Polyvictimisation (PV) - exposure to violence across multiple contexts - causes considerable morbidity and mortality among adolescents. Despite high levels of violence in urban disadvantaged ...settings, gender differences in associations between PV and mental health have not been well established.
We analysed data from a survey with 2393 adolescents aged 15-19 years, recruited using respondent-driven sampling from urban disadvantaged settings in Baltimore (USA), Delhi (India), Ibadan (Nigeria), Johannesburg (South Africa) and Shanghai (China). PV was defined as exposure to two or more types of violence in the past 12 months with family, peers, in the community, or from intimate partners and non-partner sexual violence. Weighted logistic regression models are presented by gender to evaluate whether PV is associated with posttraumatic stress, depression, suicidal thoughts and perceived health status.
PV was extremely common overall, but ranged widely, from 74.5% of boys and 82.0% of girls in Johannesburg, to 25.8 and 23.9% respectively in Shanghai. Community violence was the predominant violence type, affecting 72.8-93.7% across the sites. More than half of girls (53.7%) and 45.9% of boys had at least one adverse mental health outcome. Compared to those that did not report violence, boys exposed to PV had 11.4 higher odds of having a negative perception of health (95%CI adjusted OR = 2.45-53.2), whilst this figure was 2.58 times in girls (95%CI = 1.62-4.12). Among girls, PV was associated with suicidal thoughts (adjusted OR = 4.68; 95%CI = 2.29-9.54), posttraumatic stress (aOR = 4.53; 95%CI = 2.44-8.41) and depression (aOR = 2.65; 95%CI = 1.25-5.63). Among boys, an association was only detected between PV and depression (aOR = 1.82; 95%CI = 1.00-3.33).
The findings demonstrate that PV is common among both sexes in urban disadvantaged settings across the world, and that it is associated with poor mental health outcomes in girls, and with poor health status in both girls and boys. Clearly, prevention interventions are failing to address violence exposure across multiple contexts, but especially within community settings and in Johannesburg. Interventions are needed to identify adolescents exposed to PV and link them to care, with services targeting a range of mental health conditions among girls and perhaps focusing on depression among boys.
To assess sexual risk-taking of female sex workers (FSWs) with emotional partners (boyfriends and husbands), compared to regular and casual clients. Experiences of violence and the degree of ...relationship control that FSWs have with emotional partners are also described.
Cohort study with quarterly follow-up visit over 12-months.
Four hundred HIV-uninfected FSWs older than 16 years were recruited from their homes and guesthouses in Mombasa, Kenya. A structured questionnaire assessed participant characteristics and study outcomes at each visit, and women received risk-reduction counselling, male and female condoms, and HIV testing.
Four or more unprotected sex acts in the past week were reported by 21.3% of women during sex with emotional partners, compared to 5.8% with regular and 4.8% with casual clients (P<0.001). Total number of unprotected sex acts per week was 5-6-fold higher with emotional partners (603 acts with 259 partners) than with regular or casual clients (125 acts with 456, and 98 acts with 632 clients, respectively; P<0.001). Mostly, perceptions of "trust" underscored unprotected sex with emotional partners. Low control over these relationships, common to many women (36.9%), was linked with higher partner numbers, inconsistent condom use, and being physically forced to have sex by their emotional partners. Half experienced sexual or physical violence in the past year, similarly associated with partner numbers and inconsistent condom use.
High-risk sexual behaviour, low control and frequent violence in relationships with emotional partners heighten FSWs' vulnerability and high HIV risk, requiring targeted interventions that also encompass emotional partners.
To understand community perspectives on the effects of high ambient temperature on the health and wellbeing of neonates, and impacts on post-partum women and infant care in Kilifi.
Qualitative study ...using key informant interviews, in-depth interviews and focus group discussions with pregnant and postpartum women (n = 22), mothers-in-law (n = 19), male spouses (n = 20), community health volunteers (CHVs) (n = 22) and stakeholders from health and government ministries (n = 16).
