Conceptualisations of "good care" within informal caregiving networks for older people in rural South Africa.

Good care in social policy statements is commonly implied as familial and person-centred, provided by family members and focused on upholding the autonomy, dignity and respect of the care recipient. Policy consideration of the relational nature of caregiving, the sociomaterial determinants of good care, the practical knowledge of caregivers and responsibilities of the state, is limited. Drawing on the ethics of care theory and a care ecology framework, which conceptualises the dynamic interactions between formal and informal care "systems," we analysed ethnographic data of the interactions of 21 caregivers and their older care recipients in South Africa to understand how they conceptualised good care. Conceptualisations of good care included: having the right, altruistic and reciprocal, motivations; providing care frequently and consistently; and demonstrating hope for a better future through practical action. Caregivers also considered restricting autonomy a feature of good care, when doing so was perceived to be in the care recipient's best interest. Conceptualisations of good care were influenced by but also countered policy and cultural ideals. When they subverted policy values and practices, by overriding autonomy, for instance, caregivers' conceptualisations reflected their practical experiences of caregiving amidst gross material inadequacies, underpinned by deficiencies in the formal care system. We highlight the need for policies, interventions and theories of care that focus broadly on the care ecology and particularly on the "carescape" (formal care system). We advocate relational approaches that consider and balance the needs, desires and rights of caregivers and care recipients, and recognise caregivers' experiential knowledge, rather than person-centred approaches that focus exclusively on the care recipient.

Sexual victimisation, peer victimisation, and mental health outcomes among adolescents in Burkina Faso: a prospective cohort study.

BACKGROUND: Sexual victimisation and peer victimisation are pervasive and increase risk for mental illness. Longitudinal studies that compare their unique and cumulative effects are scarce and have been done predominantly in high-income countries. The aims of this study were to examine the prevalence, prospective associations, and gender differences in sexual and peer victimisation and mental health in a low-income, African setting. METHODS: In this prospective cohort study, data were obtained from the 2017 ARISE Adolescent Health Study, a population-representative, two-wave, prospective study of adolescents (aged 12-20 years) from Burkina Faso. A random sample of adolescents was drawn from ten villages, selected to capture the five main ethnic groups, and from one of the seven sectors of Nouna town, Burkina Faso, at two timepoints: Nov 12 to Dec 27, 2017, and Nov 15 to Dec 20, 2018. Standardised interviews were conducted in French or a local language by trained researchers. We measured victimisation exposure as sexual victimisation, peer victimisation, and polyvictimisation, using lifetime frequency of exposure, and we measured mental health symptoms and disorders using the Kutcher Adolescent Depression Scale, the Primary Care Post-Traumatic Stress Disorder screen IV and 5, and a question on lifetime self-harm and number of incidents in the past year. We calculated prevalence of victimisation and mental health symptoms and disorders at the two timepoints, and we used lifetime victimisation at the first timepoint to predict mental health at the second timepoint using logistic and negative binomial regressions. Gender differences were examined using interaction terms. FINDINGS: Of 2544 eligible adolescents, 1644 participated at time 1 and 1291 participated at time 2. The final sample with data at both timepoints included 1160 adolescents aged 12-20 years (mean 15·1, SE 0·2), of whom 469 (40·4%) were girls and 691 (59·6%) were boys. The majority ethnic group was Dafin (626 [39·1%]), followed by Bwaba (327 [20·5%]), Mossi (289 [16·0%]), Samo (206 [13·0%]), Peulh (166 [9·7%]), and other (30 [1·6%]). After survey weight adjustment, sexual victimisation (weighted percentages, time 1, 256 [13·8%] of 1620; time 2, 93 [7·2%] of 1264) and peer victimisation (weighted percentages, time 1, 453 [29·9%] of 1620; time 2, 272 [21·9%] of 1264) were common, whereas polyvictimisation was more rare (weighted percentages, time 1, 116 [6·6%] of 1620; time 2, 76 [5·7%] of 1264). Longitudinally, sexual victimisation was associated with probable clinical disorder (adjusted odds ratio 2·59, 95% CI 1·15-5·84), depressive symptoms (adjusted incidence rate ratio [aIRR] 1·39, 95% CI 1·12-1·72), and symptoms of post-traumatic stress disorder (aIRR 2·34, 1·31-4·16). Peer victimisation was associated with symptoms of post-traumatic stress disorder (aIRR 1·89, 1·13-3·17) and polyvictimisation was associated with depressive symptoms (aIRR 1·34, 1·01-1·77). Girls reported more sexual victimisation (weighted percentages, 130 [17·3%] of 681 vs 126 [11·4%] of 939), boys reported more peer victimisation (weighted percentages, 290 [33·1%] of 939 vs 163 [25·2%] of 681), and there was a significant interaction between lifetime victimisation and gender for probable clinical disorder (F [degrees of freedom 7, sample 376] 2·16; p=0·030). INTERPRETATION: Sexual and peer victimisation were common in the study setting and increased risk for mental health problems. Adolescent girls who have been sexually victimised are especially at risk of mental health problems. Interventions targeting sexual and peer violence in low-income settings are needed. FUNDING: Alexander von Humboldt Foundation, the Wellcome Trust, Fondation Botnar, and Harvard TH Chan School of Public Health.

