Challenges of developing a district child welfare plan in South Africa: lessons from a community-engaged HIV/AIDS research project.

The Amajuba Child Health and Wellbeing Research Project measured the impact of orphaning due to HIV/AIDS on South African households between 2004 and 2007. Community engagement was a central component of the project and extended through 2010. We describe researcher engagement with the community to recruit participants, build local buy-in, stimulate interest in study findings, and promote integration of government social welfare services for families and children affected by HIV/AIDS. This narrative documents the experience of researchers, drawing also on project reports, public documents, and published articles, with the objective of documenting lessons learned in this collaboration between researchers from two universities and a community in South Africa during a period that spanned seven years. This experience is then analyzed within the context of an applied research, community-engagement framework.

The prevalence of self-reported vision difficulty in economically disadvantaged regions of South Africa.

BACKGROUND: Vision impairment, resulting in vision difficulties, is a leading cause of disability, and hence one of the key barriers for people to access education and employment, which may force them into poverty. OBJECTIVES: The objective of this study was to determine the prevalence of self-reported vision difficulties as an indicator of vision impairment in economically disadvantaged regions in South Africa, and to examine the relationship between self-reported vision difficulties and socio-economic markers of poverty, namely, income, education and health service needs. METHODS: A cross-sectional study was conducted in economically disadvantaged districts to collect data from households on poverty and health, including vision difficulty. As visual acuity measurements were not conducted, the researchers used the term vision difficulty as an indicator of vision impairment. Data were collected from 27 districts (74 901 respondents). Logistic regression analysis and chi-square tests were used to determine bivariate relationships between variables and self-reported vision difficulty. Kernel density estimators were used for age, categorised by self-reported and not reported vision difficulty. RESULTS: Prevalence of self-reported vision difficulty was 11.2% (95% CI, 8.7% - 13.7%). More women (12.7%) compared to men (9.5%) self-reported vision difficulty (p < 0.01). Self-reported vision difficulty was higher (14.2%) for respondents that do not spend any money. A statistically significant relationship was found between the highest level of education and self-reporting of vision difficulty; as completed highest level of education increased, self-reporting of vision difficulty became lower (p < 0.01). A significantly higher prevalence of self-reported vision difficulty was found in respondents who are employed (p < 0.01), 17% (95% CI: 12.8% - 21.1%). CONCLUSION: The evidence from this study suggests associations between socio-economic factors and vision difficulties that have a two-fold relationship (some factors such as education, and access to eye health services are associated with vision difficulty whilst vision difficulty may trap people in their current poverty or deepen their poverty status). The results are thus indicative of the need for further research in South Africa.

The prevalence of self-reported vision difficulty in economically disadvantaged regions of South Africa

Background: Vision impairment, resulting in vision difficulties, is a leading cause of disability, and hence one of the key barriers for people to access education and employment, which may force them into poverty. Objectives: The objective of this study was to determine the prevalence of self reported vision difficulties as an indicator of vision impairment in economically disadvantaged regions in South Africa, and to examine the relationship between self-reported vision difficulties and socio-economic markers of poverty, namely, income, education and health service needs. Methods: A cross-sectional study was conducted in economically disadvantaged districts to collect data from households on poverty and health, including vision difficulty. As visual acuity measurements were not conducted, the researchers used the term vision difficulty as an indicator of vision impairment. Data were collected from 27 districts (74 901 respondents). Logistic regression analysis and chi-square tests were used to determine bivariate relationships between variables and self-reported vision difficulty. Kernel density estimators were used for age, categorised by self-reported and not reported vision difficulty.Results: Prevalence of self-reported vision difficulty was 11.2% (95% CI; 8.7% - 13.7%). More women (12.7%) compared to men (9.5%) self-reported vision difficulty (p 0.01). Self-reported vision difficulty was higher (14.2%) for respondents that do not spend any money. A statistically significant relationship was found between the highest level of education and self-reporting of vision difficulty; as completed highest level of education increased, self-reporting of vision difficulty became lower (p 0.01). A significantly higher prevalence of self-reported vision difficulty was found in respondents who are employed (p 0.01), 17% (95% CI: 12.8% - 21.1%). Conclusion: The evidence from this study suggests associations between socio-economic factors and vision difficulties that have a two-fold relationship (some factors such as education; and access to eye health services are associated with vision difficulty whilst vision difficulty may trap people in their current poverty or deepen their poverty status). The results are thus indicative of the need for further research in South Africa

Household dynamics and socioeconomic conditions in the context of incident adolescent orphaning in KwaZulu-Natal, South Africa.

We compared demographics, socioeconomic status, and food insecurity between households with and without recent orphans in a region of high HIV/AIDS mortality in South Africa. We recruited a cohort of 197 recent orphans and 528 non-orphans ages 9-15 and their households using stratified cluster sampling. Households were classified into three groups: orphan-only (N=50); non-orphan-only (N=377); and mixed (N=210). Between September 2004 and May 2007, households were interviewed three times regarding demographics, income and assets, and food insecurity. Baseline bivariate associations were assessed using chi-square- and t-tests. Longitudinal bivariate associations and multivariate models were tested using generalized estimating equations. At baseline, mixed households generally exhibited greater characteristics of vulnerability than orphan and non-orphan households. They were larger, had older, less educated household heads, and reported a much smaller annual per capita income. Orphan households were more likely to report a death in the previous year, and less likely to have an adult employed. These differences persisted over the study. Even non-orphan households exhibited characteristics of vulnerability, with 14% reporting a death one year before baseline, 45% of whom were prime-age adults. At baseline, a much smaller proportion of orphan households reported receiving the child support grant than the other household types, but notably, there were no differences among households in receipt of the grant by Round 3. Household food insecurity was highly prevalent: more than one in five orphan-only and mixed households reported being food insecure in the previous month. These findings suggest that the effects of HIV/AIDS only exacerbate existing high levels of poverty in the district, as virtually all households are vulnerable regardless of orphan status. Community-level programs must help families address a spectrum of needs, including food security, caregiving, and financial support, as well as better target social welfare grants and make them more accessible to vulnerable households.

