailed research as well as for future public health follow-on efforts such as targeting of vertical prevention of HIV/TB and antiretroviral rollout in significant child and adult mortality clusters; and assessment and provision of adequate water and sanitation in the child mortality clusters particularly in south-east where diarrheal mortality appears high. Underlying causative factors need to be identified and accurately quantified. Other questions for more detailed research are discussed.

  • 146. Sedibe, Heather M.
    et al.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gitau, Tabitha
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norris, Shane A.
    Qualitative study exploring healthy eating practices and physical activity among adolescent girls in rural South Africa2014In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 14, article id 211Article in journal (Refereed)
    Abstract [en]

    Background: Dietary behaviours and physical activity are modifiable risk factors to address increasing levels of obesity among children and adolescents, and consequently to reduce later cardiovascular and metabolic disease. This paper explores perceptions, attitudes, barriers, and facilitators related to healthy eating and physical activity among adolescent girls in rural South Africa.

    Methods: A qualitative study was conducted in the rural Agincourt subdistrict, covered by a health and sociodemographic surveillance system, in Mpumalanga province, South Africa. Semistructured "duo-interviews" were carried out with 11 pairs of adolescent female friends aged 16 to 19 years. Thematic content analysis was used.

    Results: The majority of participants considered locally grown and traditional foods, especially fruits and vegetables, to be healthy. Their consumption was limited by availability, and these foods were often sourced from family or neighbourhood gardens. Female caregivers and school meal programmes facilitated healthy eating practices. Most participants believed in the importance of breakfast, even though for the majority, limited food within the household was a barrier to eating breakfast before going to school. The majority cited limited accessibility as a major barrier to healthy eating, and noted the increasing intake of "convenient and less healthy foods". Girls were aware of the benefits of physical activity and engaged in various physical activities within the home, community, and schools, including household chores, walking long distances to school, traditional dancing, and extramural activities such as netball and soccer.

    Conclusions: The findings show widespread knowledge about healthy eating and the benefits of consuming locally grown and traditional food items in a population that is undergoing nutrition transition. Limited access and food availability are strong barriers to healthy eating practices. School meal programmes are an important facilitator of healthy eating, and breakfast provision should be considered as an extension of the meal programme. Walking to school, cultural dance, and extramural activities can be encouraged and thus are useful facilitators for increasing physical activity among rural adolescent girls, where the prevalence of overweight and obesity is increasing.

  • 147. Sedibe, Modiehi Heather
    et al.
    Pisa, Pedro T.
    Feeley, Alison B.
    Pedro, Titilola M.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, East Legon, Accra 23321, Ghana; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2198, South Africa.
    Norris, Shane A.
    Dietary Habits and Eating Practices and Their Association with Overweight and Obesity in Rural and Urban Black South African Adolescents2018In: Nutrients, ISSN 2072-6643, E-ISSN 2072-6643, Vol. 10, no 2, article id 145Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to investigate differences/similarities in dietary habits and eating practices between younger and older, rural and urban South African adolescents in specific environments (home, community and school) and their associations with overweight and obesity. Dietary habits, eating practices, and anthropometric measurements were performed on rural (n = 392, mean age = 13 years) and urban (n = 3098, mean age = 14 years) adolescents. Logistic regression analysis was used to examine the associations between dietary habits and eating practices, with overweight and obesity risk. Differences in dietary habits and eating practices by gender and by site within the three environments were identified. After adjusting for gender, site, dietary habits, and eating practices within the home, community and school environment, eating the main meal with family some days (OR = 1.78, 95% CI = 1.114-2.835; p <= 0.02), eating the main meal with family almost every day (OR = 1.61, 95% CI = 1.106-2.343; p <= 0.01), and irregular frequency of consuming breakfast on weekdays (OR = 1.38, 95% CI = 1.007-1.896; p 0.05) were all associated with increased risk of overweight and obesity. For "Year 15" adolescents, irregular frequency of consuming breakfast on weekends within the home environment (OR = 1.53, 95% CI = 1.099-2.129, p <= 0.01), was associated with increased risk of overweight and obesity. For both early- and mid-adolescents, being male (OR = 0.401, 95% CI = 0.299-0.537; p <= 0.00; OR = 0.29, 95% CI = 0.218-0.397; p <= 0.00) was associated with reduced risk of overweight and obesity, while residing in a rural setting (OR = 0.55, 95% CI = 0.324-0.924; p <= 0.02) was associated with reduced risk of overweight and obesity only among early-adolescents. Only dietary habits and eating practices within the home environment were associated with increased risk of overweight and obesity.

  • 148. Sharrow, David J
    et al.
    Clark, Samuel J
    Collinson, Mark A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa and INDEPTH Network, Accra, Ghana.
    The Age Pattern of Increases in Mortality Affected by HIV: Bayesian Fit of the Heligman-Pollard Model to Data from the Agincourt HDSS Field Site in Rural Northeast South Africa2013In: Demographic Research, ISSN 1435-9871, Vol. 29, p. 1039-1096Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: We investigate the sex-age-specific changes in the mortality of a prospectively monitored rural population in South Africa. We quantify changes in the age pattern of mortality in a parsimonious way by estimating the eight parameters of the Heligman-Pollard (HP) model of age-specific mortality. In its traditional form this model is difficult to fit and does not account for uncertainty.

