Rhian Twine

Profile: Agincourt Health and Socio-demographic Surveillance System

The Agincourt health and socio-demographic surveillance system (HDSS), located in rural northeast South Africa close to the Mozambique border, was established in 1992 to support district health systems development led by the post-apartheid ministry of health. The HDSS (90 000 people), based on an annual update of resident status and vital events, now supports multiple investigations into the causes and consequences of complex health, population and social transitions. Observational work includes cohorts focusing on different stages along the life course, evaluation of national policy at population, household and individual levels and examination of household responses to shocks and stresses and the resulting pathways influencing health and well-being. Trials target children and adolescents, including promoting psycho-social well-being, preventing HIV transmission and reducing metabolic disease risk. Efforts to enhance the research platform include using automated measurement techniques to estimate cause of death by verbal autopsy, full ‘reconciliation’ of in- and out-migrations, follow-up of migrants departing the study area, recording of extra-household social connections and linkage of individual HDSS records with those from sub-district clinics. Fostering effective collaborations (including INDEPTH multi-centre work in adult health and ageing and migration and urbanization), ensuring cross-site compatibility of common variables and optimizing public access to HDSS data are priorities.

Research into health, population and social transitions in rural South Africa: Data and methods of the Agincourt Health and Demographic Surveillance System

Rationale for study: Vital registration is generally lacking in infrastructurally weak areas where health and development problems are most pressing. Health and demographic surveillance is a response to the lack of a valid information base that can provide high-quality longitudinal data on population dynamics, health, and social change to inform policy and practice. Design and measurement procedures: Continuous demographic monitoring of an entire geographically defined population involves a multi-round, prospective community study, with annual recording of all vital events (births, deaths, migrations). Status observations and special modules add value to particular research areas. A verbal autopsy is conducted on every death to determine its probable cause. A geographic surveillance system supports spatial analyses, and strengthens field management. Population and sample size considerations: Health and demographic surveillance covers the Agincourt sub-district population, sited in rural north-eastern South Africa, of some 70,000 people (nearly a third are Mozambican immigrants) in 21 villages and 11,700 households. Data enumerated are consistent or more detailed when compared with national sources; strategies to improve incomplete data, such as counts of perinatal deaths, have been introduced with positive effect. Basic characteristics: A major health and demographic transition was documented over a 12-year period with marked changes in population structure, escalating mortality, declining fertility, and high levels of temporary migration increasing particularly amongst women. A dual burden of infectious and non-communicable disease exists against a background of dramatically progressing HIV/AIDS. Potential and research questions: Health and demographic surveillance sites — fundamental to the INDEPTH Network — generate research questions and hypotheses from empirical data, highlight health, social and population priorities, provide cost-effective support for diverse study designs, and track population change and the impact of interventions over time.

Evaluating access to a child-oriented poverty alleviation intervention in rural South Africa

Background: In April 1998, the South African government introduced the child-support grant as a poverty-alleviation measure to support the income of poor households and enable them to care for the child. Aims: This research aimed to measure equity of access to applications for the child-support grant in an area characterized by poverty. Three questions were addressed: (i) How does socioeconomic status affect the probability of a household applying for a child-care grant? (ii) What household and caregiver characteristics are associated with child-care-grant application? (iii) What barriers to access are experienced by households that do not apply for the child-care grant? Methods: The study population of 6,725 households with at least one age-eligible child was drawn from the Agincourt field site, a rural sub-district of South Africa. Data used were obtained from health and demographic surveillance, a child-grant questionnaire, and a household-asset survey. Descriptive cross-tabulations and multivariate logistic regression were used in the analysis. Results: Although these grants are intended as a pro-poor intervention, the poorest households are less likely to apply for grants than those in higher socioeconomic bands. Households in lower socioeconomic bands experienced barriers in accessing grants; these related to lack of official documentation, education level of the caregiver and household head, and distance from government service offices. Conclusions: Enhancing access will require improved provision of birth certificates and identity documents, efficient coordination and service provision from a range of rural government offices, and creative methods of communication.

