A longitudinal study combining the Double Diamond framework and Behavior Change Wheel to co-create a sedentary behavior intervention in police control rooms.

BACKGROUND: Police work can be sedentary and stressful, negatively impacting health and wellbeing. In a novel co-creation approach, we used the Behavior Change Wheel (BCW) and Double Diamond (DD) design framework to guide the collaborative design and development of a sedentary behavior intervention in the control rooms of two British police forces. METHODS: Multiple stakeholders participated in four phases of research. In Phase 1, a literature review, focus groups (n = 20) and interviews (n = 10) were conducted to 'discover' the relationship between physical activity and wellbeing in the police. In Phase 2, a steering group consolidated Phase 1 findings to 'define' a specific behavior for intervention. Phases 3 and 4 'developed' the intervention across six workshops with control room workers and six steering group workshops. RESULTS: The co-creation process identified contextual sedentary behavior as the target behavior, driven by behavioral regulation, social influence and social norms. The sedentary behavior intervention targeted these drivers and aimed to engage control room workers in short bursts of physical activity throughout their shifts. Key intervention features targeted involvement of staff in decision-making and embedding physical activity into work practices. CONCLUSIONS: The BCW and DD can be combined to co-create evidence-based and participant-informed interventions and translate science into action.

Principles for Adapting Assessments of Executive Function across Cultural Contexts.

Direct assessments of executive functions (EFs) are increasingly used in research and clinical settings, with a central assumption that they assess "universal" underlying skills. Their use is spreading globally, raising questions about the cultural appropriateness of assessments devised in Western industrialized countries. We selectively reviewed multidisciplinary evidence and theory to identify sets of cultural preferences that may be at odds with the implicit assumptions of EF assessments. These preferences relate to motivation and compliance; cultural expectations for interpersonal engagement; contextualized vs. academic thinking; cultural notions of speed and time; the willingness to be silly, be incorrect, or do the opposite; and subject-matter familiarity. In each case, we discuss how the cultural preference may be incompatible with the assumptions of assessments, and how future research and practice can address the issue. Many of the cultural preferences discussed differ between interdependent and independent cultures and between schooled and unschooled populations. Adapting testing protocols to these cultural preferences in different contexts will be important for expanding our scientific understanding of EF from the narrow slice of the human population that has participated in the research to date.

Building an assessment of community-defined social-emotional competencies from the ground up in Tanzania.

Two studies were conducted in 2017 to investigate children's competencies seen as important by communities in Mtwara, Tanzania. Qualitative data from 95 parents (34 women) and 27 teachers (11 women) in Study 1 indicated that dimensions of social responsibility, such as obedience, were valued highly. In Study 2, the competencies of 477 children (245 girls), aged 4-13 years, were rated by teachers and parents. Factor analysis found the obedient factor explained the most variance in parent rating. In line with predictions, urban residence, parental socioeconomic status (SES), and parental education were all positively associated with ratings of curiosity, and parental SES was negatively associated with obedience and emotional regulation. Findings illustrate the need for culturally specific frameworks of social-emotional learning.

Preventive malaria treatment among school-aged children in sub-Saharan Africa: a systematic review and meta-analyses.

