Pathways to transactional sex among peri-urban South African women: the role of relationship control, food insecurity and alcohol misuse.

Transactional sex increases sub-Saharan African women's risk of HIV acquisition. We quantitatively explored the pathways contributing towards women's future engagement in transactional sex with casual partners and khwapheni (secret concurrent sex partners). We conducted secondary data analysis from a cluster randomised controlled trial in urban informal settlements in eThekwini Municipality., South Africa. Data were collected at enrolment (t0) and 24 months' later (t2) using self-completed questionnaires. Structural equation modelling (SEM) assessed pathways leading to transactional sex over two years. 677 women 18-35 years were enrolled and 80.5% (n = 545) were followed up. At t2, 44.6% of respondents reported transactional sex with a casual partner or khwapheni. The SEM demonstrated a small effect (d = 0.23) between transactional sex at t0 and at t2. Controlling for past transactional sex, main partner relationship control had a large effect size on future transactional sex (d = 0.60). Hazardous drinking had a medium effect size (d = 0.45) and food insecurity a small effect (d = 0.24), (RMSEA 0.03, 90%CI 0.02-0.04; CFI 0.97; TLI 0.96). HIV prevention programming should highlight current transactional sex but also address structural issues predicting future transactional sex, including food insecurity and alcohol misuse. Gender transformative interventions to reduce controlling behaviours in main relationships are worth investigating.

The needs and opportunities for housing improvement for malaria control in southern Tanzania.

BACKGROUND: Malaria disproportionately affects low-income households in rural communities where poor housing is common. Despite evidence that well-constructed and mosquito-proofed houses can reduce malaria risk, housing improvement is rarely included in malaria control toolboxes. This study assessed the need, magnitude, and opportunities for housing improvement to control malaria in rural Tanzania. METHODS: A mixed-methods study was conducted in 19 villages across four district councils in southern Tanzania. A structured survey was administered to 1292 community members to assess need, perceptions, and opportunities for housing improvement for malaria control. Direct observations of 802 houses and surrounding environments were done to identify the actual needs and opportunities, and to validate the survey findings. A market survey was done to assess availability and cost of resources and services necessary for mosquito-proofing homes. Focus group discussions were conducted with key stakeholders to explore insights on the potential and challenges of housing improvement as a malaria intervention. RESULTS: Compared to other methods for malaria control, housing improvement was among the best understood and most preferred by community members. Of the 735 survey respondents who needed housing improvements, a majority needed window screening (91.1%), repairs of holes in walls (79.4%), door covers (41.6%), closing of eave spaces (31.2%) and better roofs (19.0%). Community members invested significant efforts to improve their own homes against malaria and other dangers, but these efforts were often slow and delayed due to high costs and limited household incomes. Study participants suggested several mechanisms of support to improve their homes, including government loans and subsidies. CONCLUSION: Addressing the need for housing improvement is a critical component of malaria control efforts in southern Tanzania. In this study, a majority of the community members surveyed needed modest modifications and had plans to work on those modifications. Without additional support, their efforts were however generally slow; households would take years to sufficiently mosquito-proof their houses. It is, therefore, crucial to bring together the key players across sectors to reduce barriers in malaria-proofing housing in endemic settings. These may include government subsidies or partnerships with businesses to make housing improvement more accessible and affordable to residents.

Moving towards social inclusion: Engaging rural voices in priority setting for health.

BACKGROUND: Achieving universal health coverage (UHC) in the context of limited resources will require prioritising the most vulnerable and ensuring health policies and services are responsive to their needs. One way of addressing this is through the engagement of marginalised voices in the priority setting process. Public engagement approaches that enable group level deliberation as well as individual level preference capturing might be valuable in this regard, but there are limited examples of their practical application, and gaps in understanding their outcomes, especially with rural populations. OBJECTIVE: To address this gap, we implemented a modified priority setting tool (Choosing All Together-CHAT) that enables individuals and groups to make trade-offs to demonstrate the type of health services packages that may be acceptable to a rural population. The paper presents the findings from the individual choices as compared to the group choices, as well as the differences among the individual choices using this tool. METHODS: Participants worked in groups and as individuals to allocate stickers representing the available budget to different health topics and interventions using the CHAT tool. The allocations were recorded at each stage of the study. We calculated the median and interquartile range across study participants for the topic totals. To examine differences in individual choices, we performed Wilcoxon rank sum tests. RESULTS: The results show that individual interests were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics like age. DISCUSSION: The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and potentially enhance the legitimacy and acceptability of priority setting. Methods that enable group level deliberation and individual level priority setting may be necessary to reconcile plurality. The paper also highlights the importance of capturing the details of public engagement processes and transparently reporting on these details to ensure valuable outcomes. PUBLIC CONTRIBUTION: The facilitator of the CHAT groups was a member from the community and underwent training from the research team. The fieldworkers were also from the community and were trained and paid to capture the data. The participants were all members of the rural community- the study represents their priorities.

