Frederik le Roux Booysen

An Overview and Evaluation of Composite Indices of Development

The search for alternative indicators of development has witnessedthe development of a variety of composite indices of development. Theseindices integrate various social, political and economic aspects ofdevelopment in measurement. This paper presents an overview andevaluation of composite indices of development in terms of certain broaddimensions of measurement. In terms of method and technique, compositeindices are generally additive ones with equally weighted componentsconsisting of variables selected in an ad hoc manner. Numerouscriticisms have been leveled at these methods employed in compositeindexing. Composite indices are mainly quantitative insofar as theindices are all presented in numerical format. Composite indices aresubject to subjectivity despite the relative objectivity of the methodsemployed in composite indexing. Composite indices are of a cardinalnature, but remain ordinal insofar as differences in index values cannotbe interpreted meaningfully. The multidimensionality of compositeindices represents one of their main advantages. Indices representaggregate measures of a combination of complex development phenomena.The comparative application of composite indices of development overspace and time remains problematic. Composite indices generally combinemeasures of ends and means. In respect of method and technique,composite indexing is relatively complex. Composite indices arerelatively flexible, because changes in selection, scaling, weightingand aggregation can be effected readily, albeit at the cost ofcomparability. Composite indices perform relatively well in terms ofcross-national availability, but few indices perform well in terms ofinter-temporal availability. On the strength of the systematic positiveassociation between income and popular composite indices such as theHDI, many have claimed that these indices represent no real contributionto the literature on indicators research. Composite indices,furthermore, are often considered to be ideological statements ratherthan practically functional indicators. Yet, composite indices representuseful supplements to income-based development indicators. These indicesremain invaluable in terms of their ability to simplify complexmeasurement constructs, to focus attention and to catch the eye, thusenhancing their political appeal.

Wording effects and the factor structure of the hospital anxiety & depression scale in HIV/AIDS patients on antiretroviral treatment in South Africa

Background Given the immense burden of HIV/AIDS on health systems in sub-Saharan Africa and the intricate link between HIV/AIDS and mental health problems, health care providers need a valid and reliable instrument to assess mental health rapidly. The Hospital Anxiety and Depression Scale (HADS) may constitute such an instrument. The aims of this study were to: (1) examine the factor structure of the HADS in a population of South African HIV/AIDS patients on antiretroviral treatment (ART); and (2) identify and control the disturbing influence of systematic wording effects in vulnerable respondent groups. Methodology/Principal Findings The translated scale was administered to 716 HIV/AIDS patients enrolled in the public sector ART program in South Africa. A combined confirmatory factor analysis and correlated-traits-correlated-methods framework was used to determine the preferred factor structure of the HADS, while controlling for the disturbing influence of systematic wording effects. When assessing the structure without a negative wording factor, all three factor structures displayed an acceptable fit to the data. The three-factor solution best fitted the data. Addition of a method factor significantly improved the fit of all three factor solutions. Using χ2 difference testing, Razavis one-factor solution displayed a superior fit compared to the other two factor solutions. Conclusions The study outcomes support the use of the HADS as a valid and reliable means to screen for mental health problems in HIV/AIDS patients enrolled in a public-sector ART program in a resource-limited context. The results demonstrate the importance of evaluating and correcting for wording effects when examining the factor structure of the screening instrument in vulnerable patient groups. In light of the inter-relationships between HIV/AIDS and mental health problems and the scarcity of adequate screening tools, additional studies on this topic are required.

A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: the moderating role of family dynamics

Given the severe shortage of human resources in the healthcare sector in many countries with high HIV prevalence, community-based peer adherence support is being increasingly cited as an integral part of a sustainable antiretroviral treatment (ART) strategy. However, the available scientific evidence on this topic reports discrepant findings on the effectiveness of peer adherence support programmes. These conflicting findings to some extent can be attributed to the lack of attention to the social contexts in which peer adherence support programmes are implemented. This study explores the potential moderating role of family dynamics by assessing the differential impact of peer adherence support in different types of families, based on the theoretical underpinnings of the family functioning framework. These relationships were explored with the aid of multivariate statistical analysis of cross-sectional, post-trial data for a sample of 340 patients interviewed as part of the Effectiveness of Aids Treatment and Support in the Free State (FEATS) study conducted in the public-sector ART programme of the Free State Province of South Africa. The analysis reveals no significant overall differences in CD4 cell count between the intervention group accessing additional peer adherence support and the control group receiving standard care. When controlling for the potential moderating role of family dynamics, however, the outcomes clearly reveal a significant interaction effect between the adherence intervention and the level of family functioning with regard to treatment outcomes. Multi-group analysis demonstrates that peer adherence support has a positive effect on immunological restoration in well-functioning families, while having a negative effect in dysfunctional families. The study outcomes stress the need for peer adherence interventions that are sensitive to the suboptimal contexts in which they are often implemented. Generic, broad-based interventions do not necessarily facilitate the treatment adherence of the most vulnerable patient groups, particularly those without supportive family contexts. Tailoring interventions aimed at creating a health-enabling environment to the needs of these at-risk patients should therefore be a priority for both research and policy.