BACKGROUND: The burden of malaria infection in sub-Saharan Africa among school-aged children aged 5-15 years is underappreciated and represents an important source of human-to-mosquito transmission of Plasmodium falciparum. Additional interventions are needed to control and eliminate malaria. We aimed to assess whether preventive treatment of malaria might be an effective means of reducing P falciparum infection and anaemia in school-aged children and lowering parasite transmission. METHODS: In this systematic review and two meta-analyses, we searched the online databases PubMed, Embase, Cochrane CENTRAL, and Clinicaltrials.gov for intervention studies published between Jan 1, 1990, and Dec 14, 2018. We included randomised studies that assessed the effect of antimalarial treatment among asymptomatic school-aged children aged 5-15 years in sub-Saharan Africa on prevalence of P falciparum infection and anaemia, clinical malaria, and cognitive function. We first extracted data for a study-level meta-analysis, then contacted research groups to request data for an individual participant data meta-analysis. Outcomes of interest included prevalence of P falciparum infection detected by microscopy, anaemia (study defined values or haemoglobin less than age-adjusted and sex-adjusted values), clinical malaria (infection and symptoms on the basis of study-specific definitions) during follow-up, and code transmission test scores. We assessed effects by treatment type and duration of time protected, and explored effect modification by transmission setting. For study-level meta-analysis, we calculated risk ratios for binary outcomes and standardised mean differences for continuous outcomes and pooled outcomes using fixed-effect and random-effects models. We used a hierarchical generalised linear model for meta-analysis of individual participant data. This study is registered with PROSPERO, CRD42016030197. FINDINGS: Of 628 studies identified, 13 were eligible for the study-level meta-analysis (n=16 309). Researchers from 11 studies contributed data on at least one outcome (n=15 658) for an individual participant data meta-analysis. Interventions and study designs were highly heterogeneous; overall risk of bias was low. In the study-level meta-analysis, treatment was associated with reductions in P falciparum prevalence (risk ratio [RR] 0·27, 95% CI 0·17-0·44), anaemia (0·77, 0·65-0·91), and clinical malaria (0·40, 0·28-0·56); results for cognitive outcomes are not presented because data were only available for three trials. In our individual participant data meta-analysis, we found treatment significantly decreased P falciparum prevalence (adjusted RR [ARR] 0·46, 95% CI 0·40-0·53; p<0·0001; 15 648 individuals; 11 studies), anaemia (ARR 0·85, 0·77-0·92; p<0·0001; 15 026 individuals; 11 studies), and subsequent clinical malaria (ARR 0·50, 0·39-0·60; p<0·0001; 1815 individuals; four studies) across transmission settings. We detected a marginal effect on cognitive function in children older than 10 years (adjusted mean difference in standardised test scores 0·36, 0·01-0·71; p=0·044; 3962 individuals; five studies) although we found no significant effect when combined across all ages. INTERPRETATION: Preventive treatment of malaria among school-aged children significantly decreases P falciparum prevalence, anaemia, and risk of subsequent clinical malaria across transmission settings. Policy makers and programme managers should consider preventive treatment of malaria to protect this age group and advance the goal of malaria elimination, while weighing these benefits against potential risks of chemoprevention. FUNDING: US National Institutes of Health and Burroughs Wellcome Fund/ASTMH Fellowship.

Practical lessons for phone-based assessments of learning.

School closures affecting more than 1.5 billion children are designed to prevent the spread of current public health risks from the COVID-19 pandemic, but they simultaneously introduce new short-term and long-term health risks through lost education. Measuring these effects in real time is critical to inform effective public health responses, and remote phone-based approaches are one of the only viable options with extreme social distancing in place. However, both the health and education literature are sparse on guidance for phone-based assessments. In this article, we draw on our pilot testing of phone-based assessments in Botswana, along with the existing literature on oral testing of reading and mathematics, to propose a series of preliminary practical lessons to guide researchers and service providers as they try phone-based learning assessments. We provide preliminary evidence that phone-based assessments can accurately capture basic numeracy skills. We provide guidance to help teams (1) ensure that children are not put at risk, (2) test the reliability and validity of phone-based measures, (3) use simple instructions and practice items to ensure the assessment is focused on the target skill, not general language and test-taking skills, (4) adapt the items from oral assessments that will be most effective in phone-based assessments, (5) keep assessments brief while still gathering meaningful learning data, (6) use effective strategies to encourage respondents to pick up the phone, (7) build rapport with adult caregivers and youth respondents, (8) choose the most cost-effective medium and (9) account for potential bias in samples.

Literacy acquisition in multilingual educational contexts: Evidence from Coastal Kenya.

Literacy is a powerful tool against poverty, leading to further education and vocational success. In sub-Saharan Africa, schoolchildren commonly learn in two languages-African and European. Multiple early literacy skills (including phonological awareness and receptive language) support literacy acquisition, but this has yet to be empirically tested in sub-Saharan Africa, where learning contexts are highly multilingual, and children are often learning to read in a language they do not speak at home. We use longitudinal data from 1,100 schoolchildren spanning three groups of native languages [Mijikenda languages (Digo, Duruma, Chonyi, and Giriama), Kiswahili, Kikamba] in coastal Kenya (language of instruction: Kiswahili and English). We find that baseline phonological awareness and receptive language are differentially important in predicting literacy skills in English and in Kiswahili, and these relations are moderated by the degree of shared cross-linguistic features between home and school languages. Importantly, the relative importance of these factors changes over development. Implications for language development and literacy acquisition in linguistically diverse contexts are discussed.