Interrupting the intergenerational cycle of violence: protocol for a three-generational longitudinal mixed-methods study in South Africa (INTERRUPT_VIOLENCE).

BACKGROUND: Violence is a global social and human rights issue with serious public health implications across the life-course. Interpersonal violence is transmitted across generations and there is an urgent need to understand the mechanisms of this transmission to identify and inform interventions and policies for prevention and response. We lack an evidence-base for understanding the underlying mechanisms of the intra- and intergenerational transmission of violence as well as potential for intervention, particularly in regions with high rates of interpersonal violence such as sub-Saharan Africa. The study has three aims: 1) to identify mechanisms of violence transmission across generations and by gender through quantitative and qualitative methods; 2) to examine the effect of multiple violence experience on health outcomes, victimisation and perpetration; 3) to investigate the effect of structural risk factors on violence transmission; and 4) to examine protective interventions and policies to reduce violence and improve health outcomes. METHODS: INTERRUPT_VIOLENCE is a mixed-methods three-generational longitudinal study. It builds on a two-wave existing cohort study of 1665 adolescents in South Africa interviewed in 2010/11 and 2011/12. For wave three and possible future waves, the original participants (now young adults), their oldest child (aged 6+), and their former primary caregiver will be recruited. Quantitative surveys will be carried out followed by qualitative in-depth interviews with a subset of 30 survey families. Adults will provide informed consent, while children will be invited to assent following adult consent for child participation. Stringent distress and referral protocols will be in place for the study. Triangulation will be used to deepen interpretation of findings. Qualitative data will be analysed thematically, quantitative data using advanced longitudinal modelling. Ethical approval was granted by the University of Edinburgh, University of the Witwatersrand, North-West University, and the Provincial Department of Health Mpumalanga. Results will be published in peer-reviewed journals, policy briefs, and at scientific meetings. DISCUSSION: The proposed study represents a major scientific advance in understanding the transmission and prevention of violence and associated health outcomes and will impact a critically important societal and public health challenge of our time.

The HIV Cascade of Care and Service Utilisation at Sex Work Programmes Among Female Sex Workers in South Africa.

Female sex workers (FSWs) in South Africa experience a uniquely high prevalence of HIV. We describe the HIV cascade of care (CoC) in FSWs in South Africa, and explored service utilisation at sex work programmes. A cross-sectional, study enrolled FSWs across 12 sites in South Africa. Participants were recruited using chain-referral method. Inclusion criteria: ≥ 18 years, cis-gender female, sold/transacted in sex, HIV positive. 1862 HIV positive FSWs were enrolled. 92% were known positive, 87% were on antiretroviral treatment (ART). Of those on ART, 74% were virally suppressed. Younger FSWs were significantly less likely to be on ART or virally suppressed. Female sex workers using HIV services from specialised programs were 1.4 times more likely to be virally suppressed than non-program users. The pre-COVID-19 pandemic HIV CoC amongst FSWs in South Africa shows striking improvement from previous estimates, and approaches achievement of 90:90:90 goals.

Quality of life and associated factors among people receiving second-line anti-retroviral therapy in Johannesburg, South Africa.