HIV/AIDS, poverty and risky sexual behaviour in South Africa

This paper employs data from the 1998 South African Demographic and Health Survey in exploring the nature of socio-economic inequalities in and determinants of risky sexual behaviour. Risky sexual behaviour was associated with poverty only in the case of multiple partnerships. Affluent women that have engaged in risky sexual behaviour were shown to be more likely to have cited negative perceptions about condom use as main reason for not using a condom at last sex. Poor women in turn were more likely to cite lack of knowledge about condoms and abstinence from condom use as main reason. Poverty plays little part in explaining differences in risky sexual behaviour, although higher education in some cases was associated positively with risky sexual behaviour. Risky sexual behaviour was associated with differences in age, urban residence and marital status. Coloured, Asian and White women were less likely than African women to have engaged in risky sexual behaviour. Violence and coercion were also associated with risky sexual behaviour. Women in affluent households that had engaged in risky sexual behaviour were more likely to have been mistreated by a husband or partner compared to poor women. There is no evidence of a definitive one-way causal relationship between poverty, gender and sexual behaviour and further research is required to elucidate this complex relationship.This paper employs data from the 1998 South African Demographic and Health Survey in exploring the nature of socio-economic inequalities in and determinants of risky sexual behaviour. Risky sexual behaviour was associated with poverty only in the case of multiple partnerships. Affluent women that have engaged in risky sexual behaviour were shown to be more likely to have cited negative perceptions about condom use as main reason for not using a condom at last sex. Poor women in turn were more likely to cite lack of knowledge about condoms and abstinence from condom use as main reason. Poverty plays little part in explaining differences in risky sexual behaviour, although higher education in some cases was associated positively with risky sexual behaviour. Risky sexual behaviour was associated with differences in age, urban residence and marital status. Coloured, Asian and White women were less likely than African women to have engaged in risky sexual behaviour. Violence and coercion were also associated w...

Families as catalysts for peer adherence support in enhancing hope for people living with HIV/AIDS in South Africa

Hope is an essential dimension of successful coping in the context of illnesses such as HIV/AIDS, because positive expectations for the future alleviate emotional distress, enhance quality of life and have been linked to the capacity for behavioural change. The social environment (e.g. family, peers) is a regulator of hope for people living with HIV/AIDS (PLWHA). In this regard, the dual aim of this article is (1) to analyze the influence of a peer adherence support (PAS) intervention and the family environment on the state of hope in PLWHA and (2) to investigate the interrelationship between the two determinants.

Who is accessing public-sector anti-retroviral treatment in the Free State, South Africa? An exploratory study of the first three years of programme implementation

BackgroundAlthough South Africa has the largest public-sector anti-retroviral treatment (ART) programme in the world, anti-retroviral coverage in adults was only 40.2% in 2008. However, longitudinal studies of who is accessing the South African public-sector ART programme are scarce. This study therefore had one main research question: who is accessing public-sector ART in the Free State Province, South Africa? The study aimed to extend the current literature by investigating, in a quantitative manner and using a longitudinal study design, the participants enrolled in the public-sector ART programme in the period 2004-2006 in the Free State Province of South Africa.MethodsDifferences in the demographic (age, sex, population group and marital status) socio-economic (education, income, neo-material indicators), geographic (travel costs, relocation for ART), and medical characteristics (CD4, viral load, time since first diagnosis, treatment status) among 912 patients enrolled in the Free State public-sector ART programme between 2004 and 2006 were assessed with one-way analysis of variance, Bonferroni post-hoc analysis, and cross tabulations with the chi square test.ResultsThe patients accessing treatment tended to be female (71.1%) and unemployed (83.4%). However, although relatively poor, those most likely to access ART services were not the most impoverished patients. The proportion of female patients increased (P < 0.05) and their socio-economic situation improved between 2004 and 2006 (P < 0.05). The increasing mean transport cost (P < 0.05) to visit the facility is worrying, because this cost is an important barrier to ART uptake and adherence. Encouragingly, the study results revealed that the interval between the first HIV-positive diagnosis and ART initiation decreased steadily over time (P < 0.05). This was also reflected in the increasing baseline CD4 cell count at ART initiation (P < 0.05).ConclusionsOur analysis showed significant changes in the demographic, socio-economic, geographic, and medical characteristics of the patients during the first three years of the programme. Knowledge of the characteristics of these patients can assist policy makers in developing measures to retain them in care. The information reported here can also be usefully applied to target patient groups that are currently not reached in the implementation of the ART programme.