Reading and Phonological Awareness in Africa.

Literacy levels in Africa are low, and school instruction outcomes are not promising. Africa also has a disproportionate number of unschooled children. Phonological awareness (PA), especially phoneme awareness, is critically associated with literacy, but there is little evidence about whether PA is gained through literacy, schooling, or both, because most children studied are in education and can read at least letters. Our previous study of PA and reading in children in and out of school in Tanzania found that PA was associated with reading ability, not schooling or age, and many unschooled children learned to read. We retested 85 children from the baseline study, on measures of PA and literacy, approximately 2 years later. We found that more unschooled children had now learned to read but PA had generally not improved for these children. Unschooled children were still poorer at PA than schooled children. At 2 years, schooling now independently predicted PA and literacy. PA also predicted literacy and vice versa. Explicit phoneme awareness was again poor, even in accurate readers. More unschooled children have now learned to read, possibly because local literacy is in their first language; however, schooling improves reading and PA.

Impact of a malaria intervention package in schools on Plasmodium infection, anaemia and cognitive function in schoolchildren in Mali: a pragmatic cluster-randomised trial.

BACKGROUND: School-aged children are rarely targeted by malaria control programmes, yet the prevalence of Plasmodium infection in primary school children often exceeds that seen in younger children and could affect haemoglobin concentration and school performance. METHODS: A cluster-randomised trial was carried out in 80 primary schools in southern Mali to evaluate the impact of a school-based malaria intervention package. Intervention schools received two interventions sequentially: (1) teacher-led participatory malaria prevention education, combined with distribution of long-lasting insecticidal nets (LLINs), followed 7 months later at the end of the transmission season by (2) mass delivery of artesunate and sulfadoxine-pyrimethamine administered by teachers, termed intermittent parasite clearance in schools (IPCs). Control schools received LLINs as part of the national universal net distribution programme. The impact of the interventions on malaria and anaemia was evaluated over 20 months using cross-sectional surveys in a random subset of 38 schools(all classes), with a range of cognitive measures (sustained attention, visual search, numeracy, vocabulary and writing) assessed in a longitudinal cohort of children aged 9-12 years in all 80 schools. RESULTS: Delivery of a single round of IPCs was associated with dramatic reductions in malaria parasitaemia (OR 0.005, 95% CI 0.002 to 0.011, p<0.001) and gametocyte carriage (OR 0.02, 95% CI 0.00 to 0.17, p<0.001) in intervention compared with control schools. This effect was sustained for 6 months until the beginning of the next transmission season. IPCs was also associated with a significant decrease in anaemia (OR 0.56, 95% CI 0.40 to 0.78, p=0.001), and increase in sustained attention (difference +0.23, 95% CI 0.10 to 0.36, p<0.001). There was no evidence of impact on other cognitive measures. CONCLUSION: The combination of malaria prevention education, LLINs and IPCs can reduce anaemia and improve sustained attention of school children in areas of highly seasonal transmission. These findings highlight the impact of asymptomatic malaria infection on cognitive performance in schoolchildren and the benefit of IPCs in reducing this burden. Additionally, malaria control in schools can help diminish the infectious reservoir that sustains Plasmodium transmission.

Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial.

BACKGROUND: Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence of the benefits of alternative school-based malaria interventions or how the impacts of interventions vary according to intensity of malaria transmission. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission. METHODS AND FINDINGS: A cluster randomised trial was implemented with 5,233 children in 101 government primary schools on the south coast of Kenya in 2010-2012. The intervention was delivered to children randomly selected from classes 1 and 5 who were followed up for 24 months. Once a school term, children were screened by public health workers using malaria rapid diagnostic tests (RDTs), and children (with or without malaria symptoms) found to be RDT-positive were treated with a six dose regimen of artemether-lumefantrine (AL). Given the nature of the intervention, the trial was not blinded. The primary outcomes were anaemia and sustained attention. Secondary outcomes were malaria parasitaemia and educational achievement. Data were analysed on an intention-to-treat basis. During the intervention period, an average of 88.3% children in intervention schools were screened at each round, of whom 17.5% were RDT-positive. 80.3% of children in the control and 80.2% in the intervention group were followed-up at 24 months. No impact of the malaria IST intervention was observed for prevalence of anaemia at either 12 or 24 months (adjusted risk ratio [Adj.RR]: 1.03, 95% CI 0.93-1.13, p = 0.621 and Adj.RR: 1.00, 95% CI 0.90-1.11, p = 0.953) respectively, or on prevalence of P. falciparum infection or scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months. CONCLUSION: In this setting in Kenya, IST as implemented in this study is not effective in improving the health or education of school children. Possible reasons for the absence of an impact are the marked geographical heterogeneity in transmission, the rapid rate of reinfection following AL treatment, the variable reliability of RDTs, and the relative contribution of malaria to the aetiology of anaemia in this setting. TRIAL REGISTRATION: www.ClinicalTrials.gov NCT00878007.

