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Item Association between HIV/AIDS related adult deaths and migration of household members in rural Rufiji District, Tanzania(2011-03-09) Murunga, Frederick WekesahIntroduction: The spread and prevalence of the HIV epidemic has resulted in extensive demographic, social and economic impacts among families in the communities affected in Sub Saharan Africa which increase with the severity and duration of the epidemic. The dramatic increase in adult mortality attributable to HIV/AIDS in households in these communities may increase the number of households that do not survive as a functional and cohesive social group in the years to come. The migration of household members and possible dissolution of these households are the challenges stemming from the epidemic. We therefore require rigorous empirical research on the socioeconomic effects of HIV/AIDS in order to develop appropriate strategies to mitigate these impacts and ultimately improve living standards in these communities. This report describes the extent at which these impacts are felt by a rural community using data from the Rufiji HDSS in rural Tanzania. Design: The study will use a longitudinal study design to identify antecedent events and dynamics and trans-temporal aspects in establishing the effects HIV/AIDS, and particularly how adult deaths from the disease determine migration of individual household members, controlling for other individual level and household factors. Objectives: The main objectives of the study include the description of the adult mortality patterns in the area with an emphasis on the HIV/AIDS related adult deaths, the description of the socioeconomic and demographic characteristics of households experiencing these adult deaths; the characterisation of the members migrating from the households as a result of these adult deaths or otherwise. We also estimate the proportion of household members migrating following the deaths of adult members and further compare these rates of migrations from households experiencing adult HIV/AIDS, Non-HIV/AIDS deaths and where there is no experience of death. Methods: Migrating individuals from 4,019 households that experienced at least one adult death were compared with migrating individuals from other households experiencing Non-HIV/AIDS deaths and those from households without deaths. A total of 32, 787 households were included in the study. An adult death was defined as a death of a household member aged 18 years and above. Those aged 60+ years were considered elderly deaths. A total of 4,603 adult deaths were recorded over the period 1st January 2000 to 31st December 2007. The mortality trends were shown by the rates calculated by Kaplan-Meier survival estimates expressed per 1000 PYO. Migration rates were computed while the association between adult mortality and out-migration of household members was assessed using Cox proportional Hazard model controlling for other individual level and household level factors. Results: Adult deaths increase by about 9% the chance of a child, male or female, to migrate within or without the DSA while HIV/AIDS adult deaths increase by a further 19 percentage point the risk of 5 the child to migrate out of the DSA. The results also show that HIV/AIDS adult deaths enhance the risk of adult female internal migration by 6% (adj. HR 1.06; 95% CI 0.91-1.23, p-value 0.01) but is not significantly associated with adult male migration. Non-HIV/AIDS adult deaths also enhance the risk for female internal migration by 5% albeit hardly significantly (adj. HR 1.05; 95% CI 1.0-1.10, pvalue 0.05) but decreases the chance of male internal migration by 13% (adj. HR 0.87; 95% CI 0.81- 0.93, p-value 0.01). Additionally, HIV/AIDS adult death is strongly associated with out-migration of adults, whatever the gender. They predispose female out-migration to 19% (adj. HR 1.19; 95% CI 1.09-1.30, p-value <0.001) and male migration to 30% increased risk (adj. HR 1.30; 95% CI 1.16-1.45, p-value <0.001). This gender difference is however non-significant (the confidence intervals overlap). Non-HIV/AIDS adult death has the inverse effect on out-migration, and the gender difference is significant: 18% increased risk for males (adj. HR 1.18 95% CI 1.14-1.22, p-value <0.001) and 29% for females (adj. HR 1.29; 95% CI 1.26-1.33, p-value <0.001). Conclusion: Adult deaths have a positive impact on out-migration, with some variation by gender. The effect of HIV/AIDS death on out-migration is not very different from other deaths‟ effect.Item The persistent urban challenges of migration and informal settlements in the context of HIV: towards the development of a framework to guide the appropriate and equity promoting urban health and developmental responses of local government within Johannesburg, South Africa(2011-01-25) Vearey, Joanna LouiseRationale Understanding how to ensure and sustain the health and health equity of urban populations is of increasing importance as over half of the world population is now urban (UNFPA, 2007). Urbanisation is taking place rapidly across Africa, with fifty percent of the continent expected to be residing in urban areas by 2030 (UNFPA, 2007). South Africa has experienced a faster rate of urbanisation compared to neighbouring countries, with almost sixty percent of the population estimated to be urban (Kok & Collinson, 2006). This process of urban growth is accompanied by in-migration from within the country and across borders. Urban growth places pressure on limited, well-located and appropriate