Longitudinal evaluation of the psychosocial wellbeing of recent orphans compared with non-orphans in a school-attending cohort in KwaZulu-Natal, South Africa.

To assess differences in psychosocial wellbeing between recent orphans and non-orphans, we followed a cohort of 157 school-going orphans and 480 non-orphans ages 9-15 in a context of high HIV/AIDS mortality in South Africa from 2004 to 2007. Several findings were contrary to published evidence to date, as we found no difference between orphans and non-orphans in anxiety/depression symptoms, oppositional behavior, self-esteem, or resilience. Female gender, self-reported poor health, and food insecurity were the most important predictors of children's psychosocial wellbeing. Notably, girls had greater odds of reporting anxiety/depression symptoms than boys, and scored lower on self-esteem and resilience scales. Food insecurity predicted greater anxiety/depression symptoms and lower resilience. Perceived social support was a protective factor, as it was associated with lower odds of anxiety/depression symptoms, lower oppositional scores, and greater self-esteem and resilience. Our findings suggest a need to identify and strengthen psychosocial supports for girls, and for all children in contexts of AIDS-affected and economic adversity.

Exploring the Cinderella myth: intrahousehold differences in child wellbeing between orphans and non-orphans in Amajuba District, South Africa.

OBJECTIVE: To determine whether differences in wellbeing (defined by a variety of education and health outcomes) exist between recent school-aged orphans and non-orphans who live in the same household in a context of high HIV/AIDS mortality in KwaZulu Natal, South Africa. DESIGN: The data come from the first 2 years (2004-2006) of an ongoing 3-year longitudinal cohort study in a district in KwaZulu-Natal, the Amajuba Child Health and Well-being Research Project. Using stratified cluster sampling based on school and age, we constructed a cohort of 197 recent orphans and 528 non-orphans aged 9-16 years and their households and caregivers. Household heads, caregivers, and children were interviewed regarding five domains of child wellbeing: demographic, economic, educational, health/nutrition/lifestyle, and psychosocial status. METHODS: The analytical sample consists of 174 children (87 orphans and 87 comparable non-orphans who live together) at baseline and 124 children in round 2. We estimated a linear regression model using household fixed effects for continuous outcomes (grade adjusted for age, annual expenditure on schooling and body mass index) and a logit model using household fixed effects for categorical variables (malnutrition) to compare co-resident orphans and non-orphans. RESULTS: We found no statistically significant differences in most education, health and labour outcomes between orphans and the non-orphans with whom they live. Paternal orphans are more likely to be behind in school, and recent mobility has a positive effect on schooling outcomes.

Methods to reduce social desirability bias in sex surveys in low-development settings: experience in Zimbabwe.

BACKGROUND: Social desirability bias hampers measurement of risk behavior for acquiring STDs and evaluation of control interventions. More confidential data collection methods reduce this bias in Western countries but generally require technology not available in less developed settings. GOAL The goal of this report was to describe and evaluate an informal, confidential, low-technology method-Informal Confidential Voting Interviews (ICVIs)-for collecting sexual behavior data in less developed settings. STUDY DESIGN: Reports of multiple sex partners by sexually active, basic-literate, population-based survey participants in rural Zimbabwe randomly assigned to ICVIs and face-to-face interviews (FTFIs) were compared. RESULTS: Ninety-two percent of respondents (n = 7,823) were sufficiently literate for ICVIs. Error rates were low but higher than in FTFIs. More male and female ICVI respondents interviewed reported multiple current sex partners (OR = 1.33 and 5.24, respectively) and multiple partners in the past month (OR = 1.71 and 2.92) and the past year (OR = 1.35 and 1.97). CONCLUSION: The ICVI method appears to reduce bias but requires further evaluation to assess viability and effect in alternative settings.

Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe.

BACKGROUND: HIV-1 prevalence typically rises more rapidly at young ages in women than in men in sub-Saharan Africa. Greater susceptibility to infection on exposure in women is believed to be a contributory factor as is greater exposure to previously infected sexual partners of the opposite sex. We investigated the latter hypothesis using data from a field study in rural Manicaland, Zimbabwe. METHODS: Quantitative data on onset and degree of sexual activity, numbers of partners, concurrent partnerships, condom use, and partner characteristics were used in conjunction with epidemiological data on age and sex specific prevalence of HIV infection to do statistical analyses of association between key variables. Mathematical models and qualitative data were used to aid analysis and interpretation. FINDINGS: Older age of sexual partner was associated with increased risk of HIV-1 infection in men (odds ratio 1.13 [95% CI 1.02-1.25]) and women (1.04 [1.01-1.07]). Young women form partnerships with men 5-10 years older than themselves, whereas young men have relationships with women of a similar age or slightly younger. Greater number of lifetime partners is also associated with increased risk of HIV (1.03 [1.00-1.05]). Young men report more partners than do women but infrequent coital acts and greater use of condoms. These behaviour patterns are underpinned by cultural factors including the expectation that women should marry earlier than men. A strong gender effect remains after factors that affect exposure to infected partners are controlled for (6.04 [1.49-24.47]). INTERPRETATION: The substantial age difference between female and male sexual partners in Manicaland is the major behavioural determinant of the more rapid rise in HIV prevalence in young women than in men. Theoretical studies have suggested that this difference is an important determinant of observed epidemiological patterns but the study reported in this paper provides clear empirical evidence of association.