Negotiating sexual and gender diversity in rural and peri-urban KwaZulu-Natal, South Africa.

A noticeable tendency in the first generation of scholarship on sexual orientation and gender identity/expression (SOGIE) in Africa has been the focus on urban or modern institutional settings. A dominant theme is to document people's struggles against stigma, fear and violence to better inform interventions to strengthen human rights and sexual health for all. In some cases, unintentionally, the impression conveyed of Africa is of a continent with cultures that are uniformly, hostile to SOGIE rights. The present study arises from a large survey among boys and men in KwaZulu-Natal, South Africa that problematises that impression. The study revealed unexpectedly high levels of same-sex sexual experience among boys and men in a mostly rural, culturally conservative setting. Following from that revelation, we conducted in-depth interviews to gain insight into their lives. Informants did indeed recount many incidents of discrimination and violence and admitted to sometimes severe emotional health problems. Yet they also spoke of finding love, acceptance, allies, resources, humour and hope for the future. In this paper, we tease out key themes from the interviews in relation to trends in the scholarship.

Mental distress and substance use among rural Black South African youth who are not in employment, education or training (NEET).

BACKGROUND: South Africa (SA) has one of the highest rates of youth unemployment and youth who are not in employment, education or training (NEET), even higher among Black South Africans. SA's NEET rates are 3 times those of UK; 5.4 times of Germany; 1.3 times of Brazil; and 2.5 times of Malaysia. Given that youths between 15 and 24 years of age make up 24% of the total population, these are significant challenges for the economy and further fuel the cyclical, pervasive and enduring nature of poverty. We hypothesised that rural youth who are NEET would have a greater prevalence of mental disorders and higher rates of substance use compared to their non-NEET counterparts. The objective of the study is to determine the differences in rates of psychological distress and substance use between NEET and non-NEET rural African 14- to 24-year-old young men. METHODS: The study took place in a remote and rural district municipality in KwaZulu-Natal, South Africa. We divided the district's five sub-municipalities into two clusters (large and small) and randomly selected one from each cluster for inclusion in the study. We further randomly selected wards from each sub-municipality and then rural settlements from each ward, for inclusion in the study. We recruited young men as part of a larger study to explore sociocultural factors important in gender-based violence in rural SA. We compared 15- to 19-year old and 20- to 24-year old youth NEET and non-NEET on rates of psychological distress symptoms (depression, anxiety, suicidal thoughts, hopelessness and worthlessness) and substance misuse (including alcohol, cannabis, other recreational drugs) using a Multivariate Analysis of Variance (MANOVA) statistics at p < .005 level of significance level. RESULTS: About 23% of the 355 male participants were NEET. There were no statistically significant differences in psychological distress or substance use between youth NEET and non-NEET, controlling for age. CONCLUSION: The study highlights difficult transitions to post-secondary education and work for Black youth in rural SA where opportunities for employment are limited. Education, training and employment appear to offer limited benefit.

Distress, desperation and despair: anxiety, depression and suicidality among rural South African youth.

Common mental disorders (CMDs) affect millions of people worldwide and impose a high cost to individuals and society. Youth are disproportionately affected, as has also been confirmed in South Africa. Mental disorders and substance use disorders often occur as concurrent disorders. Although youth in rural South Africa grow up in difficult social and economic conditions, the study of mental disorders in South Africa has focussed primarily on urban populations. One such rural area in South Africa is the Harry Gwala District, where rates of interpersonal violence and self-inflicted injuries among 15-24-year-old men, are extraordinarily high. Suicide is an important proxy measure of severe emotional distress, predominantly depression and hopelessness. This study reports on rates of fatal self-harm among 15-24-year-old men in the Harry Gwala District. We determined the rates and severity of CMDs and their correlates among 355 young males ranging in age from 14 to 24 years in the Harry Gwala District community. High rates of depression, anxiety, hopelessness and worthlessness were reported. One in four of the young men and boys reported current suicidal thoughts associated with depression, anxiety, feelings of worthlessness and binge drinking. Reports of alcohol use were high, as were those of daily cannabis use. Our findings show high rates of CMDs and alcohol use, and highlight the impact of collective dysphoria on the mental well-being of rural youth in South Africa, who are likely coping through drug and alcohol use.