We conducted our research in Kilifi County in Kenya's Coast Province. The area is largely rural and during summer, air temperatures can reach 37˚C and rarely go below 23˚C.
Data were analyzed in NVivo 12, using both inductive and deductive approaches.
High ambient temperature is perceived by community members to have direct and indirect health pathways in pregnancy and postpartum periods, including on the neonates. The direct impacts include injuries on the neonate's skin and in the mouth, leading to discomfort and affecting breastfeeding and sleeping. Participants described babies as "having no peace". Heat effects were perceived to be amplified by indoor air pollution and heat from indoor cooking fires. Community members believed that exclusive breastfeeding was not practical in conditions of extreme heat because it lowered breast milk production, which was, in turn, linked to a low scarcity of food and time spend by mothers away from their neonates performing household chores. Kangaroo Mother Care (KMC) was also negatively affected. Participants reported that postpartum women took longer to heal in the heat, were exhausted most of the time and tended not to attend postnatal care.
High ambient temperatures affect postpartum women and their neonates through direct and indirect pathways. Discomfort makes it difficult for the mother to care for the baby. Multi-sectoral policies and programs are required to mitigate the negative impacts of high ambient temperatures on maternal and neonatal health in rural Kilifi and similar settings.
Measuring CD4 counts remains an important component of HIV care. The Visitect CD4 is the first instrument-free low-cost point-of-care CD4 test with results interpreted visually after 40 min, ...providing a result of ≥350 CD4 cells/mm
The field performance and diagnostic accuracy of the test was assessed among HIV-infected pregnant women in South Africa. A nurse performed testing at the point-of-care using both venous and finger-prick blood, and a counselor and laboratory staff tested venous blood in the clinic laboratory (four Visitect CD4 tests/participant). Performance was compared to the mean CD4 count from duplicate flow cytometry tests on venous blood (FACSCalibur Trucount). In 2017, 156 patients were enrolled, providing a total of 624 Visitect CD4 tests (468 venous and 156 finger-prick samples). Of 624 tests, 28 (4.5%) were inconclusive. Generalized linear mixed modeling showed better performance of the test on venous blood (sensitivity = 81.7%; 95% confidence interval CI = 72.3 to 91.1; specificity = 82.6%, 95% CI = 77.1 to 88.1) than on finger-prick specimens (sensitivity = 60.7%; 95% CI = 45.0 to 76.3; specificity = 89.5%, 95% CI = 83.2 to 95.8;
= 0.001). No difference in performance was detected by cadre of health worker (
= 0.113) or between point-of-care versus laboratory-based testing (
= 0.108). Adequate performance of Visitect CD4 with different operators and at the point of care, with no need of electricity or instrument, shows the potential utility of this device, especially for facilitating decentralization of CD4 testing services in rural areas.
Unmanaged urban growth in southern and eastern Africa has led to a growth of informal housing in cities, which are home to poor, marginalised populations, and associated with the highest HIV ...prevalence in urban areas. This article describes and reflects on the authors' experiences in designing and implementing an HIV intervention originally intended for migrant men living in single-sex hostels of inner-city Johannesburg. It shows how formative research findings were incorporated into project design, substantially shifting the scope of the original project.
Formative research activities were undertaken to better understand the demand- and supply-side barriers to delivering HIV prevention activities within this community. These included community mapping, a baseline survey (n = 1458) and client-simulation exercise in local public sector clinics. The intervention was designed and implemented in the study setting over a period of 18 months. Implementation was assessed by way of a process evaluation of selected project components.
The project scope expanded to include women living in adjacent informal settlements. Concurrent sexual partnerships between these women and male hostel residents were common, and HIV prevalence was higher among women (56%) than men (24%). Overwhelmingly, hostel residents were internal migrants from another province, and most felt 'alienated' from the rest of the city. While men prioritised the need for jobs, women were more concerned about water, sanitation, housing and poverty alleviation. Most women (70%) regarded their community as unsafe (cf. 47% of men). In the final intervention, project objectives were modified and HIV prevention activities were embedded within a broader health and development focus. 'Community health clubs' were established to build residents' capacity to promote health and longer term well-being, and to initiate and sustain change within their communities.