BACKGROUND: Studies which examine quality of life (QOL) provide important insights that are needed to understand the impacts of HIV/AIDS anti-retroviral treatment (ART), comorbid conditions and other factors on the daily activities of people living with HIV/AIDS (PLH). This study aimed to determine the inter-relationships between clinical factors, behavioural, socio-demographic variables and QOL among PLH. METHODS: The secondary analysis used data collected from 293 people living with HIV/AIDS (PLH) receiving second-line ART in Johannesburg in a clinical trial which evaluated the non-inferiority of ritonavir-boosted darunavir (DRV/r 400/100 mg) compared to ritonavir-boosted lopinavir (LPV/r) over a 48 week-period. Physical functioning, cognitive and mental QOL were measured using the Aids Clinical Trial Group questionnaire. Exploratory factor analyses were used to examine the structure, the relationships between and the construct validity of QOL items. Structural equation models which tested the a priori-hypothesised inter-relationships between QOL and other variables were estimated and goodness of fit of the models to the data was assessed. RESULTS: Patients on darunavir presented with lower pill burden. Older patients and women were more likely to report lower QOL scores. Pill burden mediated the effects of age, sex and treatment regimen on physical functioning QOL and adverse effects; the effects of age, sex, treatment regimen and adverse effects on cognitive QOL; and the effects of sex on mental QOL. CONCLUSION: QOL among PLH is associated with socio-demographic and clinical factors. Therefore, QOL could be enhanced by considering PLH characteristics, clinical factors such as regimen side-effects profile, management of comorbid conditions and mitigating risks such as potential adverse drug-to-drug interactions among patients on ART.

Addressing key gaps in implementation of mosquito larviciding to accelerate malaria vector control in southern Tanzania: results of a stakeholder engagement process in local district councils.

BACKGROUND: Larval source management was historically one of the most effective malaria control methods but is now widely deprioritized in Africa, where insecticide-treated nets (ITNs) and indoor residual spraying (IRS) are preferred. However, in Tanzania, following initial successes in urban Dar-es-Salaam starting early-2000s, the government now encourages larviciding in both rural and urban councils nationwide to complement other efforts; and a biolarvicide production-plant has been established outside the commercial capital. This study investigated key obstacles and opportunities relevant to effective rollout of larviciding for malaria control, with a focus on the meso-endemic region of Morogoro, southern Tanzania. METHODS: Key-informants were interviewed to assess awareness and perceptions regarding larviciding among designated health officials (malaria focal persons, vector surveillance officers and ward health officers) in nine administrative councils (n = 27). Interviewer-administered questionnaires were used to assess awareness and perceptions of community members in selected areas regarding larviciding (n = 490). Thematic content analysis was done and descriptive statistics used to summarize the findings. RESULTS: A majority of malaria control officials had participated in larviciding at least once over the previous three years. A majority of community members had neutral perceptions towards positive aspects of larviciding, but overall support for larviciding was high, although several challenges were expressed, notably: (i) insufficient knowledge for identifying relevant aquatic habitats of malaria vectors and applying larvicides, (ii) inadequate monitoring of programme effectiveness, (iii) limited financing, and (iv) lack of personal protective equipment. Although the key-informants reported sensitizing local communities, most community members were still unaware of larviciding and its potential. CONCLUSIONS: The larviciding programme was widely supported by both communities and malaria control officials, but there were gaps in technical knowledge, implementation and public engagement. To improve overall impact, it is important to: (i) intensify training efforts, particularly for identifying habitats of important vectors, (ii) adopt standard technical principles for applying larvicides or larval source management, (iii) improve financing for local implementation and (iv) improve public engagement to boost community awareness and participation. These lessons could also be valuable for other malaria endemic areas wishing to deploy larviciding for malaria control or elimination.

Hybrid mosquitoes? Evidence from rural Tanzania on how local communities conceptualize and respond to modified mosquitoes as a tool for malaria control.

BACKGROUND: Different forms of mosquito modifications are being considered as potential high-impact and low-cost tools for future malaria control in Africa. Although still under evaluation, the eventual success of these technologies will require high-level public acceptance. Understanding prevailing community perceptions of mosquito modification is, therefore, crucial for effective design and implementation of these interventions. This study investigated community perceptions regarding genetically-modified mosquitoes (GMMs) and their potential for malaria control in Tanzanian villages where no research or campaign for such technologies has yet been undertaken. METHODS: A mixed-methods design was used, involving: (i) focus group discussions (FGD) with community leaders to get insights on how they frame and would respond to GMMs, and (ii) structured questionnaires administered to 490 community members to assess awareness, perceptions and support for GMMs for malaria control. Descriptive statistics were used to summarize the findings and thematic content analysis was used to identify key concepts and interpret the findings. RESULTS: Nearly all survey respondents were unaware of mosquito modification technologies for malaria control (94.3%), and reported no knowledge of their specific characteristics (97.3%). However, community leaders participating in FGDs offered a set of distinctive interpretive frames to conceptualize interventions relying on GMMs for malaria control. The participants commonly referenced their experiences of cross-breeding for selecting preferred traits in domestic plants and animals. Preferred GMMs attributes included the expected reductions in insecticide use and human labour. Population suppression approaches, requiring as few releases as possible, were favoured. Common concerns included whether the GMMs would look or behave differently than wild mosquitoes, and how the technology would be integrated into current malaria control policies. The participants emphasised the importance and the challenge of educating and engaging communities during the technology development. CONCLUSIONS: Understanding how communities perceive and interpret novel technologies is crucial to the design and effective implementation of new vector control programmes. This study offers vital clues on how communities with no prior experience of modified mosquitoes might conceptualize or respond to such technologies when deployed in the context of malaria control programmes. Drawing upon existing interpretive frames and locally-resonant analogies when deploying such technologies may provide a basis for more durable public support in the future.

