Differential influences of early growth and social factors on young children's cognitive performance in four low-and-middle-income birth cohorts (Brazil, Guatemala, Philippines, and South Africa).

BACKGROUND: Studies relating childhood cognitive development to poor linear growth seldom take adequate account of social conditions related to both, leading to a focus on nutrition interventions. We aimed to assess the roles of both biological and social conditions in determining early childhood cognition, mediated by birthweight and early linear growth. METHODS: After exploratory structural equation modelling to identify determining factors, we tested direct and indirect paths to cognitive performance through birthweight and child height-for-age at 2 years, assessed between 4 and 8.5 years of age among 2448 children in four birth cohort studies in low-and-middle-income countries (Brazil, Guatemala, Philippines and South Africa). Determinants were compared across the cohorts. FINDINGS: Three factors yielded excellent fit, comprising birth endowment (primarily maternal age and birth order), household resources (crowding, dependency) and parental capacity (parental education). We estimated their strength together with maternal height in determining cognitive performance. Percentage shares of total effects of the four determinants show a marked transition from mainly biological determinants of birth weight (birth endowment 34%) and maternal height (30%) compared to household resources (25%) and parental capacity (11%), through largely economic determinants of height at 2 years (household resources (60%) to cognitive performance being predominantly determined by parental capacity (64%) followed by household resources (29%). The largely biological factor, birth endowment (maternal age and birth order) contributed only 7% to childhood cognitive performance and maternal height was insignificant. In summary, the combined share of social total effects (household resources and parental capacity) rises from 36∙2% on birth weight, to 78∙2% on height for age at 24 m, and 93∙4% on cognitive functioning. INTERPRETATION: Across four low- and middle-income contexts, cognition in childhood is influenced more by the parental capacity of families and their economic resources than by birth weight and early linear growth. Improving children's cognitive functioning requires multi-sectoral interventions to improve parental education and enhance their economic wellbeing, interventions that are known to improve also early childhood growth.

Does free schooling affect pathways from adverse childhood experiences via mental health distress to HIV risk among adolescent girls in South Africa: a longitudinal moderated pathway model.

INTRODUCTION: Adolescent girls are at high risk of HIV infection in sub-Saharan Africa. Mental health distress, driven by adverse childhood experiences (ACEs) such as abuse, poverty and family HIV, may be an important driver of HIV risk behaviour among adolescent girls, while education may mitigate these risks. This study aimed to develop an empirically based theoretical model between ACEs, mental health distress and HIV risk behaviour among adolescent girls in South Africa and to investigate the potential moderating effects of free schooling provision. METHODS: Self-report questionnaires using validated scales were completed by adolescent girls aged 12 to 17 at baseline in two provinces in South Africa in 2011, with a 99% one-year follow-up in 2012 (n = 1498). Sampling included every household in randomly selected census enumeration areas of four deprived health districts. Confirmatory factor analysis was employed to identify measurement models and a structural equation model was developed to test pathways of risk and protection. RESULTS: Internalizing and externalizing mental health distress fully mediated the positive relationship between ACEs at baseline and HIV risk behaviour at follow-up among adolescent girls. Internalizing mental health distress was associated with increased sexual risk at follow-up via higher externalizing problems. Free schooling provision at baseline and follow-up eliminated the pathway from internalizing to externalizing mental health distress by moderating the pathway between ACEs and internalizing mental health distress. It also weakened the pathway from externalizing mental health distress to HIV risk behaviour at follow-up through a direct negative effect on externalizing mental health distress. CONCLUSIONS: Reducing ACEs and adolescent mental health distress is essential for reducing HIV risk behaviour among girls in South Africa. Free schooling provision may be an important tool for reducing these problems and mitigating negative pathways to HIV risk among vulnerable adolescent girls.

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

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.

Measuring environmental health status in Oukasie, 1987.

This article reports on some aspects of the physical environment and on environmental health services at Oukasie. The data were collected over a weekend in August 1987 by an interview and by direct inspection of the environment using a standard schedule. We had a 100% response rate on the interviews. There was a mean of 2.2 +/- 1.6 persons per room in the households, with brick houses being less crowded than non-brick houses. Private yards were generally kept very clean. Bucket latrines were unhygienic and used by an average of 4 families. No latrine was built to accepted standards. Garbage collection and emptying of the bucket latrines by the municipality seemed to be unsatisfactory. Our overall impression was that where responsibility for maintenance of hygiene is either undefined, such as the collection chambers of bucket latrines, or a responsibility of the public authorities, such as garbage collection and water drainage, there is an unsatisfactory state of hygiene. Where maintenance of cleanliness is clearly a private responsibility, such as the maintenance of the cleanliness of private yards, the general status of hygiene is good.

Community health survey of Oukasie, 1987.

A series of surveys were conducted at the request of the community of Oukasie to determine certain public health information in the township, a peri-urban black community. This article describes two of these surveys. The first, a census and partial demographic survey, showed that the total black population was around 6,300 with a mean household occupancy of 4.1. Some of the estimated vital statistics calculated were an infant mortality rate of 36.6/1,000, a crude birth rate of 28.0/1,000, a crude death rate of 6.5/1,000, and a general fertility rate of 99.3/1,000. The second survey into the nutritional and immunisation status of children aged under 5 years showed that 20% of children were underweight and nearly half were incompletely immunised at 1 year of age. These studies, involving local community and student volunteers, were rapidly and inexpensively done and provide basic public health information.