The Importance of the Family: A Longitudinal Study of the Predictors of Depression in HIV Patients in South Africa

As a chronic illness, HIV/AIDS requires life-long treatment adherence and retention—and thus sufficient attention to the psychosocial dimensions of chronic disease care in order to produce favourable antiretroviral treatment (ART) outcomes in a sustainable manner. Given the high prevalence of depression in chronic HIV patients, there is a clear need for further research into the determinants of depression in this population. In order to comprehensively study the predictors of depressive symptoms in HIV patients on ART, the socio-ecological theory postulates to not only incorporate the dominant individual-level and the more recent community-level approaches, but also incorporate the intermediate, but crucial family-level approach. The present study aims to extend the current literature by simultaneously investigating the impact of a wide range individual-level, family-level and community-level determinants of depression in a sample of 435 patients enrolled in the Free State Province of South Africa public-sector ART program. Structural equation modeling is used to explore the relationships between both latent and manifest variables at two time points. Besides a number of individual-level correlates—namely education, internalized and external stigma, and avoidant and seeking social support coping styles—of depressive symptoms in HIV patients on ART, the study also revealed the important role of family functioning in predicting depression. While family attachment emerged as the only factor to continuously and negatively impact depression at both time points, the second dimension of family functioning, changeability, was the only factor to produce a negative cross-lagged effect on depression. The immediate and long-term impact of family functioning on depression draws attention to the role of family dynamics in the mental health of people living with HIV/AIDS. In addition to individual-level and community-based factors, future research activities should also incorporate the role of the family context in research into the mental health of HIV patients, as our results demonstrate that the familial context in which a person with HIV on ART resides is inextricably interconnected with his/her health outcomes.

Public sector antiretroviral treatment programme in South Africa: health care workers' attention to mental health problems

Although there is a high prevalence of anxiety and depression amongst people receiving antiretroviral treatment (ART), many patients are not screened, diagnosed or referred for mental health problems. This study aims to determine whether public sector health care workers in South Africa observe, screen, diagnose and refer ART patients that show symptoms of common mental disorders. It also aims to ascertain the extent of mental health training received by public sector health care workers working in ART. The study was cross-sectional in design. Self-administered questionnaires were completed by 40 nurses and structured interviews were conducted with 23 lay workers across the five districts in the Free State between July 2009 and October 2009. STATA version 12 was used to perform statistical data analysis. The health care workers reported observing a high frequency of symptoms of common mental disorders among public sector ART patients. While 70% of nurses screened and diagnosed, only 40% of lay workers screened and diagnosed patients on ART for a mental disorder. Health care workers who had received training in mental health were more likely to screen or diagnose a mental disorder, but only 14% of the workers had received such training. We recommend that health care workers should receive task-specific training to screen and/or diagnose patients on ART for common mental disorders using the guidelines of the South African HIV Clinicians Society. A positive diagnosis should be referred to a health care practitioner for appropriate evidence-based treatment in the form of medication or psychotherapy.

Mutual HIV status disclosure is associated with consistent condom use in public sector ART clients in Free State province, South Africa: a short report

ABSTRACT Risky sexual behaviour in PLWHA on antiretroviral therapy threatens both prevention and treatment efforts, but disclosure promises to support safer sexual practices. This paper investigates the association between HIV self-disclosure and consistent condom use in a cohort of public sector patients on antiretroviral (ARV) treatment. Using data from the FEATS cohort study, logistic regression analysis shows that knowledge of your partner’s HIV status is positively associated with consistent condom use (OR 2.73, 95% CI 1.37–5.43, p = 0.004) and so too mutual HIV disclosure (OR 3.38, 95% CI 1.60–7.18, p = 0.001). Prevention and treatment programmes, through couple HIV counselling and testing (CHCT) and other assistance programmes, should focus on supporting the mutual disclosure of HIV status among PLWHA on ARV treatment.

Who Should We Target? The Impact of Individual and Family Characteristics on the Expressed Need for Community-Based Treatment Support in HIV Patients in South Africa.

Reviews of impact evaluations of community-based health workers and peer support groups highlight the considerable variability in the effectiveness of such support in improving antiretroviral treatment (ART) outcomes. Evidence indicates that community-based support interventions targeting patients known to be at risk will probably display better results than generic interventions aimed at the entire population of people living with HIV. It is however difficult to identify these at-risk populations, rendering knowledge on the characteristics of patients groups who are in need of community-based support a clear research priority. The current study aims to address the knowledge gap by exploring the predictors of the willingness to (1) receive the support from a community-based health worker or (2) to participate in a support group in public sector ART programme of the Free State Province of South Africa. Based on the Individual-Family-Community framework for HIV research, the study employs a comprehensive approach by not only testing classical individual-level but also family-level predictors of the willingness to receive community-based support. In addition to individual-level predictors—such as age, health status and coping styles—our analysis demonstrated the importance of family characteristics. The results indicated that discrepancies in the family’s changeability level were an important predictor of the demand for community-based support services. Conversely, the findings indicated that patients living in a family more flexible than deemed ideal are more likely to require the support of a community health worker. The current study expands theory by indicating the need to acknowledge all social ecological levels in the study of chronic HIV care. The detection of both individual level and family level determinants of the expressed need for community-based support can inform health policy to devise strategies to target scarce resources to those vulnerable patients who report the greatest need for this support. In this way, the study results are a first step in an attempt to move away from generic, broad based community-based interventions towards community support that is tailored to the patient needs at both the individual and family level.