Effectiveness of a pre-adolescent inter-generational intervention to address HIV and obesity in South Africa, using a pretest-posttest design.

BACKGROUND: Strengthening pre-adolescents knowledge and skills through an age- and culturally-appropriate intervention could prevent health issues later in life. Early interventions could influence the trajectory of future risky behaviour, and may influence health behaviour amongst their parents. The CIrCLE of Life Initiative was developed to address HIV and obesity. We evaluated whether the combined intervention increased knowledge, enhanced skills, and/or promoted healthy behaviour among students (9-12 years old) and their parents. METHODS: The study was conducted from May to December 2018. Trained educators delivered 30-min lessons over ten consecutive weeks with 537 Grade 6 students at five government-run schools, in a district, in South Africa. Schools were purposively selected based on socioeconomic status and urban-rural classification. Students communicated with parents through shared homework activities. A pretest-posttest study design was used, with a 3-month follow up. Both groups completed self-administered paper-based questionnaires. A score of subscales was used in analysis. The pretest and posttest scores were compared for students and parents using a dependent t-test. Differences in outcomes by school quintile were compared using one-way ANOVA. RESULTS: Response rates were high for both students (80.6%) and their parents (83.4%). Statistically significant differences were observed in HIV knowledge in students pretest (mean 8.04, SD 3.10) and posttest scores (mean 10.1, SD 2.70; p < 0.01), and their parents (mean 10.32, SD 2.80 vs 11.0, SD 2.50; p < 0.01). For both students and parents, pre- and post-test obesity awareness mean scores were similar, 1.93, SD 0.92 and 2.78, SD 0.57; p < 0.01, for students; and 2.47, SD 0.82 and 2.81, SD 0.54; p < 0.01, for parents. In the posttest, statistically significant changes were also observed in both groups, enhancing skills in measuring body mass index and pulse rate, and interpreting food labels. Students had a high intention to share gained knowledge with parents who had a high intention to receive it (89.4 and 89.5%, respectively). CONCLUSION: The intervention increased knowledge about HIV and obesity-related awareness, and it enhanced skills in selected outcomes among pre-adolescents and parents. Accurate messages and enhanced communication skills could support inter-generational knowledge transfer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04307966 retrospectively registered on 12 March 2020.

Prevalence and factors associated with PTSD among female urban slum dwellers in Ibadan, Nigeria: a cross-sectional study.

BACKGROUND: Little is known about the prevalence of and factors associated with PTSD among adult females in Nigeria, particularly those who live in slums. PTSD is a mental health condition that develops among some individuals who experience or witness a traumatic event. Several other factors could place individuals at heightened risk of PTSD including stress and comorbid mental disorders. Therefore, this study aimed to examine the prevalence and factors associated with PTSD among female urban slum dwellers in Ibadan, Nigeria. METHODS: We conducted a cross sectional survey using multistage sampling of 550 women aged 18 and above from selected slums. Interviewer administered questionnaires were used to elicit information on experience of childhood trauma, recent stressors, intimate partner violence, other mental disorders, sociodemographic characteristics and PTSD. PTSD was measured using the Harvard Trauma Questionnaire (HTQ) which is based on DSM IV. A multivariable linear regression model was built to test associations between PTSD and independent variables. RESULTS: The prevalence for PTSD was found to be 4.18% and the mean PTSD score was 5.80 ± 7.11. Sexual abuse in childhood, past year intimate partner violence and anxiety were significantly associated with higher PTSD scores. PTSD was not significantly associated with a history of recent stressors. Education, employment and marital status were not associated with PTSD however, age and wealth index showed marginal association with PTSD. CONCLUSION: The prevalence of PTSD among women living in Ibadan slums was relatively low. Both child sexual abuse and intimate partner violence can be prevented. We also recommend longitudinal studies to better understand risk and protective factors.