Corrigendum to "Counting adolescents in: the development of an adolescent health indicator framework for population-based settings".

[This corrects the article DOI: 10.1016/j.eclinm.2023.102067.].

Prevalence of Curable Sexually Transmitted Infections in a Population-Representative Sample of Young Adults in a High HIV Incidence Area in South Africa.

BACKGROUND: Recent population-representative estimates of sexually transmitted infection (STI) prevalence in high HIV burden areas in southern Africa are limited. We estimated the prevalence and associated factors of 3 STIs among adolescents and young adults (AYA) in rural South Africa. METHODS: Between March 2020 and May 2021, a population-representative sample of AYA aged 16 to 29 years were randomly selected from a Health and Demographic Surveillance Site in rural KwaZulu-Natal, South Africa, for a 2 × 2 factorial randomized controlled trial. Participants in 2 intervention arms were offered baseline testing for gonorrhea, chlamydia, and trichomoniasis using GeneXpert. Prevalence estimates were weighted for participation bias, and logistic regression models were used to assess factors associated with STIs. RESULTS: Of 2323 eligible AYA, 1743 (75%) enrolled in the trial. Among 863 eligible for STI testing, 814 (94%) provided specimens (median age of 21.8 years, 52% female, and 71% residing in rural areas). Population-weighted prevalence estimates were 5.0% (95% confidence interval [CI], 4.2%-5.8%) for gonorrhea, 17.9% (16.5%-19.3%) for chlamydia, 5.4% (4.6%-6.3%) for trichomoniasis, and 23.7% (22.2%-25.3%) for any STI. In multivariable models, female sex (adjusted odds ratio [aOR], 2.24; 95% CI, 1.48-3.09) and urban/periurban (vs. rural) residence (aOR, 1.48; 95% CI, 1.02-2.15) were associated with STIs; recent migration was associated with lower odds of STI (aOR, 0.37; 95% CI, 0.15-0.89). Among those with an STI, 53 (31.0%) were treated within 7 days; median time to treatment was 11 days (interquartile range, 6-77 days). CONCLUSIONS: We identified a high prevalence of curable STIs among AYA in rural South Africa. Improved access to STI testing to enable etiologic diagnosis and rapid treatment is needed.

Exploring risk factors of drive for muscularity and muscle dysmorphia in male adolescents from a resource-limited setting in Burkina Faso.

In low-income countries, Muscle Dysmorphia (MD) has only been investigated in adult south African amateur-bodybuilders. To date, there is no epidemic study about MD or its cardinal symptom "drive for muscularity" (DFM) and its impact on young men's lives in African low-income settings. We analyzed a population-representative cross-sectional study of 838 adolescent males aged 12-20 in the rural northwestern Burkina Faso. Participants were assessed for MD with the research criteria of Pope and its cardinal symptom DFM based on the DFM scale (DMS). Since DFM has not been studied in a comparable sample so far, all possible influencing variables were examined exploratively in a linear regression model. Many respondents were underweight (41.5%) and few overweight (1.3%). No-one met standard clinical MD criteria. While 60.1% of 837 wished to be more muscular, only 8.7% of 824 desired a lower body-fat percentage. Regression analysis revealed that higher DMS scores were associated with greater internalization of the muscular body ideal, going to school, living in a rural area, older age, and a history of having faced sexual harassment or assault, but not with media exposure. Our results show that levels of DMS in Burkinabe adolescents were elevated. Risk factors for DFM in environmental circumstances where undernutrition and poverty are common are discussed.

