Ar Yakubovich

Achieving equity in HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?

ABSTRACT Low ART-adherence amongst adolescents is associated with morbidity, mortality and onward HIV transmission. Reviews find no effective adolescent adherence-promoting interventions. Social protection has demonstrated benefits for adolescents, and could potentially improve ART-adherence. This study examines associations of 10 social protection provisions with adherence in a large community-based sample of HIV-positive adolescents. All 10–19-year-olds ever ART-initiated in 53 government healthcare facilities in a health district of South Africa’s Eastern Cape were traced and interviewed in 2014–2015 (n = 1175 eligible). About 90% of the eligible sample was included (n = 1059). Social protection provisions were “cash/cash in kind”: government cash transfers, food security, school fees/materials, school feeding, clothing; and “care”: HIV support group, sports groups, choir/art groups, positive parenting and parental supervision/monitoring. Analyses used multivariate regression, interaction and marginal effects models in SPSS and STATA, controlling for socio-demographic, HIV and healthcare-related covariates. Findings showed 36% self-reported past-week ART non-adherence (<95%). Non-adherence was associated with increased opportunistic infections (p = .005, B .269, SD .09), and increased likelihood of detectable viral load at last test (>75 copies/ml) (aOR 1.98, CI 1.1–3.45). Independent of covariates, three social protection provisions were associated with reduced non-adherence: food provision (aOR .57, CI .42–.76, p < .001); HIV support group attendance (aOR .60, CI .40–.91, p < .02), and high parental/caregiver supervision (aOR .56, CI .43–.73, p < .001). Combination social protection showed additive benefits. With no social protection, non-adherence was 54%, with any one protection 39–41%, with any two social protections, 27–28% and with all three social protections, 18%. These results demonstrate that social protection provisions, particularly combinations of “cash plus care”, may improve adolescent adherence. Through this they have potential to improve survival and wellbeing, to prevent HIV transmission, and to advance treatment equity for HIV-positive adolescents.

Can Social Protection Improve Sustainable Development Goals for Adolescent Health

Background The first policy action outlined in the Sustainable Development Goals (SDGs) is the implementation of national social protection systems. This study assesses whether social protection provision can impact 17 indicators of five key health-related SDG goals amongst adolescents in South Africa. Methods We conducted a longitudinal survey of adolescents (10–18 years) between 2009 and 2012. Census areas were randomly selected in two urban and two rural health districts in two South African provinces, including all homes with a resident adolescent. Household receipt of social protection in the form of ‘cash’ (economic provision) and ‘care’ (psychosocial support) social protection, and health-related indicators within five SDG goals were assessed. Gender-disaggregated analyses included multivariate logistic regression, testing for interactions between social protection and socio-demographic covariates, and marginal effects models. Findings Social protection was associated with significant adolescent risk reductions in 12 of 17 gender-disaggregated SDG indicators, spanning SDG 2 (hunger); SDG 3 (AIDS, tuberculosis, mental health and substance abuse); SDG 4 (educational access); SDG 5 (sexual exploitation, sexual and reproductive health); and SDG 16 (violence perpetration). For six of 17 indicators, combined cash plus care showed enhanced risk reduction effects. Two interactions showed that effects of care varied by poverty level for boys’ hunger and girls’ school dropout. For tuberculosis, and for boys’ sexual exploitation and girls’ mental health and violence perpetration, no effects were found and more targeted or creative means will be needed to reach adolescents on these challenging burdens. Interpretation National social protection systems are not a panacea, but findings suggest that they have multiple and synergistic positive associations with adolescent health outcomes. Such systems may help us rise to the challenges of health and sustainable development.

How effective is help on the doorstep? A longitudinal evaluation of community-based organisation support

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9–13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9–13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12–15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input.

Prospective risk and protective factors for intimate partner violence victimisation among women: a systematic review and meta-analysis

Abstract Background The lifetime prevalence of intimate partner violence (IPV), violence committed by a current or former partner, is estimated to be 30% among women worldwide. Effective prevention requires targeting conditions that increase and decrease the risk of IPV—or risk and protective factors, respectively. We aimed to systematically review and quantify the associations between prospective longitudinal risk and protective factors and IPV against women and identify evidence gaps. Methods Systematic searches were conducted in English in 16 databases including Medline and PsycINFO from inception to June 1, 2016, using free-text terms and controlled vocabulary for violence, partner, adults, and study design. English-language studies that prospectively analysed an adjusted association between any risk or protective factor or factors and self-reported IPV victimisation among women were included. Study quality was assessed with the Cambridge Quality Checklists. Studies investigating the same risk or protective factor using similar measures, and with appropriate data available, were combined to compute odds ratios using random-effects meta-analyses. Heterogeneity was indicated by I 2 and τ 2 . All results, including those not meta-analysed, were synthesised with harvest plots to illustrate evidence gaps and trends towards negative or positive associations. This study is registered with PROSPERO, number CRD42016039213. Findings Of 18 608 studies identified, 60 were included, and 35 meta-analysed. The strongest evidence for modifiable risk factors for IPV against women were unplanned pregnancy (odds ratio 1·66, 95% CI 1·20–1·31) and having parents with less than a high school education (1·55, 1·10–2·17). Being older (0·96, 0·93–0·98) and married (0·93, 0·87–0·99) were protective. Interpretation Study limitations include English-language restrictions and low statistical power. Nevertheless, to our knowledge this is the first systematic, meta-analytical review of all risk and protective factors for IPV against women without location, time, or publication restrictions. Education and sexual health interventions may be effective targets for preventing IPV against women, with young, unmarried women most at risk. More prospective evidence for perpetrator-related and context-related risk and protective factors for womens IPV experiences outside the USA is urgently needed to inform global recommendations. Funding Rhodes Trust, Canadian Institutes of Health Research (DFS152265).