"Knowledge I seek because culture doesn't work anymore It doesn't work, death comes": the experiences of third-generation female caregivers (gogos) in South Africa discussing sex, sexuality and HIV and AIDS with children in their care.

BACKGROUND: Sexual reproductive health communication between parents and children has been shown to promote safer sexual choices. In many South African households, third-generation female caregivers, often grandmothers or other older females, locally known as gogos, are primary caregivers of children due to parents being deceased or absent. Subsequently, the responsibility of talking about sex and related issues has shifted to these gogos. This study explored the experiences of gogos living in Alexandra, Johannesburg on talking about sex, sexuality and HIV and AIDS with children aged 10-18 years that are in their care. METHODS: Ten primary caregivers were purposively selected. Data were collected through in-depth individual interviews. Thematic analysis was performed and inductive codes and themes identified. RESULTS: All gogos selected found it difficult to discuss sex, sexuality and HIV and AIDS due to culture and traditional values impacting on personal experiences as well as generation and gender barriers. Perceived low self-efficacy due to low levels of knowledge and limited skills in speaking about sex, sexuality and HIV and AIDS also contributed to low levels of sexual reproductive health communication. CONCLUSIONS: This study highlights the need for interventions that focus on improving gogos' knowledge about sexual reproductive health in addition to providing them with the skills to talk about sex, sexuality and HIV and AIDS with children in their care.

Health promotion capacity and institutional systems: an assessment of the South African Department of Health.

Health promotion (HP) capacity of staff and institutions is critical for health-promoting programmes to address social determinants of health and effectively contribute to disease prevention. HP capacity mapping initiatives are the first step to identify gaps to guide capacity strengthening and inform resource allocation. In low-and-middle-income countries, there is limited evidence on HP capacity. We assessed collective and institutional capacity to prioritize, plan, deliver, monitor and evaluate HP within the South African Department of Health (DoH). A concurrent mixed methods study that drew on data collected using a participatory HP capacity assessment tool. We held five 1-day workshops (one national, two provincial and two districts) with DoH staff (n = 28). Participants completed self-assessments of collective capacity across three areas: technical, coordinating and systems capacity using a four-point Likert scale. HP capacity scores were analysed and presented as means with standard deviations (SDs). Thematic analysis of verbatim transcripts of audio-recorded group discussions that provided rationale and evidence for scores were conducted using deductive and inductive codes. At all levels, groups revealed that capacity to develop long-term, sustainable HP interventions was limited. We found limited collaboration between national and provincial HP levels. There was limited monitoring of HP indicators in the health information system. Coordination of HP efforts across different sectors was largely absent. Lack of capacity in budgeting emerged as a major challenge, with few resources available to conduct HP activities at any level. Overall, the capacity mean score was 2.08/4.00 (SD = 0.83). There is need to overcome institutional barriers, and strengthen capacity for HP implementation, support and evaluation within the South African DoH.

Opinions of key stakeholders on alternative interventions for malaria control and elimination in Tanzania.

BACKGROUND: Malaria control in Tanzania currently relies primarily on long-lasting insecticidal nets and indoor residual spraying, alongside effective case management and behaviour change communication. This study explored opinions of key stakeholders on the national progress towards malaria elimination, the potential of currently available vector control interventions in helping achieve elimination by 2030, and the need for alternative interventions that could be used to supplement malaria elimination efforts in Tanzania. METHODS: In this exploratory qualitative study, Focus group discussions were held with policy-makers, regulators, research scientists and community members. Malaria control interventions discussed were: (a) improved housing, (b) larval source management, (c) mass drug administration (MDA) with ivermectin to reduce vector densities, (d) release of modified mosquitoes, including genetically modified or irradiated mosquitoes, (e) targeted spraying of mosquito swarms, and (f) spatial repellents. RESULTS: Larval source management and spatial repellents were widely supported across all stakeholder groups, while insecticide-spraying of mosquito swarms was the least preferred. Support for MDA with ivermectin was high among policy makers, regulators and research scientists, but encountered opposition among community members, who instead expressed strong support for programmes to improve housing for poor people in high transmission areas. Policy makers, however, challenged the idea of government-supported housing improvement due to its perceived high costs. Techniques of mosquito modification, specifically those involving gene drives, were viewed positively by community members, policy makers and regulators, but encountered a high degree of scepticism among scientists. Overall, policy-makers, regulators and community members trusted scientists to provide appropriate advice for decision-making. CONCLUSION: Stakeholder opinions regarding alternative malaria interventions were divergent except for larval source management and spatial repellents, for which there was universal support. MDA with ivermectin, housing improvement and modified mosquitoes were also widely supported, though each faced concerns from at least one stakeholder group. While policy-makers, regulators and community members all noted their reliance on scientists to make informed decisions, their reasoning on the benefits and disadvantages of specific interventions included factors beyond technical efficiency. This study suggests the need to encourage and strengthen dialogue between research scientists, policy makers, regulators and communities regarding new interventions.