Correction: Older persons experiences of healthcare in rural Burkina Faso: Results of a cross sectional household survey.

[This corrects the article DOI: 10.1371/journal.pgph.0000193.].

Challenges and achievements in the utilization of the health system among adolescents in a region of Burkina Faso particularly affected by poverty.

OBJECTIVE: Healthcare for adolescents receives little attention in low-income countries globally despite their large population share in these settings, the importance of disease prevention at these ages for later life outcomes and adolescent health needs differing from those of other ages. We therefore examined healthcare need and use among adolescents in rural Burkina Faso to identify reasons for use and gaps in provision and uptake. METHODS: We interviewed 1,644 adolescents aged 12-20 living in rural northwestern Burkina Faso in 2017. Topics included healthcare need and satisfaction with care provided. We calculated response-weighted prevalence of perceived healthcare need and utilization, then conducted multivariable regression to look at predictors of need, realized access and successful utilization based on the Andersen and Aday model. RESULTS: 43.7 [41.2 - 46.0] % of participants perceived need for healthcare at least once in the preceding 12 months - 52.0 [48.1 - 56.0] % of females and 35.6 [32.5 - 39.0] % of males. Of those with perceived need, 92.6 [90.0 - 94.3] % were able to access care and 79.0 [75.6 - 82.0] % obtained successful utilization. Need was most strongly predicted by gender, education and urbanicity, while predictors of successful use included household wealth and female guardian's educational attainment. CONCLUSION: Healthcare utilization among adolescents is low in rural Burkina Faso, but mostly thought of as sufficient with very few individuals reporting need that was not linked to care. Future objective assessment of healthcare need could help identify whether our results reflect a well-functioning system for these adolescents, or one where barriers lead to low awareness of needs or low expectations for service provision.

Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review.

OBJECTIVE: In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA. DESIGN: Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach. DATA SOURCES: A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021. ELIGIBILITY CRITERIA: Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10-24 years. DATA EXTRACTION AND SYNTHESIS: We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants. RESULTS: Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes. CONCLUSIONS: The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts. PROSPERO REGISTRATION NUMBER: CRD42021258826.

Effects of education and age on the experience of youth violence in a very low-resource setting: a fixed-effects analysis in rural Burkina Faso.

OBJECTIVE: The study aimed to investigate the effects of education and age on the experience of youth violence in low-income and middle-income country settings. DESIGN: Using a standardised questionnaire, our study collected two waves of longitudinal data on sociodemographics, health practices, health outcomes and risk factors. The panel fixed-effects ordinary least squares regression models were used for the analysis. SETTINGS: The study was conducted in 59 villages and the town of Nouna with a population of about 100 000 individuals, 1 hospital and 13 primary health centres in Burkina Faso. PARTICIPANTS: We interviewed 1644 adolescents in 2017 and 1291 respondents in 2018 who participated in both rounds. OUTCOME AND EXPOSURE MEASURES: We examined the experience of physical attacks in the past 12 months and bullying in the past 30 days. Our exposures were completed years of age and educational attainment. RESULTS: A substantial minority of respondents experienced violence in both waves (24.1% bullying and 12.2% physical attack), with males experiencing more violence. Bullying was positively associated with more education (ß=0.12; 95% CI 0.02 to 0.22) and non-significantly with older age. Both effects were stronger in males than females, although the gender differences were not significant. Physical attacks fell with increasing age (ß=-0.18; 95% CI -0.31 to -0.05) and this association was again stronger in males than females; education and physical attacks were not substantively associated. CONCLUSIONS: Bullying and physical attacks are common for rural adolescent Burkinabe. The age patterns found suggest that, particularly for males, there is a need to target violence prevention at younger ages and bullying prevention at slightly older ones, particularly for those remaining in school. Nevertheless, a fuller understanding of the mechanisms behind our findings is needed to design effective interventions to protect youth in low-income settings from violence.