housing, resulting in the development of informal settlements within and on the periphery of urban areas. In addition to the multiple exposures to a variety of health hazards in informal settlements, HIV presents a contextual challenge, particularly in South Africa where the highest HIV prevalence is found within urban informal settlements (Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005). South African local government has a ‘developmental mandate’ which calls for government to work with citizens to develop sustainable interventions to address their social, economic and material needs (The Republic of South Africa, 1998a). This requires local government to address the challenges of urban growth, migration, informal settlements and HIV, as outlined above (Bocquier, 2008; Landau & Singh, 2008; Landau, 2007). The current (2007 – 2011) South African National Strategic Plan (NSP) for HIV signalled a welcome shift in HIV policy, with recognition of the role of government in ensuring that (1) internal and cross-border migrant groups and (2) residents of informal settlements are able to access the continuum of HIV-related services, which includes prevention, testing, support, treatment, and access to basic services. However, guidelines are lacking to assist local government in addressing HIV-related concerns with migrant groups and in informal settlements at the local level. As a result, migrant groups and residents of informal settlements struggle to access HIV-related services, including healthcare, adequate housing, and basic services such as water, sanitation and refuse removal. Given the developmental mandate of local government in South Africa (The Republic of South Africa, 1998a), this raises the question: how should local government respond to the urban challenges of migration and informal settlements in the context of high HIV prevalence? This thesis explores how the challenges of migration and informal settlements – within a context of high HIV prevalence – interact to generate a specific urban reality that requires an appropriate urban health response at the local government level. The question of how to address the gap between discourse, theory and action is tackled. Various frameworks for urban health have been developed that aim to assist in understanding the impact of city living on urban health, several of which draw on the concept of the social determinants of urban health (SDUH) (for example Galea, Freudenberg, & Vlahov, 2005; WHO, 2008b, 2008a). However, as I will go on to argue, none of the existing urban health frameworks deal adequately with the specific complexities of developing country urban environments. In particular, the frameworks have failed to adequately account for guiding local government in responding to the challenges identified above, namely: urban growth and informal settlements; internal and cross-border migration; high HIV prevalence; and, the responsibilities of a developmental local government. Aim Based on the findings from four studies, this PhD research aims to generate a revised urban health framework that will address the following specific challenges that I argue are associated with developing country contexts: (1) urban growth and informal settlements; (2) internal and cross-border migration; (3) high HIV prevalence; and, (4) the responsibilities of developmental local government. It is proposed that this revised framework will assist local government in responding to the interlinked challenges of informal settlements and migration in a context of high HIV prevalence. Methods A series of four studies were undertaken in Johannesburg. A review of international and local literature – including existing policy – was undertaken. In order to engage with the complexity of the urban environment, the four studies draw on both quantitative and qualitative methods. These include: a cross-sectional household survey across Johannesburg inner-city and one urban informal settlement (n = 487); a cross-sectional survey with ART clients at four ART sites in the inner-city (n = 449); and semi-structured interviews with community health worker volunteers, healthcare providers, local level policy makers and programmers involved with urban health and HIV in Johannesburg. By reflecting on involvement in participatory photography and film projects, the experiences of rural migrants who enter the city through ‘hidden spaces’ are examined; the concept of ‘being hidden’ is explored as a tactic employed by marginalised groups so that they are able to find a way to enter and participate in the city. Through the four studies, a series of four central themes were identified: (1) rights to the urban social determinants of health; (2) urban livelihoods; (3) policy and governance; and (4) urban methodologies. These four themes assist in synthesising the study findings and generating a revised approach to guide local government in responding to urban health challenges in a developmental way. Key findings The developmental mandate of local government is evolving very slowly (Paper I, V). Local level responses to the interlinked urban health challenges of migration, informal settlements and HIV are lacking (Paper I, V). Where they do exist, HIV is not viewed as an intersectoral developmental challenge and vertical HIV programmes prevail (Paper V). It will be argued that informal settlements require integrated local developmental responses (Paper V). In general, policies and guidelines that outline the right to basic healthcare and ART for crossborder migrants are not implemented at the local level (Papers I and III). In addition, residents of informal settlements struggle to access adequate housing and basic services (Papers IV and V). Some internal migrant groups, who reside in ‘hidden spaces’ of the innercity, are found to employ deliberate tactics in order to evade the state, whilst others are marginalised through a lack of state intervention (Paper II). The research shows that innovative methods are required to engage with urban populations, both for research and intervention purposes. Participatory approaches are found to be useful methods for engaging with urban migrant groups and this research draws on participatory photography and film projects as examples (Paper II, V). It is essential that urban public health practitioners and other development professionals learn how to engage with the complexities of the urban environment. A review of existing urban health frameworks finds that whilst these frameworks are themselves complex, and include the multiple levels and determinants that ultimately impact health outcomes, they result in generalised and static models of urban health. I argue that these existing frameworks are unable to inform responses to the specific complexities present within a particular urban context. Through the synthesis of the four study findings, an alternative approach to assist local government and other stakeholders in responding to urban health challenges is proposed. The idea of ‘concept mapping’ is suggested as a way to vii enable local government, and other actors, to engage with the complexities of the urban context in a participatory way. A core set of components have been identified that can be used to guide the creation of city-specific ‘concept maps’, that are able to work towards identifying and addressing the specific urban health needs associated with different areas within a city. A recommitment to intersectoral action, ‘healthy urban governance’ and public health advocacy is considered critical to the effectiveness of such an approach. It is suggested that the resultant ‘concept map’ will assist local government in responding in a developmental way to the interlinked challenges of migration and informal settlements in a context of high HIV prevalence. Implications Based on the findings of the PhD research, a new approach to urban health is suggested. ‘Concept mapping’ is presented as a new tool to assist local government in achieving its developmental mandate and address urban health. Whilst developed to address the challenges faced by urban migrants and residents of informal settlements in a context of high HIV prevalence, the concept map approach is likely to be a useful tool for considering the health and development needs of other urban groups. Future research is needed to evaluate the effectiveness of the application of participatory ‘concept mapping’ to assisting local level urban health policy makers, planners, and other stakeholders respond to the interlinked challenges of migration and informal settlements in a context of HIV.Item "You can only claim your yard and not a country": exploring context, discourse and practices of cosmopolitanism amongst African migrants in Johannesburg(2010-11-24) Haupt, IriannAdopting a social constructionist methodology, this research explores the contexts, discourse and practices of cosmopolitanism amongst African migrants in Johannesburg, South(ern) Africa’s economic hub and top migrant destination. The research argues that the central function of this cosmopolitanism is to serve as a counter-narrative to an exclusive South African nationalism and as an expression of a more general struggle to overcome the unwarranted limitations of being born in a country which does not provide enough opportunities. On the basis of both qualitative and quantitative data collected between 2006 and 2008 in Johannesburg, this study challenges the still widely held assumption that cosmopolitanism is not for those whose mobility is ‘unprivileged’ and argues that this assumption becomes particularly unsustainable once situated in the contexts of Africa’s unachieved nation-states, hyper-diverse urban centres and multiple alternative systems of belonging and identity. Instead, this study argues that it is exactly these conditions that have actually allowed a particular type of cosmopolitanism to emerge rather than having suppressed it. The three empirical chapters explore how migrants’ counter-narrative to discourses of nationalism, exclusion and pathologisation of migration constructs notions of mobility and space in particularly cosmopolitan, de-territorialised terms; generates a concept of cultural diversity and the engagement with the Other as normal, enriching and unproblematic; and establishes a more inclusive and multifaceted cosmopolitan social order that is claimed to be morally superior to that of nationalism. Finally, the conclusion provides some pointers towards three central imperatives for future research on cosmopolitanism: firstly, the imperative to address the present disconnect between cosmopolitanism from above and from below – and as part of that the lack of attention to empirical forms of cosmopolitanism; secondly, the importance of paying more attention to the social, cultural and economic contexts in which forms of empirical cosmopolitanism are embedded; and, thirdly, the need to overcome the three ‘isms’ that the majority of research on cosmopolitanism and migration remains stunted by: ethnocentrism, class-centrism and, somewhat ironically, methodological nationalism. The study argues that if we want to know