Predictors and Patterns of Transactional Sex with Casual Partners Among Adult Men Living in an Informal Urban Area, South Africa.

Few studies have explored the relationship between transactional sex and HIV in adult men, with even fewer exploring the predictors of providing money or goods in exchange for sex. This study aimed to characterise the predictors and patterns of transactional sex in adult men in an urban informal area in South Africa. We used baseline, cross-sectional data from a study of 2406 men aged 18-40 years from an urban informal area. Past year transactional sex was assessed through questions adapted from those used previously. Controlling behaviour was measured using an adapted Sexual Relationship Power Scale. Multivariable logistic regression was used to determine associations between transactional sex and other potential explanatory variables. Nearly half (47%) of respondents who had ever had sex reported at least one type of transactional sex with a casual partner in the past year. A third of men provided support or money for a sex partner's family, 30% provided cash and 28% provided somewhere to stay. Controlling for other factors, men with higher levels of controlling behaviour had nearly double the odds of engaging in transactional sex. Men reporting three or more sexual partners had significantly higher odds of engaging in transactional sex. Hazardous drinkers had 33% higher odds of engaging in transactional sex. Men's provision of money or goods in exchange for sex with women is related to other high-risk behaviours, such as multiple sexual partners, hazardous drinking and controlling behaviour. To address transactional sex-related HIV risks, programming should address harmful masculinities, including relationship control.

Implementing without guidelines, learning at the coalface: a case study of health promoters in an era of community health workers in South Africa.

BACKGROUND: Internationally, there has been renewed focus on primary healthcare (PHC). PHC revitalisation is one of the mechanisms to emphasise health promotion and prevention. However, it is not always clear who should lead health promotion activities. In some countries, health promotion practitioners provide health promotion; in others, community health workers (CHWs) are responsible. South Africa, like other countries, has embarked on reforms to strengthen PHC, including a nationwide CHW programme - resulting in an unclear role for pre-existing health promoters. This paper examined the tension between these two cadres in two South African provinces in an era of primary health reform. METHODOLOGY: We used a qualitative case study approach. Participants were recruited from the national, provincial, district and facility levels of the health system. Thirty-seven face-to-face in-depth interviews were conducted with 16 health promotion managers, 12 health promoters and 13 facility managers during a 3-month period (November 2017 to February 2018). Interviews were audio-recorded and transcribed verbatim. Both inductive and deductive thematic content analysis approaches were used, supported by MAXQDA software. RESULTS: Two South African policy documents, one on PHC reform and the other on health promotion, were introduced and implemented without clear guidelines on how health promoter job descriptions should be altered in the context of CHWs. The introduction of CHWs triggered anxiety and uncertainty among some health promoters. However, despite considerable role overlap and the absence of formal re-orientation processes to re-align their roles, some health promoters have carved out a role for themselves, supporting CHWs (for example, providing up-to-date health information, jointly discussing how to assist with health problems in the community, providing advice and household-visit support). CONCLUSIONS: This paper adds to recent literature on the current wave of PHC reforms. It describes how health promoters are 'working it out' on the ground, when the policy or process do not provide adequate guidance or structure. Lessons learnt on how these two cadres could work together are important, especially given the shortage of human resources for health in low- and middle-income settings. This is a missed opportunity, researchers and policy-makers need to think more about how to feed experience/tacit knowledge up the system.

Relationship power and HIV sero-status: an analysis of their relationship among low-income urban Zimbabwean postpartum women.