Thetha Nami ngithethe nawe (Let's Talk): a stepped-wedge cluster randomised trial of social mobilisation by peer navigators into community-based sexual health and HIV care, including pre-exposure prophylaxis (PrEP), to reduce sexually transmissible HIV amongst young people in rural KwaZulu-Natal, South Africa.

BACKGROUND: Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality and incidence. Effective ART based prevention has not translated into population-level impact in southern Africa due to sub-optimal coverage among youth. We aim to investigate the effectiveness, implementation and cost effectiveness of peer-led social mobilisation into decentralised integrated HIV and sexual reproductive health (SRH) services amongst adolescents and young adults in KwaZulu-Natal (KZN). METHODS: We are conducting a type 1a hybrid effectiveness/implementation study, with a cluster randomized stepped-wedge trial (SWT) to assess effectiveness and a realist process evaluation to assess implementation outcomes. The SWT will be conducted in 40 clusters in rural KZN over 45 months. Clusters will be randomly allocated to receive the intervention in period 1 (early) or period 2 (delayed). 1) Intervention arm: Resident peer navigators in each cluster will approach young men and women aged 15-30 years living in their cluster to conduct health, social and educational needs assessment and tailor psychosocial support and health promotion, peer mentorship, and facilitate referrals into nurse led mobile clinics that visit each cluster regularly to deliver integrated SRH and differentiated HIV prevention (HIV testing, UTT for those positive, and PrEP for those eligible and negative). Standard of Care is UTT and PrEP delivered to 15-30 year olds from control clusters through primary health clinics. There are 3 co-primary outcomes measured amongst cross sectional surveys of 15-30 year olds: 1) effectiveness of the intervention in reducing the prevalence of sexually transmissible HIV; 2) uptake of universal risk informed HIV prevention intervention; 3) cost of transmissible HIV infection averted. We will use a realist process evaluation to interrogate the extent to which the intervention components support demand, uptake, and retention in risk-differentiated biomedical HIV prevention. DISCUSSION: The findings of this trial will be used by policy makers to optimize delivery of universal differentiated HIV prevention, including HIV pre-exposure prophylaxis through peer-led mobilisation into community-based integrated adolescent and youth friendly HIV and sexual and reproductive health care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier-NCT05405582. Registered: 6th June 2022.

Counting adolescents in: the development of an adolescent health indicator framework for population-based settings.

Changing realities in low- and middle-income countries (LMICs) in terms of inequalities, urbanization, globalization, migration, and economic adversity shape adolescent development and health, as well as successful transitions between adolescence and young adulthood. It is estimated that 90% of adolescents live in LMICs in 2019, but inadequate data exist to inform evidence-based and concerted policies and programs tailored to address the distinctive developmental and health needs of adolescents. Population-based data surveillance such as Health and Demographic Surveillance Systems (HDSS) and school-based surveys provide access to a well-defined population and provide cost-effective opportunities to fill in data gaps about adolescent health and well-being by collecting population-representative longitudinal data. The Africa Research Implementation Science and Education (ARISE) Network, therefore, systematically developed adolescent health and well-being indicators and a questionnaire for measuring these indicators that can be used in population-based LMIC settings. We conducted a multistage collaborative and iterative process led by network members alongside consultation with health-domain and adolescent health experts globally. Seven key domains emerged from this process: socio-demographics, health awareness and behaviors; nutrition; mental health; sexual and reproductive health; substance use; and healthcare utilization. For each domain, we generated a clear definition; rationale for inclusion; sub-domain descriptions, and a set of questions for measurement. The ARISE Network will implement the questionnaire longitudinally (i.e., at two time-points one year apart) at ten sites in seven countries in sub-Saharan Africa and two countries in Asia. Integrating the questionnaire within established population-based data collection platforms such as HDSS and school settings can provide measured experiences of young people to inform policy and program planning and evaluation in LMICs and improve adolescent health and well-being.

Prevalence and correlates of adolescent self-injurious thoughts and behaviors: A population-based study in Burkina Faso.