    OBJECTIVE: 1. To quantify changes in the sex-age pattern of mortality experienced by a population with endemic HIV. 2. To develop and demonstrate a robust Bayesian estimation method for the HP model that accounts for uncertainty.

    METHODS: Bayesian estimation methods are adapted to work with the HP model. Temporal changes in parameter values are related to changes in HIV prevalence.

    RESULTS: Over the period when the HIV epidemic in South Africa was growing, mortality in the population described by our data increased profoundly with losses of life expectancy of ~15 years for both males and females. The temporal changes in the HP parameters reflect in a parsimonious way the changes in the age pattern of mortality. We develop a robust Bayesian method to estimate the eight parameters of the HP model and thoroughly demonstrate it.

    CONCLUSIONS: Changes in mortality in South Africa over the past fifteen years have been profound. The HP model can be fit well using Bayesian methods, and the results can be useful in developing a parsimonious description of changes in the age pattern of mortality.

    COMMENTS: The motivating aim of this work is to develop new methods that can be useful in applying the HP eight-parameter model of age-specific mortality. We have done this and chosen an interesting application to demonstrate the new methods.

  • 149. Stoner, Marie C. D.
    et al.
    Dennis, Ann M.
    Hughes, James P.
    Eshleman, Susan H.
    Sivay, Marisa, V
    Hudelson, Sarah E.
    Grabowski, M. Kate
    Gomez-Olive, E. Xavier
    MacPhail, Catherine
    Piwowar-Manning, Estelle
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. INDEPTH Network, Accra, Ghana.
    Pettifor, Audrey
    Characteristics Associated With Human Immunodeficiency Virus Transmission Networks Involving Adolescent Girls and Young Women in Human Immunodeficiency Virus Prevention Trials Network 068 Study2019In: Sexually Transmitted Diseases, ISSN 0148-5717, E-ISSN 1537-4521, Vol. 46, no 5, p. E46-E49Article in journal (Refereed)
    Abstract [en]

    We combined behavioral survey data from the human immunodeficiency virus (HIV) Prevention Trials Network 068 study with phylogenetic information to determine if cluster membership was associated with characteristics of young women and their partners. Clusters were more likely to involve young women from specific villages and schools, indicating some localized transmission.

  • 150. Stoner, Marie C. D.
    et al.
    Edwards, Jessie K.
    Miller, William C.
    Aiello, Allison E.
    Halpern, Carolyn T.
    Julien, Aimee
    Rucinski, Katherine B.
    Selin, Amanda
    Twine, Rhian
    Hughes, James P.
    Wang, Jing
    Agyei, Yaw
    Gómez-Olivé, Francesc Xavier
    Wagner, Ryan G.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
    Laeyendecker, Oliver
    Macphail, Catherine
    Kahn, Kathleen
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana.
    Pettifor, Audrey
    Does Partner Selection Mediate the Relationship Between School Attendance and HIV/Herpes Simplex Virus-2 Among Adolescent Girls and Young Women in South Africa: An Analysis of HIV Prevention Trials Network 068 Data2018In: Journal of Acquired Immune Deficiency Syndromes, ISSN 1525-4135, E-ISSN 1944-7884, Vol. 79, no 1, p. 20-27Article in journal (Refereed)
    Abstract [en]

    Objective: School attendance prevents HIV and herpes simplex virus-2 (HSV-2) in adolescent girls and young women, but the mechanisms to explain this relationship remain unclear. Our study assesses the extent to which characteristics of sex partners, partner age, and number mediate the relationship between attendance and risk of infection in adolescent girls and young women in South Africa.

    Design: We use longitudinal data from the HIV Prevention Trials Network 068 randomized controlled trial in rural South Africa, where girls were enrolled in early adolescence and followed in the main trial for more than 3 years. We examined older partners and the number of partners as possible mediators.

    Methods: We used the parametric g-formula to estimate 4-year risk differences for the effect of school attendance on the cumulative incidence of HIV/HSV-2 overall and the controlled direct effect (CDE) for mediation. We examined mediation separately and jointly for the mediators of interest.

    Results: We found that young women with high attendance in school had a lower cumulative incidence of HIV compared with those with low attendance (risk difference = -1.6%). Partner age difference (CDE = -1.2%) and the number of partners (CDE = -0.4%) mediated a large portion of this effect. In fact, when we accounted for the mediators jointly, the effect of schooling on HIV was almost removed, showing full mediation (CDE = -0.3%). The same patterns were observed for the relationship between school attendance and cumulative incidence of HSV-2 infection.

    Conclusion: Increasing school attendance reduces the risk of acquiring HIV and HSV-2. Our results indicate the importance of school attendance in reducing partner number and partner age difference in this relationship.

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