The salience and symbolism of numbers across cultural beliefs and practice.

Numbers are ubiquitous to modern existence and have evolved with humanity over millenia. They structure, record and quantify human behaviour, spiritual belief systems and the evolution of innovation across all spheres of life. Furthermore, cultural identities and interpersonal expression often have numerical components to them for instance rites of passage, population demography and fiscal measures. The salience of numbers in both historical and contemporary cultural life arguably plays a role in individual psyches and the experience of distress or wellness. This paper illustrates the cultural relativism of numbers through superstition and foreboding to auspiciousness in different societies. As a short hand for the quantification of multiple phenomena in low literacy to high technology populations, rural and urban societies as well as traditional and evolving societies, numbers have and will continue to be core to all cultures as they have from prehistoric to contemporary times.

Interventions for improving employment outcomes for workers with HIV.

BACKGROUND: The vast majority of people infected with human immunodeficiency virus (HIV) are adults of working age. Therefore unemployment and job loss resulting from HIV infection are major public health and economic concerns. Return to work (RTW) after diagnosis of HIV is a long and complex process, particularly if the individual has been absent from work for long periods. There have been various efforts to improve the RTW of persons living with HIV (HIV+), and many of these have been assessed formally in intervention studies. OBJECTIVES: To evaluate the effect of interventions aimed at sustaining and improving employment in HIV+ persons. SEARCH METHODS: We conducted a comprehensive search from 1981 until December 2014 in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, OSH UPDATE databases (CISDOC, HSELINE, NIOSHTIC, NIOSHTIC-2, RILOSH), and PsycINFO. SELECTION CRITERIA: We considered for inclusion all randomized controlled trials (RCTs) or controlled before-after (CBA) studies assessing the effectiveness of pharmacological, vocational and psychological interventions with HIV+ working-aged (16 years or older) participants that had used RTW or other indices of employment as outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all potential references for inclusion. We determined final selection of studies by consensus. We performed data extraction and management, as well as Risk of bias assessment, in duplicate. We measured the treatment effect using odds ratio (OR) for binary outcomes and mean difference (MD) for continuous outcomes. We applied the GRADE approach to appraise the quality of the evidence. MAIN RESULTS: We found one RCT with 174 participants and five CBAs with 48,058 participants assessing the effectiveness of vocational training (n = 1) and antiretroviral therapy (ART) (n = 5). We found no studies assessing psychological interventions. The one RCT was conducted in the United States; the five CBA studies were conducted in South Africa, India, Kenya, and Uganda. We graded all six studies as having a high risk of bias.The effectiveness of vocational intervention was assessed in only one study but we could not infer the intervention effect due to a lack of data.For pharmacological interventions, we found very low-quality evidence for a beneficial effect of ART on employment outcomes in five studies. Due to differences in outcome measurement we could only combine the results of two studies in a meta-analysis.Two studies compared employment outcomes of HIV+ persons on ART therapy to healthy controls. One study found a MD of -1.22 days worked per month (95% confidence interval (CI) -1.74 to -1.07) at 24-months follow-up. The other study found that the likelihood of being employed steadily increased for HIV+ persons compared to healthy individuals from ART initiation (OR 0.35, 95% CI 0.26 to 0.47) to three- to five-years follow-up (OR 0.73, 95% CI 0.42 to 1.28).Three other studies compared HIV+ persons on ART to HIV+ persons not yet on ART. Two studies indicated an increase in the likelihood of employment over time due to the impact of ART for HIV+ persons compared to HIV+ persons pre-ART (OR 1.75, 95% CI 1.44 to 2.12). One study found that the group on ART worked 12.1 hours more (95% CI 6.99 to 17.21) per week at 24-months follow-up than the average of the cohort of ART and pre-ART HIV+ persons which was 20.1 hours.We rated the evidence as very low quality for all comparisons due to a high risk of bias. AUTHORS' CONCLUSIONS: We found very low-quality evidence showing that ART interventions may improve employment outcomes for HIV+ persons. For vocational interventions, the one included study produced no evidence of an intervention effect. We found no studies that assessed psychological interventions. We need more high-quality, preferably randomized studies to assess the effectiveness of RTW interventions for HIV+ persons.