Self-injurious thoughts and behaviors (SITBs) are a growing concern among youth in sub-Saharan Africa, but their prevalence and correlates in this region are poorly understood. We therefore examined self-reported SITBs in a population-representative sample of youth in rural Burkina Faso. We used interviews from 1,538 adolescents aged 12 to 20 years living in 10 villages and 1 town in northwestern Burkina Faso. Adolescents were asked about their experiences with suicidal and nonsuicidal SITBs, adverse environmental factors, psychiatric symptoms, and interpersonal-social experiences. SITBs included lifetime prevalence of life is not worth living, passive suicide ideation, active suicide ideation, and nonsuicidal self-injury (NSSI). After describing SITB prevalence, we ran logistic and negative binomial regression models to predict SITBs. Weighted lifetime SITB prevalence estimates were: 15.6% (95% confidence interval [CI]: 13.7-18.0) for NSSI; 15.1% (95% CI: [13.2, 17.0]) for life is not worth living; 5.0% (95% CI [3.9, 6.0]) for passive suicide ideation; and 2.3% (95% CI [1.6, 3.0]) for active suicide ideation. Prevalence of life is not worth living increased with age. All four SITBs were significantly positively associated with mental health symptoms (depression symptoms, probable posttraumatic stress disorder) and interpersonal-social experiences (peer and social connectedness, physical assault, sexual assault and unwanted sexual experiences). Females were significantly more likely to report that their life was not worth living compared to males (aOR = 0.68; 95% CI [0.48, 0.96]). There is a high prevalence of SITBs among youth in rural Burkina Faso, most notably NSSI and life is not worth living, with interpersonal-social factors being the strongest predictors. Our results highlight the need for longitudinal SITB assessment to understand how risk for SITBs operates in resource-constrained settings, and to design interventions to mitigate risk. Given low school enrollment in rural Burkina Faso, it will be important to consider youth suicide prevention and mental health initiatives that are not school-based.

COVID-19 vaccine uptake, confidence and hesitancy in rural KwaZulu-Natal, South Africa between April 2021 and April 2022: A continuous cross-sectional surveillance study.

High COVID-19 vaccine hesitancy in South Africa limits protection against future epidemic waves. We evaluated how vaccine hesitancy and its correlates evolved April 2021-April 2022 in a well-characterized rural KwaZulu-Natal setting. All residents aged >15 in the Africa Health Research Institute's surveillance area were invited to complete a home-based, in-person interview. We described vaccine uptake and hesitancy trends, then evaluated associations with pre-existing personal factors, dynamic environmental context, and cues to action using ordinal logistic regression. Among 10,011 respondents, vaccine uptake rose as age-cohorts became vaccine-eligible before levelling off three months post-eligibility; younger age-groups had slower uptake and plateaued faster. Lifetime receipt of any COVID-19 vaccine rose from 3.0% in April-July 2021 to 32.9% in January-April 2022. Among 7,445 unvaccinated respondents, 47.7% said they would definitely take a free vaccine today in the first quarter of the study time period, falling to 32.0% in the last. By March/April 2022 only 48.0% of respondents were vaccinated or said they would definitely would take a vaccine. Predictors of lower vaccine hesitancy included being male (adjusted odds ratio [aOR]: 0.70, 95% confidence interval [CI]: 0.65-0.76), living with vaccinated household members (aOR:0.65, 95%CI: 0.59-0.71) and knowing someone who had had COVID-19 (aOR: 0.69, 95%CI: 0.59-0.80). Mistrust in government predicted greater hesitancy (aOR: 1.47, 95%CI: 1.42-1.53). Despite several COVID-19 waves, vaccine hesitancy was common in rural South Africa, rising over time and closely tied to mistrust in government. However, interpersonal experiences countered hesitancy and may be entry-points for interventions.

Evaluating use of mass-media communication intervention 'MTV-Shuga' on increased awareness and demand for HIV and sexual health services by adolescent girls and young women in South Africa: an observational study.