To improve efforts to address HIV in urban informal settings, intervention designers must acknowledge and engage with the priorities set by the marginalised communities that live here, which may well encompass more pressing issues associated with daily survival.
Risk-taking in sex work is related to financial gains from condom-protected and condomless-acts alongside vulnerabilities, including socio-economic factors, which influence the safety of sex workers. ...Large international sporting events have been shown to significantly impact the economies of host countries, but there is a dearth of studies that examine how major sporting events may affect the economics of sex work and the risks taken by sex workers and clients. This study examines the determinants of the price of commercial sex alongside the price premium for and correlates of, condomless sex before, during and after the 2010 world cup in South Africa. We analysed data from three phases of repeated cross-sectional surveys with sex workers. Bivariate and multivariable logistic regression models were fitted to examine the predictors of condomless sex. We also fitted fixed-effect regression models to examine the determinants of the price of commercial sex across each survey phase. Findings suggest that the price of sex was higher during the world cup compared to before and after, whilst the price premium for condomless-sex increased from 36% before the world cup to 40% (p-value<0.001) and 57% (p-value<0.001) during and after the world cup, respectively. Across the survey phases, anal, oral or masturbation sex were more likely to be supplied without a condom compared to vaginal sex. The type of sex was the primary determinant of the price of sex across all phases. We show indicative evidence that the 2010 world cup was associated with an increase in the price of sex and supply of condomless-sex. Although these findings should be interpreted as associations rather than causal relationships, we recommend that countries with substantial sex-worker populations that host major events shouldexplicitly consider the context and structures of sex work, and promote client-focused safe-sex-interventions that explicitly consider the economic pressures faced by sexworkers to provide riskier acts, to minimise health impacts.
Background
Fetal alcohol spectrum disorder (FASD) and fetal alcohol syndrome (FAS) are common in some South African populations, notably those of mixed ancestry descent in rural areas and small ...towns. Little is known about FAS/FASD prevalence in the majority of South Africans: city dwellers of Black African ethnicity. This study describes the prevalence of FAS in a South African city, comparing 2 suburbs with predominantly mixed ancestry (Roodepan) and Black African (Galeshewe) populations that house over 60% of the city population.
Methods
We conducted a tiered, active case ascertainment study for the prevalence of FAS and also detected some less clinically specific FASD cases. All first‐grade learners in the 2 suburbs were eligible for anthropometric screening, and screen‐positive learners were assessed for dysmorphic features of FAS. Those with suggestive clinical features received neurocognitive assessment, and maternal or collateral interview. Final diagnosis was made following a case conference.
Results
Complete ascertainment of FAS status was made in 1,503 (94.7%) of 1,587 eligible learners (435 in Roodepan and 1,152 in Galeshewe). Overall, FAS was diagnosed in 83 (5.5%, 95% confidence interval CI = 4.4 to 6.8) learners and FASD in 96 (6.4%, 95% CI = 5.2 to 7.7). Levels of FAS were high in both areas: 26 (6.3%, 95% CI = 4.2 to 9.2) learners from Roodepan, compared to 57 (5.2%, 95% CI = 4.0 to 6.7) from Galeshewe (p = 0.39). No cases were previously diagnosed. The mortality rate for mothers of FASD children from Galeshewe was 19 of 65 (29%), compared to 3 of 31 (9.7%; p = 0.03) for Roodepan. Interviewed mothers in Galeshewe were older and had higher body mass index.
Conclusions
Prevalence of FAS is high in both Galeshewe and Roodepan, and the lack of prior diagnoses indicates that awareness remains low. The maternal mortality rate was especially high in Galeshewe. The unexpectedly high burden of FAS in an urban area with predominantly Black African population mandates extension of surveillance and intervention measures in southern Africa.
Important unanswered questions remain on the impact of international sporting events on the sex industry. Speculation about increased demand and supply of sex work often generates significant ...attention, but also additional funding for HIV programmes. This study assessed whether changes occurred in the demand and supply of paid sex during the 2010 Soccer World Cup in South Africa.