Interventions to reduce risky sexual behaviour for preventing HIV infection in workers in occupational settings.

BACKGROUND: The workplace provides an important avenue to prevent HIV. OBJECTIVES: To evaluate the effect of behavioral interventions for reducing HIV on high risk sexual behavior when delivered in an occupational setting. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO up until March 2011 and CINAHL, LILACS, DARE, OSH Update, and EPPI database up until October 2010. SELECTION CRITERIA: Randomised control trials (RCTs) in occupational settings or among workers at high risk for HIV that measured HIV, sexual transmitted diseases (STD), Voluntary Counseling and Testing (VCT), or risky sexual behaviour. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected studies for inclusion, extracted data and assessed risk of bias. We pooled studies that were similar. MAIN RESULTS: We found 8 RCTs with 11,164 participants but one study did not provide enough data. Studies compared VCT to no VCT and education to no intervention and to alternative education.VCT uptake increased to 51% when provided at the workplace compared to a voucher for VCT (RR=14.0 (95% CI 11.8 to16.7)). After VCT, self-reported STD decreased (RR = 0.10 (95% CI 0.01 to 0.73)) but HIV incidence (RR=1.4 (95% CI 0.7 to 2.7)) and unprotected sex (RR=0.71 (0.48 to 1.06)) did not decrease significantly. .Education reduced STDs (RR = 0.68 (95%CI 0.48 to 0.96)), unprotected sex (Standardised Mean Difference (SMD)= -0.17 (95% CI -0.29 to -0.05), sex with a commercial sex worker (RR = 0.88 (95% CI 0.81 to 0.96) but not multiple sexual partners (Mean Difference (MD) = -0.22 (95% CI -0.52 to 0.08) nor use of alcohol before sex (MD = -0.01 (95% CI of -0.11 to 0.08). AUTHORS' CONCLUSIONS: Workplace interventions to prevent HIV are feasible. There is moderate quality evidence that VCT offered at the work site increases the uptake of testing. Even though this did no lower HIV-incidence, there was a decrease in self-reported sexual transmitted diseases and a decrease in risky sexual behaviour. There is low quality evidence that educational interventions decrease sexually transmitted diseases, unprotected sex and sex with commercial sex workers but not sex with multiple partners and the use of alcohol before sex.More and better randomised trials are needed directed at high risk groups such as truck drivers or workers in areas with a very high HIV prevalence such as Southern Africa. Risky sexual behaviour should be measured in a standardised way.

Pain profiles and psychosocial distress symptoms in workers with low back pain.

PURPOSE: The current study investigated the pain profiles of patients with subacute non-specific low back pain attending an outpatient return-to-work rehabilitation programme. Differences in symptoms of distress (depression and anxiety) and return to work between the pain-profile groups were assessed. METHODS: Sixty-five volunteers who met the eligibility criteria and had complete follow-up data were included in the analysis. The mean age was 38.8 years (minimum 18, maximum 64); 38 (58.5%) were men. The median time since onset of low back pain was 30 days. Cluster analysis was used to categorize patients into groups according to pain severity scores (VAS). RESULTS: Two distinct clusters-severe pain and moderate pain-emerged. There were significant differences in depressive and anxiety symptoms between the pain profiles. Further, return-to-work rates varied significantly between the two groups (31% in the severe pain cluster compared to 90% in the moderate pain cluster). CONCLUSION: Although both groups showed significant improvements in depression and anxiety symptoms over time, the severe pain cluster scored higher at discharge (higher scores indicating worse outcomes). These results highlight the importance of early identification of sub-groups at risk so that rehabilitation interventions can be focused with the goal of minimizing long-term disability.