OBJECTIVE: To investigate the effect of exposure to MTV Shuga:Down South' (MTVShuga-DS) during the scale-up of combination HIV-prevention interventions on awareness and uptake of sexual reproductive health (SRH) and HIV-prevention services by adolescent girls and young women (AGYW). DESIGN: One longitudinal and three cross-sectional surveys of representative samples of AGYW. SETTING: AGYW in four South African districts with high HIV prevalence (>10%) (May 2017 and September 2019). PARTICIPANTS: 6311 AGYW aged 12-24. MEASURES: Using logistic regression, we measured the relationship between exposure to MTV Shuga-DS and awareness of pre-exposure prophylaxis (PrEP), condom use at last sex, uptake of HIV-testing or contraception, and incident pregnancy or herpes simplex virus 2 (HSV-2) infection. RESULTS: Within the rural cohort 2184 (85.5%) of eligible sampled individuals were enrolled, of whom 92.6% had at least one follow-up visit; the urban cross-sectional surveys enrolled 4127 (22.6%) of eligible sampled individuals. Self-report of watching at least one MTV Shuga-DS episode was 14.1% (cohort) and 35.8% (cross-section), while storyline recall was 5.5% (cohort) and 6.7% (cross-section). In the cohort, after adjustment (for HIV-prevention intervention-exposure, age, education, socioeconomic status), MTVShuga-DS exposure was associated with increased PrEP awareness (adjusted OR (aOR) 2.06, 95% CI 1.57 to 2.70), contraception uptake (aOR 2.08, 95% CI 1.45 to 2.98) and consistent condom use (aOR 1.84, 95% CI 1.24 to 2.93), but not with HIV testing (aOR 1.02, 95% CI 0.77 to 1.21) or acquiring HSV-2 (aOR 0.92, 95% CI 0.61 to 1.38). In the cross-sections, MTVShuga-DS was associated with greater PrEP awareness (aOR 1.7, 95% CI 1.20 to 2.43), but no other outcome. CONCLUSIONS: Among both urban and rural AGYW in South Africa, MTVShuga-DS exposure was associated with increased PrEP awareness and improved demand for some HIV prevention and SRH technologies but not sexual health outcomes. However, exposure to MTVShuga-DS was low. Given these positive indications, supportive programming may be required to raise exposure and allow future evaluation of edu-drama impact in this setting.

Community Health Worker Use of Smart Devices for Health Promotion: Scoping Review.

BACKGROUND: Community health workers (CHWs) have become essential to the promotion of healthy behaviors, yet their work is complicated by challenges both within and beyond their control. These challenges include resistance to the change of existing behaviors, disbelief of health messages, limited community health literacy, insufficient CHW communication skills and knowledge, lack of community interest and respect for CHWs, and CHWs' lack of adequate supplies. The rising penetration of "smart" technology (eg, smartphones and tablets) in low- and middle-income countries facilitates the use of portable electronic devices in the field. OBJECTIVE: This scoping review examines to what extent mobile health in the form of smart devices may enhance the delivery of public health messages in CHW-client interactions, thereby addressing the aforementioned challenges and inducing client behavior change. METHODS: We conducted a structured search of the PubMed and LILACS databases using subject heading terms in 4 categories: technology user, technology device, use of technology, and outcome. Eligibility criteria included publication since January 2007, CHWs delivering a health message aided by a smart device, and face-to-face communication between CHWs and clients. Eligible studies were analyzed qualitatively using a modified version of the Partners in Health conceptual framework. RESULTS: We identified 12 eligible studies, 10 (83%) of which used qualitative or mixed methods approaches. We found that smart devices mitigate challenges encountered by CHWs by improving their knowledge, motivation, and creativity (eg, through self-made videos); their status within the community; and the credibility of their health messages. The technology stimulated interest in both CHWs and clients-and sometimes even in bystanders and neighbors. Media content produced locally or reflecting local customs was strongly embraced. Yet, the effect of smart devices on the quality of CHW-client interactions was inconclusive. Interactions suffered as CHWs were tempted to replace educational conversations with clients by passively watching video content. Furthermore, a series of technical difficulties experienced especially by older and less educated CHWs compromised some of the advantages brought about by mobile devices. Adequate CHW training ameliorated these difficulties. Only 1 study (8%) considered client health behavior change as an end point, thus revealing a major research gap. CONCLUSIONS: Smart mobile devices may augment CHWs' field performance and enhance face-to-face interactions with clients, yet they also generate new challenges. The available evidence is scarce, mostly qualitative, and focused on a limited range of health outcomes. Future research should include larger-scale interventions across a wide range of health outcomes and feature client health behavior change as an end point.

Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study.