Early childhood malaria prevention and children's patterns of school leaving in the Gambia.

BACKGROUND: Early childhood malaria is often fatal, but its impact on the development and education of survivors has not received much attention. Malaria impacts cognitive development in a number of ways that may impact later educational participation. AIMS: In this study, we examine the long-term educational effects of preventing early childhood malaria. Does intermittent preventive treatment (IPT) during early childhood reduce the risk of dropout? If so, does this effect vary by school type - government school versus madrassa? SAMPLE: We use data from a 2001 follow-up of a 1985-1987 malaria prevention randomized controlled trial in the Gambia. The sample consists of 562 youth born between 1981 and 1986. METHODS: We use discrete-time survival analysis to identify the impact of the intervention on dropout risk over time. RESULTS: We find that IPT has a positive impact on dropout for government school students, but not for madrassa attendees. The difference was striking: in government schools, the odds of dropout in the treatment group were one third of those in the control group. CONCLUSIONS: Our findings suggest that preventing early childhood malaria may reduce dropout at a relatively low cost. In this intervention, the drugs cost less than one dollar per year per child. While IPT is no longer practised in many countries due to concerns over drug resistance, these results support the conclusion that any type of effective malaria control programme protecting young children, such as consistent and correct use of bed nets, could improve educational attainment in areas where malaria is prevalent.

Cluster-randomised trial of the impact of school-based deworming and iron supplementation on the cognitive abilities of schoolchildren in Sri Lanka's plantation sector.

OBJECTIVE: To assess the impact of deworming and iron supplementation on the cognitive abilities and educational achievement of school-age children in Sri Lanka. METHODS: Prospective, placebo-controlled randomised study. The treatment group received deworming and weekly iron supplementation for 6 months; the control group received placebo for both the anthelmintic and iron. A mixed effects regression model was used to answer the main research question. To increase the precision of this study's estimates, various background variables were controlled for that were not related to treatment but could have some impact on the outcome. RESULTS: The prevalence of soil-transmitted helminth (STH) infection was reduced in the treatment group (n = 615), with significant differences between treatment and control groups (n = 575) in the levels of Ascaris and Trichuris. No impact was found on haemoglobin (Hb) levels, nor any significant impact on concentration levels or on educational test scores. CONCLUSION: Decline in STH prevalence alone, in the absence of improved Hb status, produced no evidence of impact on concentration levels or educational test scores.

Challenges for consent and community engagement in the conduct of cluster randomized trial among school children in low income settings: experiences from Kenya.

BACKGROUND: There are a number of practical and ethical issues raised in school-based health research, particularly those related to obtaining consent from parents and assent from children. One approach to developing, strengthening, and supporting appropriate consent and assent processes is through community engagement. To date, much of the literature on community engagement in biomedical research has concentrated on community- or hospital-based research, with little documentation, if any, of community engagement in school-based health research. In this paper we discuss our experiences of consent, assent and community engagement in implementing a large school-based cluster randomized trial in rural Kenya. METHODS: Data collected as part of a qualitative study investigating the acceptability of the main trial, focus group discussions with field staff, observations of practice and authors' experiences are used to: 1) highlight the challenges faced in obtaining assent/consent; and 2) strategies taken to try to both protect participant rights (including to refuse and to withdraw) and ensure the success of the trial. RESULTS: Early meetings with national, district and local level stakeholders were important in establishing their co-operation and support for the project. Despite this support, both practical and ethical challenges were encountered during consenting and assenting procedures. Our strategy for addressing these challenges focused on improving communication and understanding of the trial, and maintaining dialogue with all the relevant stakeholders throughout the study period. CONCLUSIONS: A range of stakeholders within and beyond schools play a key role in school based health trials. Community entry and information dissemination strategies need careful planning from the outset, and with on-going consultation and feedback mechanisms established in order to identify and address concerns as they arise. We believe our experiences, and the ethical and practical issues and dilemmas encountered, will be of interest for others planning to conduct school-based research in Africa. TRIAL REGISTRATION: National Institute of Health NCT00878007.