OP92 A systematic review of prospective risk and protective factors for intimate partner violence victimisation among women

Note: Presentation moved to health inequalities 2 session on wednesday Background Rates of intimate partner violence (IPV) against women are unacceptably high worldwide. There has been no systematic review in over 10 years of all risk and protective factors without location or peer-review restrictions. Resultantly, there is no recent, systematically-developed model of the causes of IPV at all levels (individual, relationship, community, and structural) that accounts for differences, similarities, and evidence-gaps across low- to high-income contexts. This remains a barrier to the effective prevention of IPV, with significant uncertainty over what works and within which contexts. We aimed to systematically review all prospective, longitudinal risk and protective factors of IPV victimisation among women. Methods Systematic searches were conducted in 16 databases and references of relevant studies were hand-searched. Published or unpublished studies in English that prospectively analysed the association between any risk or protective factor(s) and self-reported IPV victimisation among women, controlling for at least one other variable, were included. Study quality was assessed using the Cambridge Quality Checklists. Study screening, extraction, and quality appraisal were completed and checked by three independent reviewers. Results were graphically synthesised using harvest plots, which allow for the synthesis of heterogeneous evidence and identification of trends towards negative, null, or positive associations. Results Searches retrieved 10 444 unique results. After title and abstract review, 387 studies were screened by full-text. Sixty studies from 35 cohorts met inclusion criteria. Most studies were from the USA (80.0%). A total of 71 risk/protective factors were identified, mostly at the individual- (n=21) or relationship-level (n=25) rather than the community- (n=7) or structural-level (n=18). Variables that showed positive or a mix of null-positive associations with women’s IPV victimisation were: at the individual-level, women’s identification as non-white, younger age, alcohol use, depressive symptoms, antisocial behaviour, aggressive personality, and experience of child abuse; at the relational-level, partners’ identification as non-white, alcohol use, antisocial behaviour, low relationship satisfaction, poor parental relationship quality, and experience of low parental monitoring; and at the structural-level, partners’ unemployment, women’s lower education, and financial difficulties. Other variables were under-studied (< 2 studies) or showed mixed or mainly null effects. Conclusion Significant work is needed to develop an ecological model of IPV against women using prospective data. Many commonly accepted risk factors for IPV victimisation among women such as exposure to inter-parental violence and community factors have little (if any) prospective evidence from outside the USA. Further prospective research on the aetiology of IPV against women is needed to inform rigorous prevention models.

OP29 Are socioeconomic conditions associated with asthma prevalence, severity, and treatment access? A cross-sectional study of children living in low-income South African communities

Background South Africa has the highest prevalence of childhood asthma in sub-Saharan Africa and the fourth highest asthma mortality rate among young people worldwide. While poverty and social deprivation are pervasive, asthma studies in the region have largely focused on biomedical factors or urban-rural differences. This study sought to identify broader socioeconomic risk factors for childhood asthma prevalence, severity, and treatment access in South Africa and possible mediating pathways. Methods We recruited 6,002 children aged 10–17 through door-to-door household sampling of six randomly selected low-income urban and rural sites in three South African provinces. Self-report questionnaires measured demographics, family structure, community violence, social support, household responsibilities, poverty, employment, and psychological symptoms. Asthma was indicated by self-reported diagnosis, with severe asthma defined as at least one asthma attack in the past month. Asthma treatment was defined, by minimum standards, as having a reliever inhaler. Multivariable logistic regressions provided odds ratios (ORs) for possible risk factors for asthma prevalence, severe asthma prevalence, and treatment access, adjusted for age, gender, urban-rural location, and province. Multiple mediation analyses using bootstrap confidence intervals (CIs) were conducted to test indirect risk pathways. Results Child anxiety [OR = 1.08, (95% CI) 1.04–1.12] and community violence (OR = 1.14, 1.00–1.30) were associated with greater odds of having asthma. Children with more outdoor housework (OR = 0.83, 0.71–0.98) and living in greater poverty (OR = 0.93, 0.88–0.99) had lower odds of having asthma. Severe asthma was predicted by child depression (OR = 1.14, 1.03–1.26) and greater household poverty (OR = 1.14, 1.01–1.28). Responsibility for more outdoor (OR = 0.66, 0.46–0.95) or indoor (OR = 0.73, 0.53–0.99) household tasks and living with more children were associated with lower odds of having asthma treatment (OR = 0.80, 0.67–0.96), while children living with more employed people had higher odds of having treatment (OR = 1.42, 1.06–1.92). Most socioeconomic factors operated in ‘risk pathways’, wherein structural factors (e.g., urban living) were associated with individual factors (e.g., less outdoor tasks), which predicted greater odds of having asthma or severe exacerbations. Conclusion Children living in greater poverty had lower odds of having asthma, potentially due to less urbanised lifestyles, but higher odds of having severe asthma and lacking treatment. Higher psychosocial stress may contribute to asthma onset and severity, while household-level stress may impede children’s access to treatment. While prospective longitudinal research is needed to infer causality, findings support the utility of moving beyond the biomedical model in addressing the prevention and treatment of childhood asthma.