Faculty of Health Sciences
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Item Pension exposure and health: Evidence from a longitudinal study in South Africa(2023-10) Carlos Riumallo Herl; Chodziwadziwa Kabudula; Kathleen Kahn; Stephen Tollman; David CanningSocial protection schemes have been expanding around the world with the objective of protecting older persons during retirement. While theoretically they have been seen as tools to improve individual wellbeing, there are few studies that evaluate whether social pensions can improve health. In this study, we exploit the change in eligibility criteria for the South African Old Age grant to estimate the association between pension exposure eligibility and health of older persons. For this, we use data from the Health and Aging in Africa: A longitudinal Study of an INDEPTH Community in South Africa (HAALSI) and model pension exposure in terms of its cumulative effect. Our results show that pension exposure is associated with better health as measured by a set of health indices. Disentangling these effects, we find that pension exposure is most likely to improve health through the delayed onset of physical disabilities in the elderly population. Our study highlights the relevance of social protection schemes as a mechanism to protect older persons physical health.Item Built Environment and HIV Linkage to Care in Rural South Africa(2023-01) Nosipho Shangase; Brian Pence; Sheri A. Lippman; Mi-Suk Kang Dufour; Chodziwadziwa Whiteson Kabudula; F. Xavier Gomez-Olive; Kathleen Kahn; Audrey PettiforBackground: We assessed built environment (residential density, landuse mix and aesthetics) and HIV linkage to care (LTC) among 1,681 (18–49 years-old) residents of 15 Mpumalanga villages, South Africa. Methods: Multilevel models (linear-binomial) were used for the association between built environment, measured using NEWS for Africa, and LTC from a clinical database of 9 facilities (2015–2018). Additionally, we assessed effect-measure modification by universal test-and-treat policy (UTT). Results: We observed, a significant association in the adjusted 3-month probability of LTC for residential density (risk difference (RD)%: 5.6, 95%CI: 1.2–10.1), however, no association for land-use mix (RD%: 2.4, 95%CI: 0.4, 5.2) and aesthetics (RD%: 1.2, 95% CI: 4.5–2.2). Among those diagnosed after UTT, residents of high land-use villages were more likely to link-to-care than those of low land-use villages at 12 months (RD%: 4.6, 95%CI: 1.1–8.1, p < 0.04), however, not at 3 months (RD%: 3.0, 95%CI: 2.1–8.0, p > 0.10). Conclusion: Findings suggest, better built environment conditions (adequate infrastructure, proximity to services etc.) help facilitate LTC. Moreover, UTT appears to have a protective effect on LTC.Item The adolescent HIV executive function and drumming (AHEAD) study, afeasibility trial of a group drumming intervention amongst adolescents with HIV(2023-04-11) Kirsten Rowe; Julia Ruiz Pozuelo; Alecia Nickless; Absolum David Nkosi; Andeline Dos Santos; Kathleen Kahn; Stephen Tollman; Ryan G Wagner; Gaia Scerif; Alan SteinAHEAD feasibility trial assessed the feasibility and acceptability of an 8-session group drummingprogramme aiming to improve executive function, depression and anxiety symptoms, andperceived social support in adolescents living with HIV in a rural low-income South Africansetting. Sixty-eight 12- to 19-year-old adolescents participated. They were individuallyrandomised. The intervention arm (n= 34) received weekly hour-long group drumming sessions.Controls (n= 34) received no intervention. Feasibility and acceptability were assessed usingrates of: enrolment; retention; attendance; logistical problems; adolescent-reportedacceptability. Secondary measures included:five Oxford Cognitive Screen-Executive Function(OCS-EF) tasks; two Rapid Assessment of Cognitive and Emotional Regulation (RACER) tasks; theSelf-Reporting Questionnaire-20 (SRQ-20) measuring depression and anxiety symptoms; theMultidimensional Scale of Perceived Social Support (MSPSS). All feasibility criteria were withingreen progression limits. Enrolment, retention, and acceptability were high. There was a positiveeffect on adolescent depressed mood with signal for a working memory effect. There were nosignificant effects on executive function or socio-emotional scales. Qualitativefindingssuggested socio-emotional benefits including: group belonging; decreased internalised stigma;improved mood; decreased anxiety. Group drumming is a feasible and acceptable interventionamongst adolescents living with HIV in rural South Africa. A full-scale trial is recommended.Item Incidence and Transmission Dynamics of Bordetella pertussis Infection in Rural and Urban Communities, South Africa, 2016‒2018(2023-02-02) Fahima Moosa; Stefano Tempia; Jackie Kleynhans; Meredith McMorrow; Jocelyn Moyes; Mignon du Plessis; Maimuna Carrim; Florette K. Treurnicht; Orienka Helfersee; Thulisa Mkhencele; Azwifarwi Mathunjwa; Neil A. Martinson; Kathleen Kahn; Limakatso Lebina; Floidy Wafawanaka; Cheryl Cohen; Anne von Gottberg; Nicole WolterWe conducted 3 prospective cohort studies (2016–2018), enrolling persons from 2 communities in South Africa. Nasopharyngeal swab specimens were collected twice a week from participants. Factors associated with Bordetella pertussis incidence, episode duration, and household transmission were