more about how individuals become cosmopolitan agents of change and reformulate social orders ‘from below’, we should begin to treat migrant populations, and particularly those who move within and across the African continent, as a crucial source of knowledge about how to negotiate both the uncertainties and the opportunities that are intrinsic to more de-territorialised, post-national forms of social organisation and identity.Item The impact of migration on Emnambithi households: a class and gender analysis(2010-06-30T10:42:01Z) Fakier, KhayaatAbstract This dissertation is a study of social reproduction in different classes of migrant households in Emnambithi, a town in northern KwaZulu-Natal, South Africa. It traces the history of households in this community under the impact of racialised dispossession and migration, and illustrates how households were stratified into distinct classes. The three classes identified are a semi-professional, educated class, a migratory working class, and the marginalised, a segment of the “bantustan” population who never had the possibility of working in the capitalist economy during apartheid. The research then focuses on the gendered nature of social reproduction in households in the post-apartheid era, when this community continues to be shaped by migration. The research illustrates that class-based advantage and disadvantage are reproduced in post-apartheid South Africa. The dissertation analyses the different ways in which household members – predominantly migrant and resident women – deal with daily provisioning and consumption, education and care of the dependants of migrants in the absence of some members of the household. The study argues that social reproduction varies significantly in different classes of households. The class-based and gendered nature of social reproduction has implications for an understanding of developmental needs in post-apartheid South Africa, and this research opens up ways in which job creation and social policies could lead to class-based redress and gender equity.Item Migration, sexual behaviour, and human immunodeficiency virus infection in rural South Africa(2008-03-11T10:52:37Z) Lumfwa, Louis Adolf MuzingaABSTRACT HIV has been linked to many risk factors such as sexual behaviour, gender, gender based violence, poverty, migration, conflicts, sexually transmitted diseases and circumcision. In this project, the role played by migration was particularly underscored. The aim of the study was to estimate and to compare the prevalence of HIV infection among migrants and non-migrants and to investigate whether migration leads to increased high risk sexual behaviour among migrant workers aged between 14 and 35 years from Limpopo Province. This study was based on a secondary data analysis from a large community intervention study. A random sample of 2860 participants were selected in a cross sectional study after pair matching a community of villages set for an intervention. Data were collected using a questionnaire in English with a version in Sotho. HIV test was performed on oral fluid using Vironostika HIV Uniform oral fluid. The study was approved by Wits University and Informed consent was previously obtained by the original study. Stata was used for the statistical analyses of the data. This study found that the HIV prevalence among migrants was not statistically different from the prevalence among non-migrants (10.04% versus 10.97%; p = 0.662), that the slight association between migration and HIV infection was not significant (Adjusted OR = 1.19; 95% CI: 0.7 – 2.01) (p = 0.520). There was no association between migration and sexual behaviour such as sexual experience, age at first sexual relationship, have ever had sexual relationship and used a condom. However the study showed an association between migration and the number of sexual partners. These striking findings suggest that migration does not always lead to an increased risk of HIV infection even though it can lead to an increase of number of sexual partners. The study concludes that migration did not prove to be a risk factor for HIV infection. However, other underlying structural factors need to be examined for a better understanding of the conditions that lead to HIV infection. It recommends interventions that cover information (Knowledge, attitude and belief), risk perception and change of sexual behaviour.Item 'Return-Migration in Contemporary South Africa’(2007-03-01T13:42:28Z) Lauckner-Rothschild, SandraAgainst the background of theories of culture, this research questions the motives and experiences of expatriates that return to South Africa, their country of origin. In re-telling their personal stories the research aims to shed light on the decisionmaking processes that repatriates go through and explores the experiences associated with such migration so as to better comprehend what social reintegration and re-adaptation means for the individual returnee. The research uses a range of interview-focused methodologies and concentrates on the interrelated topics of migration, home, identity and social experience as the primary thematic loci. In total, fourteen returnees were interviewed. The Life Histories of two of them are examined in greater detail and their fuller stories anchor the findings and research results. All interviewees stated that special emotional bonds with South Africa had brought them back “home”: they either wanted to ‘reconnect’ with their families or the country itself; they wanted to expose their children to it or they wanted to be part of the new