The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial

BACKGROUND Cash transfers have been proposed as an intervention to reduce HIV-infection risk for young women in sub-Saharan Africa. However, scarce evidence is available about their effect on reducing HIV acquisition. We aimed to assess the effect of a conditional cash transfer on HIV incidence among young women in rural South Africa. METHODS We did a phase 3, randomised controlled trial (HPTN 068) in the rural Bushbuckridge subdistrict in Mpumalanga province, South Africa. We included girls aged 13-20 years if they were enrolled in school grades 8-11, not married or pregnant, able to read, they and their parent or guardian both had the necessary documentation necessary to open a bank account, and were residing in the study area and intending to remain until trial completion. Young women (and their parents or guardians) were randomly assigned (1:1), by use of numbered sealed envelopes containing a randomisation assignment card which were numerically ordered with block randomisation, to receive a monthly cash transfer conditional on school attendance (≥80% of school days per month) versus no cash transfer. Participants completed an Audio Computer-Assisted Self-Interview (ACASI), before test HIV counselling, HIV and herpes simplex virus (HSV)-2 testing, and post-test counselling at baseline, then at annual follow-up visits at 12, 24, and 36 months. Parents or guardians completed a Computer-Assisted Personal Interview at baseline and each follow-up visit. A stratified proportional hazards model was used in an intention-to-treat analysis of the primary outcome, HIV incidence, to compare the intervention and control groups. This study is registered at ClinicalTrials.gov (NCT01233531). FINDINGS Between March 5, 2011, and Dec 17, 2012, we recruited 10 134 young women and enrolled 2537 and their parents or guardians to receive a cash transfer programme (n=1225) or not (control group; n=1223). At baseline, the median age of girls was 15 years (IQR 14-17) and 672 (27%) had reported to have ever had sex. 107 incident HIV infections were recorded during the study: 59 cases in 3048 person-years in the intervention group and 48 cases in 2830 person-years in the control group. HIV incidence was not significantly different between those who received a cash transfer (1·94% per person-years) and those who did not (1·70% per person-years; hazard ratio 1·17, 95% CI 0·80-1·72, p=0·42). INTERPRETATION Cash transfers conditional on school attendance did not reduce HIV incidence in young women. School attendance significantly reduced risk of HIV acquisition, irrespective of study group. Keeping girls in school is important to reduce their HIV-infection risk. FUNDING National Institute of Allergy and Infectious Diseases, National Institute of Mental Health of the National Institutes of Health.

Conceptualizing Community Mobilization for HIV Prevention: Implications for HIV Prevention Programming in the African Context

Introduction Community mobilizing strategies are essential to health promotion and uptake of HIV prevention. However, there has been little conceptual work conducted to establish the core components of community mobilization, which are needed to guide HIV prevention programming and evaluation. Objectives We aimed to identify the key domains of community mobilization (CM) essential to change health outcomes or behaviors, and to determine whether these hypothesized CM domains were relevant to a rural South African setting. Method We studied social movements and community capacity, empowerment and development literatures, assessing common elements needed to operationalize HIV programs at a community level. After synthesizing these elements into six essential CM domains, we explored the salience of these CM domains qualitatively, through analysis of 10 key informant in-depth-interviews and seven focus groups in three villages in Bushbuckridge. Results CM domains include: 1) shared concerns, 2) critical consciousness, 3) organizational structures/networks, 4) leadership (individual and/or institutional), 5) collective activities/actions, and 6) social cohesion. Qualitative data indicated that the proposed domains tapped into theoretically consistent constructs comprising aspects of CM processes. Some domains, extracted from largely Western theory, required little adaptation for the South African context; others translated less effortlessly. For example, critical consciousness to collectively question and resolve community challenges functioned as expected. However, organizations/networks, while essential, operated differently than originally hypothesized - not through formal organizations, but through diffuse family networks. Conclusions To date, few community mobilizing efforts in HIV prevention have clearly defined the meaning and domains of CM prior to intervention design. We distilled six CM domains from the literature; all were pertinent to mobilization in rural South Africa. While some adaptation of specific domains is required, they provide an extremely valuable organizational tool to guide CM programming and evaluation of critically needed mobilizing initiatives in Southern Africa.

Temporal changes in pneumococcal colonization in a rural African community with high HIV prevalence following routine infant pneumococcal immunization.