BACKGROUND: HIV disproportionately infects women in many regions. Zimbabwe is one of the countries, most heavily affected. Unequal gender power relations between men and women can increase women's vulnerability to HIV. The aim of this paper was to determine the relationship between gender power and HIV sero-status among postpartum women in Zimbabwe. METHODOLOGY: A cross-sectional survey was conducted among 2042 women aged 15-49 years, attending postnatal-care at six public primary health care clinics in low-income urban communities of Harare in 2011. Women were asked about relationship power factors using an interviewer-administered questionnaire. The questionnaire included adapted WHO multi-country study items, which measure partner violence perpetrated against women. HIV status data were based on rapid HIV diagnostic tests done during earlier antenatal visits. The analysis was restricted to women with known HIV test results (n = 1951). Multivariable logistic regression analyses were performed to assess the predictors of HIV and relationship power factors. RESULTS: HIV prevalence was 15.3% (n = 299/1951). Three quarters of the women (76.9%, n = 1438/1871) reported some level of relationship control in their current/most recent intimate relationship. HIV positive women reported higher levels of control by the male partner in their intimate relationships. In adjusted models, the study found a significant association between relationship-control by the male partner and women's HIV status (AOR 1.11, 95% CI 1.01-1.22), and the decision-making dimensions of relationship power. Although there were indications of high male partner control in participants' intimate relationships, some women still had agency, as they were able to make independent decisions to fall pregnant. These women were less likely to be HIV positive (AOR 0.54, 95% CI 0.29-1.00). Having a partner who ever refused use of a family planning method was associated with increased odds of having a positive HIV status among the postpartum women (AOR 1.88, 95% CI 1.20-2.90). CONCLUSION: Unequal gender power relations continue to be a risk factor for heterosexual transmission of HIV. This suggests that prevention efforts have not successfully resulted in gender equality. HIV prevention interventions should address gender power dynamics to help curb the disproportionate HIV burden among women.

Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study.

BACKGROUND: The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries. METHODS: In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins. RESULTS: In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age. CONCLUSIONS: This study found that being a virgin, multiple perpetration rape and the examiner's qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

Obesogenic Environments: Access to and Advertising of Sugar-Sweetened Beverages in Soweto, South Africa, 2013.

INTRODUCTION: Rates of obesity and overweight among South Africans are increasing. Food marketing has a profound impact on children and affects their lifelong eating patterns; in urban areas of South Africa, disposable incomes are growing and ultra-processed food is increasingly available at low cost. The combination of these factors will strain an already fragile health system. Our aim was to investigate the density of outdoor sugar sweetened beverage (SSB) advertising and the number of formal and informal vendors selling SSBs in a transforming, historically disadvantaged urban setting of South Africa. METHODS: A digital camera and global positioning system navigation system were used to record the location of SSB advertisements and food vendors in a demarcated area in Soweto. Data were collected by walking or driving through each street; a food inventory was completed for every food vendor. Spatial analyses were conducted using a geographic information system. RESULTS: A total of 145 advertisements for SSBs were found over a driven or walked distance of 111.9 km. The density of advertisements was 3.6 per km(2) in relation to schools, and 50% of schools had branded advertising of SSBs on their school property. Most (n = 104; 58%) of the 180 vendors in the study sold SSBs. CONCLUSION: This is the first study in South Africa to document the location of billboard advertisements and vendors in relation to schools. Marketing of products that contribute to obesity is common in urban Soweto. Our findings have implications for policies that regulate SSB advertising, especially in the proximity of schools.

Women's experiences leaving abusive relationships: a shelter-based qualitative study.

Intimate partner violence is a worldwide problem. South Africa has one of the highest rates of intimate partner violence and therefore requires effective and sustainable approaches to prevention and response. For abused women, the process of leaving an intimate partner is difficult and mired in an abundance of complex factors that influence decision making. This qualitative study explored women's experiences of leaving abusive homes and relationships and the critical factors that pushed them to leave. In-depth interviews were conducted with 11 adult women who had experienced partner abuse and were residents of a shelter in Gauteng Province, South Africa. All interviews were audio-taped with consent, translated where necessary and transcribed verbatim. Thematic analysis of interviews was carried out. Two themes emerged as being instrumental to leaving: 'a phase of change' and the 'process of leaving the abusive relationship'. Leaving an abusive relationship was found to be a complex process that did not necessarily imply the end of the relationship and it reflected women's changing attitudes over time. Awareness of shelters and social support was found to be critical in facilitating departure from abusive relationships.