South Africa and help bring about change. As a consequence of their migrant journeys the interviewees gained a much stronger awareness for the cultural (i.e., geographical and lifestyle) sources of their personal identities. By exposing themselves to different surroundings and cultures they developed hybrid identities, thereby layering international associations onto their established cultural traditions and senses of self. Existing models on repatriation do not adequately account for the importance culture plays in people’s experiences of repatriation; yet clearly social as well as cultural issues play an important role. The main factors relating to ease of re-integration and re-adaptation (identified by the literature as economic, logistical, financial and social support) seem to hold true - but again the current literature tends to overlook the role that culture plays in these processes. The majority of these repatriates have established strong residential ties to overseas, whether it be through multiple citizenship or a foreign spouse, and several would consider leaving again should circumstances deteriorate locally. The research was fundamentally qualitative and therefore narrowly focused in nature. A so-called ‘snow-ball’ system was used to identify possible interviewees. This resulted in findings that may have limited statistical validity in the strict sense. Nonetheless, the data generated valuable insights that might be considered applicable for later analytical incorporation and/or policy applications in regards to the continuing ‘brain drain’ out of South Africa and other countries of the Developing World.Item Gender social networks and income generation among Congolese migrants in Johannesburg(2007-02-16T13:29:22Z) Monche, FelixA significant number of refugees and asylum seekers are living in urban areas in developing countries. In addition to the fact that they receive little assistance from international organizations, host government policies represent obstacles to their livelihoods. Generally, the economic behaviour, reasons for migrating and experiences of female migrants often differ from those of male. This research report examines the impact of gender on social networks and how gender might influence access to income. In contrast to other studies on social networks that focus on the social relationships between individuals and communities located in sending and receiving societies, this study produces greater understanding of urban migrants’ livelihoods by exploring how women use social networks to generate income and contrasting these with those of men. This is rooted in the assumption that women refugees are facing additional challenges to livelihood including their social responsibilities and job stereotyping. To document how gender might influence social networks and access to income, qualitative data collected through semi structured, face-to-face, in-depth interviews among Congolese refugees in Johannesburg was used. Findings reveal that gender does not have impact on the nature of social networks used by Congolese men and women to facilitate their access to income generating activities. However, friendships and social relations among Congolese refugees are based on gender and as a result Congolese refugees may be channelled in gender-dominated occupations. Congolese women are facing specific challenges such as domestic labour and child care that may limit their access to jobs and businesses.Item Prescribing Patterns of Health Care Givers to Patients Attending a Health Center in an Informal Urban Settlement in Gauteng for the Period March 2003 to June 2003(2006-11-01T09:22:42Z) Shingwenyana, NtiyisoAn increasing number of people are migrating to South African urban centers (GJMC, 2000). There are various reasons that can be attributed to this migration; including the hope of finding employment and better living conditions. Recent urban migrants find themselves faced with the basic problem of lack of shelter and, depending on the migrant’s situation, they may choose to live in indoor shacks within the city center, backyard shacks in the black townships or join the growing number of informal settlement dwellers (GJMC, 2000). The number of informal settlements continues to grow at an alarming rate in Johannesburg (CEROI, 2000). This poses unique health care challenges as well as presenting the health care system with unusual disease conditions associated with general lack of infrastructure and services (CEROI, 2000). It has been established that the proportion of HIV infected patients is higher in people living in informal settlements when compared to people living in private houses (SAHR, 2000). Thus, it is expected that more people will be presenting with HIV and AIDS related illnesses in an informal settlement health center as compared to well-developed residential areas. This study aimed at exploring the prescribing patterns of health care givers for patients attending a health center in an informal settlement as well as to determine the major disease patterns prevalent in the area. The study was carried out in Davidsonville and OR Tambo clinics as well as Bophelong and Hikhensile clinics in Ivory Park. The study covered regions five, one and two respectively according to Gauteng metropolitan services area classification (GJMC, 2000). The findings of the study will help the appropriate policy makers improve the Essential Drug List and inform public health officials in formulating strategies that may lead to health status improvement for people living in informal settlements.