Background: Pneumococcal conjugate vaccine (PCV) immunization of children decreases their risk of nasopharyngeal acquisition of vaccine serotypes. We studied the impact of routine infant PCV immunization alone on the epidemiology of nasopharyngeal pneumococcal colonization among a rural African community with high prevalence of HIV positivity. Methods: Two cross-sectional surveys were undertaken in a rural South African community from May to October 2009 (period 1) and 2011 (period 2). Seven-valent PCV was introduced into the public immunization program for infants in April 2009, without catch-up campaign for older children. Randomly selected households with at least 1 child <2 years of age were recruited. Nasopharyngeal swabs from all consenting household members were obtained for Streptococcus pneumoniae culture and serotyping by Quellung method. Results: The median ages (SD) of children enrolled were 4.32 (SD, 3.4) and 3.80 (SD, 3.4) years in periods 1 and 2, respectively. Overall, the prevalence of vaccine serotype colonization declined from 18.3% (368/2010) in period 1 to 11.4% (418/3659) by period 2 (P < 0.0001). This included reductions (adjusted risk ratio) of 50% [95% confidence interval (95% CI): 0.42–0.59], 34% (95% CI: 0.48–0.92) and 64% (95% CI: 0.18–0.74) in age groups <2 years, 6–12 years and adults. The prevalence of vaccine serotype colonization among primary caregivers decreased from 10.2% to 5.4% (P ⩽ 0.001) by period 2. The prevalence of nonvaccine serotype colonization increased by 35% (95% CI: 1.17–1.56) among <2-year-old children by period 2, while it declined by 45–54% among adolescents and adults. Conclusions: An indirect effect of PCV7 was realized in a high HIV prevalence setting within 2 years of PCV introduction. The unexpected decline in nonvaccine serotypes colonization among adolescents/adults may indicate lag in replacement colonization by nonvaccine serotypes in this group.

Prevalence and risk factors for active convulsive epilepsy in rural northeast South Africa

Highlights • Epilepsy is prevalent in rural South Africa, but less than other parts of Africa.• Most epilepsy starts in childhood.• Poor obstetric history and snoring were associated with active convulsive epilepsy.• HIV and parasitic infection were not associated with active convulsive epilepsy.

A cluster randomized-controlled trial of a community mobilization intervention to change gender norms and reduce HIV risk in rural South Africa: study design and intervention

BackgroundCommunity mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa.MethodsCommunity Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18–35 years at baseline and endline about two years later.ConclusionsThis is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective.Trial registrationClinicalTrials.gov NCT02129530

Development, validation, and performance of a scale to measure community mobilization

RATIONALE Community mobilization approaches (CMAs) are increasingly becoming key components of health programming. However, CMAs have been ill defined and poorly evaluated, largely due to the lack of measurement tools to assess mobilization processes and impact. OBJECTIVE We developed the Community Mobilization Measure (CMM), composed of a set of scales to measure mobilization domains hypothesized to operate at the community-level. The six domains include: shared concerns, critical consciousness, leadership, collective action, social cohesion, and organizations and networks. We also included the domain of social control to explore synergies with the related construct of collective efficacy. METHOD A survey instrument was developed and pilot tested, then revised and administered to 1181 young people, aged 18-35, in a community-based survey in rural South Africa. Item response modeling and exploratory factor analyses were conducted to assess model fit, dimensionality, reliability, and validity. RESULTS Results indicate the seven-dimensional model, with linked domains but no higher order construct, fit the data best. Internal consistency reliability of the factors was strong, with ρ values ranging from 0.81 to 0.93. Six of seven scales were sufficiently correlated to represent linked concepts that comprise community mobilization; social control was less related to the other components. At the village level, CMM sub-scales were correlated with other metrics of village social capital and integrity, providing initial evidence of higher-level validity, however additional evaluation of the measure at the community-level is needed. CONCLUSION This is the first effort to develop and validate a comprehensive measure for community mobilization. The CMM was designed as an evaluation tool for health programming and should facilitate a more nuanced understanding of mechanisms of change associated with CM, ultimately making mobilizing approaches more effective.

Acceptability and Feasibility of Cash Transfers for HIV Prevention Among Adolescent South African Women

Women are at increased risk of HIV infection in much of sub-Saharan Africa. Longitudinal and cross-sectional studies have found an association between school attendance and reduced HIV risk. We report feasibility and acceptability results from a pilot of a cash transfer intervention conditional on school attendance paid to young women and their families in rural Mpumalanga, South Africa for the prevention of HIV infection. Twenty-nine young women were randomised to intervention or control and a cash payment based on school attendance made over a 2-month period. Quantitative (survey) and qualitative (focus group and interview) data collection was undertaken with young women, parents, teachers and young men in the same school. Qualitative analysis was conducted in Atlas.ti using a framework approach and basic descriptive analysis in Excel was conducted on the quantitative data. Results indicate it was both feasible and acceptable to introduce such an intervention among this population in rural South Africa. There was good understanding of the process of randomisation and the aims of the study, although some rumours developed in the study community. We address some of the changes necessary to ensure acceptability and feasibility of the main trial.