determined by using Poisson regression, Weibull accelerated time-failure, and logistic regression hierarchical models, respectively. Among 1,684 participants, 118 episodes of infection were detected in 107 participants (incidence 0.21, 95% CI 0.17–0.25 infections/100 person-weeks). Children <5 years of age who had incomplete vaccination were more likely to have pertussis infection. Episode duration was longer for participants who had higher bacterial loads. Transmission was more likely to occur from male index case-patients and persons who had >7 days infection duration. In both communities, there was high incidence of B. pertussis infection and most cases were colonized.Item The Association Between HIV‑Related Stigma and the Uptake of HIV Testing and ART Among Older Adults in Rural South Africa: Findings from the HAALSI Cohort Study(2023-11-07) Nomsa B. Mahlalela; Jennifer Manne‑Goehle; Daniel Ohene‑Kwofe; Leslie B. Adams; Livia Montana; Kathleen Kahn; Julia K. Rohr; Till Bärnighausen; Francesc X. Gómez‑OlivéHIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (refecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84–0.86), and social stigma was also frequent 25% (95% CI 0.24– 0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR=0.66, 95% CI 0.53–0.81, p=0.000) for a score of 1 and (OR=0.56, 95% CI 0.38–0.83, p=0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR =0.41, 95% CI 0.19–0.87, p=0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95–95–95 targets.Item Estimating the Prevalence of over- and Under-Reporting in HIV Testing, Status and Treatment in Rural Northeast South Africa: A Comparison of a Survey and Clinic Records(2023-10-27) Hannah H Leslie; Chodziwadziwa W Kabudula; Rebecca L West; Mi-Suk Kang Dufour; Aimée Julien; Nkosinathi G Masilela; Stephen M Tollman; Audrey Pettifor; Kathleen Kahn; Sheri A LippmanWe assess the accuracy of self-reported testing, HIV status, and treatment responses compared to clinical records in Ehlanzeni District, South Africa. We linked a 2018 population-based survey of adults 18-49 years old with clinical data at local primary healthcare facilities from 2014 to 2018. We calculated self-reported testing, HIV status, and treatment, and triangulated findings with clinic record data. We adjusted testing estimates for known gaps in HIV test documentation. Of 2089 survey participants, 1657 used a study facility and were eligible for analysis. Half of men and 84% of women reported an HIV test in the past year. One third of reported tests could be confirmed in clinic data within 1 year and an additional 13% within 2 years; these fractions increased to 57% and 22% respectively limiting to participants with a verified clinic file. After accounting for gaps in clinic documentation, we found that prevalence of recent HIV testing was closer to 15% among men and 51% in women. Estimated prevalence of known HIV was 16.2% based on self-report vs. 27.6% with clinic documentation. Relative to clinical records among confirmed clinic users, self report of HIV testing and of current treatment were highly sensitive but non-specific (sensitivity 95.5% and 98.8%, specificity 24.2% and 16.1% respectively), while self report of HIV status was highly specific but not sensitive (sensitivity 53.0%, specificity 99.3%). While clinical records are imperfect, survey-based measures should be interpreted with caution in this rural South African setting.Item Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries(2023-07-19) Ursula Gazeley; Georges Reniers; Julio E. Romero-Prieto; Clara Calvert; Momodou Jasseh; Kobus Herbst; Sammy Khagayi; David Obor; Daniel Kwaro; Albert Dube; Merga Dheresa; Chodziwadziwa W. Kabudula; Kathleen Kahn; Mark Urassa; Amek Nyaguara; Marleen Temmerman; Laura A. Magee; Peter von Dadelszen; Veronique FilippAbstract Objective: To compare the causes of death for women who died during pregnancy and within the first 42days postpartum with those of women who died between >42days and within 1 year postpartum. Design: Open population cohort (Health and Demographic Surveillance Systems). Setting: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. Population: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. Methods: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42days versus 43–365days postpartum adjusting for HDSS and time period (2000–2009 and 2010–2019). Main outcome measures: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). Results: Of 2114 deaths, 1212 deaths occurred within 42days postpartum and 902 between 43 and 365days postpartum. Compared with deaths within 42days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42days postpartum did not change significantly between 2000–2009 and 2010–2019. Conclusions: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.Item Executive function and pre-academic skills in preschoolers from South Africa(2023-08-25) Caylee J. Cook; Steven Howard; Gaia Scerif; Rhian Twine; Kathleen Kahn; Shane Norris; Catherine DraperBackground: While there is now considerable evidence in support of a relationship between executive function (EF) and academic success, these findings almost uniformly derive from Western and high-income countries. Yet, recent findings from low- to middle-income countries have suggested that patterns of EF and academic skills differ in these contexts, but there is little clarity on the extent, direction and nature