Plasmodium falciparum, anaemia and cognitive and educational performance among school children in an area of moderate malaria transmission: baseline results of a cluster randomized trial on the coast of Kenya.

OBJECTIVES: Studies have typically investigated health and educational consequences of malaria among school-aged children in areas of high malaria transmission, but few have investigated these issues in moderate transmission settings. This study investigates the patterns of and risks for Plasmodium falciparum and anaemia and their association with cognitive and education outcomes on the Kenyan coast, an area of moderate malaria transmission. METHODS: As part of a cluster randomised trial, a baseline cross-sectional survey assessed the prevalence of and risk factors for P. falciparum infection and anaemia and the associations between health status and measures of cognition and educational achievement. Results are presented for 2400 randomly selected children who were enrolled in the 51 intervention schools. RESULTS: The overall prevalence of P. falciparum infection and anaemia was 13.0% and 45.5%, respectively. There was marked heterogeneity in the prevalence of P. falciparum infection by school. In multivariable analysis, being male, younger age, not sleeping under a mosquito net and household crowding were adjusted risk factors for P. falciparum infection, whilst P. falciparum infection, being male and indicators of poor nutritional intake were risk factors for anaemia. No association was observed between either P. falciparum or anaemia and performance on tests of sustained attention, cognition, literacy or numeracy. CONCLUSION: The results indicate that in this moderate malaria transmission setting, P. falciparum is strongly associated with anaemia, but there is no clear association between health status and education. Intervention studies are underway to investigate whether removing the burden of chronic asymptomatic P. falciparum and related anaemia can improve education outcomes.

The impact of education on sexual behavior in sub-Saharan Africa: a review of the evidence.

Many studies have attempted to determine the relationship between education and HIV status. However, a complete and causal understanding of this relationship requires analysis of its mediating pathways, focusing on sexual behaviors. We developed a series of hypotheses based on the differential effect of educational attainment on three sexual behaviors. We tested our predictions in a systematic literature review including 65 articles reporting associations between three specific sexual behaviors -- sexual initiation, number of partners, and condom use -- and educational attainment or school enrollment in sub-Saharan Africa. The patterns of associations varied by behavior. The findings for condom use were particularly convergent; none of the 44 studies using educational attainment as a predictor reviewed found that more educated people were significantly less likely to use condoms. Findings for sexual initiation and number of partners were more complex. The contrast between findings for condom use on the one hand and sexual initiation and number of partners on the other supports predictions based on our theoretical framework.

Cost analysis of school-based intermittent screening and treatment of malaria in Kenya.

BACKGROUND: The control of malaria in schools is receiving increasing attention, but there remains currently no consensus as to the optimal intervention strategy. This paper analyses the costs of intermittent screening and treatment (IST) of malaria in schools, implemented as part of a cluster-randomized controlled trial on the Kenyan coast. METHODS: Financial and economic costs were estimated using an ingredients approach whereby all resources required in the delivery of IST are quantified and valued. Sensitivity analysis was conducted to investigate how programme variation affects costs and to identify potential cost savings in the future implementation of IST. RESULTS: The estimated financial cost of IST per child screened is US$ 6.61 (economic cost US$ 6.24). Key contributors to cost were salary costs (36%) and malaria rapid diagnostic tests (RDT) (22%). Almost half (47%) of the intervention cost comprises redeployment of existing resources including health worker time and use of hospital vehicles. Sensitivity analysis identified changes to intervention delivery that can reduce programme costs by 40%, including use of alternative RDTs and removal of supervised treatment. Cost-effectiveness is also likely to be highly sensitive to the proportion of children found to be RDT-positive. CONCLUSION: In the current context, school-based IST is a relatively expensive malaria intervention, but reducing the complexity of delivery can result in considerable savings in the cost of intervention. (Costs are reported in US$ 2010).

Improving educational achievement and anaemia of school children: design of a cluster randomised trial of school-based malaria prevention and enhanced literacy instruction in Kenya.