Background: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success. Methods: We therefore designed a cohort study (named Sixhumene or 'we are connected') to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people's sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions. Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.

Correcting for selection bias in HIV prevalence estimates: an application of sample selection models using data from population-based HIV surveys in seven sub-Saharan African countries.

INTRODUCTION: Population-based biomarker surveys are the gold standard for estimating HIV prevalence but are susceptible to substantial non-participation (up to 30%). Analytical missing data methods, including inverse-probability weighting (IPW) and multiple imputation (MI), are biased when data are missing-not-at-random, for example when people living with HIV more frequently decline participation. Heckman-type selection models can, under certain assumptions, recover unbiased prevalence estimates in such scenarios. METHODS: We pooled data from 142,706 participants aged 15-49 years from nationally representative cross-sectional Population-based HIV Impact Assessments in seven countries in sub-Saharan Africa, conducted between 2015 and 2018 in Tanzania, Uganda, Malawi, Zambia, Zimbabwe, Lesotho and Eswatini. We compared sex-stratified HIV prevalence estimates from unadjusted, IPW, MI and selection models, controlling for household and individual-level predictors of non-participation, and assessed the sensitivity of selection models to the copula function specifying the correlation between study participation and HIV status. RESULTS: In total, 84.1% of participants provided a blood sample to determine HIV serostatus (range: 76% in Malawi to 95% in Uganda). HIV prevalence estimates from selection models diverged from IPW and MI models by up to 5% in Lesotho, without substantial precision loss. In Tanzania, the IPW model yielded lower HIV prevalence estimates among males than the best-fitting copula selection model (3.8% vs. 7.9%). CONCLUSIONS: We demonstrate how HIV prevalence estimates from selection models can differ from those obtained under missing-at-random assumptions. Further benefits include exploration of plausible relationships between participation and outcome. While selection models require additional assumptions and careful specification, they are an important tool for triangulating prevalence estimates in surveys with substantial missing data due to non-participation.

The sexual and reproductive health needs of school-going young people in the context of COVID-19 in rural KwaZulu-Natal, South Africa.

Background: The impact of school closures due to COVID-19 raised widespread concerns about children's health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa.Methods: In july-November 2020 and August-November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data.Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners' SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g., contraception) increased learner pregnancies. Gender-based violence in learners' households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms).Conclusion: The COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role.

Health and economic benefits of secondary education in the context of poverty: Evidence from Burkina Faso.

Even though formal education is considered a key determinant of individual well-being globally, enrollment in secondary schooling remains low in many low- and middle-income countries, suggesting that the perceived returns to such schooling may be low. We jointly estimate survival and monetary benefits of secondary schooling using detailed demographic and surveillance data from the Boucle du Mouhoun region, Burkina Faso, where national upper secondary schooling completion rates are among the lowest globally (<10%). We first explore surveillance data from the Nouna Health and Demographic Surveillance System from 1992 to 2016 to determine long-term differences in survival outcomes between secondary and higher and primary schooling using Cox proportional hazards models. To estimate average increases in asset holdings associated with secondary schooling, we use regionally representative data from the Burkina Faso Demographic Health Surveys (2003, 2010, 2014, 2017-18; N = 3,924). Survival was tracked for 14,892 individuals. Each year of schooling was associated with a mortality reduction of up to 16% (95% CI 0.75-0.94), implying an additional 1.9 years of life expectancy for men and 5.1 years for women for secondary schooling compared to individuals completing only primary school. Relative to individuals with primary education, individuals with secondary or higher education held 26% more assets (SE 0.02; CI 0.22-0.30). Economic returns for women were 3% points higher than male returns with 10% (SE 0.03; CI 0.04-0.16) vs. 7% (SE 0.02; CI 0.02-0.012) and in rural areas 20% points higher than in urban areas with 30% (SE 0.06; CI 0.19-0.41) vs. 4% (SE 0.01; CI 0.02-0.07). Our results suggest that secondary education is associated with substantial health and economic benefits in the study area and should therefore be considered by researchers, governments, and other major stakeholders to create for example school promotion programs.

The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study.

Background: Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings.We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa. Method: We used baseline survey data from the HAALSI study ("Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa") among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members' literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health. Results: In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network. Conclusions: Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.