of their association. Aim: This study aimed to investigate the contribution of EF to pre-academic skills in a sample of preschool children (N = 124; Mage = 50.91 months; 45% female). Setting: Two preschools were recruited from an urban setting in a community with both formal and informal housing, overcrowding, high levels of crime and violence, and poor service delivery. Three preschools were recruited from rural communities with household plots, a slow rate of infrastructure development, reliance on open fires for cooking, limited access to running water and rudimentary sanitation. Methods: Pre-academic skills were assessed using the Herbst Early Childhood Development Criteria test, and EF was assessed using the Early Years Toolbox. Results: Although EF scores appeared high and pre-academic skills were low (in norm comparisons), EF inhibition (ß = 0.23, p = 0.001) and working memory (ß = 0.25, p < 0.001) nevertheless showed strong prediction of pre-academic skills while shifting was not significant. Conclusion: While EF is an important predictor of pre-academic skills even in this low- and middle-income country context, factors in addition to EF may be equally important targets to foster school readiness in these settings. Contribution: The current study represents a first step towards an understanding of the current strengths that can be leveraged, and opportunities for additional development, in the service of preparing all children for the demands of schoolItem Participatory action research to address lack of safe water, a community-nominated health priority in rural South Africa(2023-07-27) Jennifer Hove; Denny Mabetha; Maria van der Merwe; Rhian Twine; Kathleen Kahn; Sophie Witter; Lucia D’AmbruosoBackground Despite international evidence supporting community participation in health for improved health outcomes and more responsive and equitable health systems there is little practical evidence on how to do this. This work sought to understand the process involved in collective implementation of a health-related local action plan developed by multiple stakeholders. Methods Communities, government departments and non-government stakeholders convened in three iterative phases of a participatory action research (PAR) learning cycle. Stakeholders were involved in problem identification, development, and implementation of a local action plan, reflection on action, and reiteration of the process. Participants engaged in reflective exercises, exploring how factors such as power and interest impacted success or failure. Conclusion The process offered new ways of thinking and stakeholders were supported to generate local evidence for action and learning. The process also enabled exploration of how different stakeholders with different levels of power and interest coalesce to design, plan, and act on evidence. Creation of safe spaces was achievable, meanwhile changing stakeholders’ level of power and interest was possible but challenging. This study suggests that when researchers, service providers and communities are connected as legitimate participants in a learning platform with access to information and decision-making, a shift in power and interest may be feasible. Results The local action plan was partially successful, with three out of seven action items achieved. High levels of both power and interest were key factors in the achievement of action items. For the achieved items, stakeholders reported that continuous interactions with one another created a shift in both power and interest through ownership of implementation processes. Participants who possessed significant power and influence were able to leverage resources and connections to overcome obstacles and barriers to progress the plan. Lack of financial support, shifting priorities and insufficient buy-in from stakeholders hindered implementation.Item We Should Not Be Quiet but We Should Talk’: Qualitative Accounts of CommunityBased Communication of HIV PreExposure Prophylaxis(2023) Hannah Goymann1; Mxolisi Mavuso; Shannon A. McMahon; Anita Hettema; Allison B. Hughey; Sindy Matse; Phiwa Dlamini; Kathleen Kahn; Till Barnighausen; Albrecht Jahn; Kate BarnighausenCommunity leaders play an important role in the acceptance of public health services, but little is known about their willingness to facilitate HIV pre-exposure prophylaxis (PrEP) roll-out in Eswatini. We conducted in-depth interviews (n = 25) with purposefully selected male and female community leaders in Eswatini. We analysed our data inductively using a thematic analysis approach. Community leaders feel they are important communicators of culturally appropriate PrEP messaging. Our participants described a complex social space within their communities influenced by religion, tradition, values, and HIV stigma. Community leaders use their position to provide leverage for unique, effective, and easily accessible messages and platforms to reach the community in a manner that ensures trust, relatability, familiarity, and shared faith. Community leaders feel that they are trusted and see trust manifesting in the conversations they are able to engage in, and have a reach that extends beyond formal health services. Existing PrEP programming should embed community leader participation in PrEP programming and engage the trust, knowledge, and potential of community leaders to support PrEP uptake and acceptance.