BACKGROUND: Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence on the benefits of school-based malaria prevention or how health interventions interact with other efforts to improve education quality. This study aims to evaluate the impact of school-based malaria prevention and enhanced literacy instruction on the health and educational achievement of school children in Kenya. DESIGN: A factorial, cluster randomised trial is being implemented in 101 government primary schools on the coast of Kenya. The interventions are (i) intermittent screening and treatment of malaria in schools by public health workers and (ii) training workshops and support for teachers to promote explicit and systematic literacy instruction. Schools are randomised to one of four groups: receiving either (i) the malaria intervention alone; (ii) the literacy intervention alone; (iii) both interventions combined; or (iv) control group where neither intervention is implemented. Children from classes 1 and 5 are randomly selected and followed up for 24 months. The primary outcomes are educational achievement and anaemia, the hypothesised mediating variables through which education is affected. Secondary outcomes include malaria parasitaemia, school attendance and school performance. A nested process evaluation, using semi-structured interviews, focus group discussion and a stakeholder analysis will investigate the community acceptability, feasibility and cost-effectiveness of the interventions. DISCUSSION: Across Africa, governments are committed to improve health and education of school-aged children, but seek clear policy and technical guidance as to the optimal approach to address malaria and improved literacy. This evaluation will be one of the first to simultaneously evaluate the impact of health and education interventions in the improvement of educational achievement. Reflection is made on the practical issues encountered in conducting research in schools in Africa. TRIAL REGISTRATION: National Institutes of Health NCT00878007.

Assessment of cognitive abilities in multiethnic countries: the case of the Wolof and Mandinka in the Gambia.

BACKGROUND: The use of cognitive tests is increasing in Africa but little is known about how such tests are affected by the great ethnic and linguistic diversity on the continent. AIM: To assess ethnic and linguistic group differences in cognitive test performance in the West African country of the Gambia and to investigate the sources of these differences. SAMPLES: Study 1 included 579 participants aged 14-19 years from the Wolof and Mandinka ethnic groups of the Gambia. Study 2 included 41 participants aged 12-18 years from the two ethnic groups. METHODS: Study 1 assessed performance on six cognitive tests. Participants were also asked about their history of education, residence in the city, parental education, and family socio-economic status. Study 2 assessed performance on two versions of the digit span test. Recall of the numbers 1-5 were compared with recall of numbers 1-9 for both the Wolof (who count in base 5) and the Mandinka (who count in base 10). RESULTS: Study 1 established that Wolof performance was lower than that of the Mandinka on five out of six cognitive tests. In four of these tests, group differences were partially mediated by participation in primary school and migration to the city. Group differences were substantial for the digit span test and were not attenuated by mediating variables. Study 2 found that digit span among the Wolof was shorter than that of the Mandinka for numbers 1-9 but not for numbers 1-5. CONCLUSIONS: Several suggestions are made on how to consider the ethnicity, language, education, and residence (urban vs. rural) of groups when conducting comparative cognitive assessments or collecting normative data.

Contrasting causal pathways contribute to poorer health and nutrition outcomes in orphans in Zimbabwe.

Orphaned children have been found to be at greater risk of poor health and malnutrition compared to non-orphans in sub-Saharan African countries. However, levels of disadvantage vary by location and little is known about the causal pathways that lead from orphanhood to poorer health and malnutrition. Aggregate data from recent Demographic and Health Surveys in 22 countries were used to compare overall levels of ill-health and malnutrition by orphan status. Data from the Manicaland Child Cohort Study in Zimbabwe - a closed cohort study with detailed longitudinal information on orphan's experience - were used to describe how patterns of ill-health and malnutrition alter over the child's life-course and to test causal pathways between orphanhood and ill-health and malnutrition, hypothesized in a previously published theoretical frame-work. Modest increases in ill-health and malnutrition were found in orphans in the Demographic and Health Surveys data, with maternal and double orphans being worst affected. Non-significant associations were found between orphanhood and ill-health in the Manicaland Child Cohort Study data, but no associations with malnutrition were found. None the less, smaller increases in body mass index with age were seen among orphans (ologit test for difference: adjusted odds ratio = 0.68; p = 0.07) and maternal orphans (ologit test for difference: adjusted odds ratio = 0.67; p = 0.03) than among non-orphans. Stigma and discrimination contributed to poor diet, malnutrition and ill-health in children whose mothers had died, while heightened poverty was a more important factor for paternal orphans. These results suggest social and psychological support for orphans and their families could be as important as material support in preventing malnutrition and ill-health.