Trained sex worker interviewers conducted face-to-face semi-structured interviews among consenting female sex workers during May-September 2010. Using bivariate analyses we compared supply, demand, sexual risk-taking, and police and health services contact pre-World Cup, to levels during the World Cup and after the event.
No increases were detected in indicators of sex work supply, including the proportion of sex workers newly arrived in the city (< 2.5% in each phase) or those recently entering the trade (≤ 1.5%). Similarly, demand for sex work, indicated by median number of clients (around 12 per week) and amount charged per transaction ($13) remained similar in the three study periods. Only a third of participants reported observing any change in the sex industry ascribed to the World Cup. Self-reported condom-use with clients remained high across all samples (> 92.4% in all phases). Health-care utilisation decreased non-significantly from the pre- to during World Cup period (62.4% to 57.0%; P = 0.075). Across all periods, about thirty percent of participants had interacted with police in the preceding month, two thirds of whom had negative interactions.
Contrary to public opinion, no major increases were detected in the demand or supply of paid sex during the World Cup. Although the study design employed was unable to select population-based samples, these findings do not support the public concern and media speculation prior to the event, but rather signal a missed opportunity for public health action. Given the media attention on sex work, future sporting events offer strategic opportunities to implement services for sex workers and their clients, especially as health service utilisation might decrease in this period.
In South Africa we have witnessed a gripping drought in the Western Cape, devastating heavy rains, fires, flooding and strong winds caused by an upper-air cut-off low in October 2017 in Durban,1 and ...regular heatwave and fire risk warnings in several provinces. One foremost cause of weather-related deaths is heat (leading to heatstroke), which is on the rise as towns and cities across South Africa shatter record all-time high temperatures year-on-year.2 In January 2016, for example, the North-West Health Department reported that 11 people (aged 22–58 years) died over a period of 48 h in the province from heatstroke.3 Deaths among groups such as the elderly, those with chronic disease and infants rise during heatwaves. These deaths may not be directly related to ‘heat shock’, but to the additional physiological stress associated with high heat. While there is some uncertainty as to whether these weather events are linked to climate change, the increase in heat levels generally, extreme weather events and current climate predictions for warming temperatures are strongly indicative that this is the case.By the end of the 21st century, climate change in South Africa is predicted to result in, on average, temperatures 4 °C warmer than they are now.4 Summers may become longer and warmer. Some areas of the country are projected to get drier while other parts may experience unseasonal rainfall. Even though there is some uncertainty around such climate predictions, preparing and adapting for climate change impacts is imperative.
Temperature extremes vary across Africa. A continent-wide examination of the impacts of heat on health in Africa, and a synthesis of Africa-informed evidence is, however, lacking. A systematic review ...of ar ticles published in peer-reviewed journals between January 1992 and April 2019 was conducted. To be eligible, ar ticles had to be Africa-specific, in English, and focused on how heatwaves and high ambient temperatures affect morbidity and mor tality. A secondary systematic analysis on policies and interventions comprising 17 studies was also conducted, and the findings synthesised together with those of the 20 primary studies. Eleven studies showed that high ambient temperatures and heat waves are linked with increased mor tality rates in Africa. These linkages are characterised by complex, linear and non-linear (J or U) relationships. Eight of the nine primary studies of morbidity outcome repor ted that an increase in temperature was accompanied by raised disease incidence. Children and the elderly were the population groups most vulnerable to extreme heat exposure. Location-specific interventions and policy suggestions include developing early warning systems, creating heat-health plans, changing housing conditions and implementing heat-health awareness campaigns. In summary, this review demonstrates that, while heat-health relationships in Africa are complex, extreme temperatures are associated with high mor tality and morbidity, especially amongst vulnerable populations. As temperatures increase across Africa, there is an urgent need to develop heat-health plans and implement interventions. Future studies must document intervention effectiveness and quantify the costs of action and inaction on extreme heatrelated mor tality and morbidity.
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