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Schröder H, Mataboge P, McMahon SA, Gómez-Olivé FX, Schatz EJ, Bärnighausen T, De Neve JW. "I am adhering to HIV treatment so that I can live to support her": A qualitative study of upward intergenerational support in South Africa. J Glob Health 2024; 14:04083. [PMID: 38726557 PMCID: PMC11082624 DOI: 10.7189/jogh.14.04083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Background Intergenerational family care, which was upended by the HIV epidemic in sub-Saharan Africa (SSA), may return to a pre-HIV era arrangement as access to antiretroviral therapy (ART) expands and treated adults can once again provide support for older household members. Empirical research has demonstrated positive 'spillover effects' of ART uptake from treated adults to younger generations, yet much less is known about the nature and breadth of such effects to older generations. This study explores the role and lived experiences among adults who take up ART and those of an older generation with whom they live. Methods We conducted a qualitative study consisting of semi-structured interviews (n = 46) embedded in the Agincourt Health and Demographic Surveillance System (HDSS) in rural South Africa, between July and September 2022. We purposefully sampled two respondent categories: (i) young or middle-aged adults on ART (aged 18-59 years old); and (ii) older adults (aged ≥60 years old) who were affiliated with a young or middle-aged adult on ART. We used thematic content analysis to extract, code, and categorise relevant text by types of upward spillover effects from ART in younger adults to older adults. Quantitative data was extracted from the existing Agincourt HDSS database and matched to qualitative interview data based on Clinic link unique identifiers of study participants. Results Mean age was 41 years among young or middle-aged adults (n = 29) and 72 years among older adults (n = 17). Among younger adults, time on ART ranged from five months to more than 21 years. Both young or middle-aged adults on ART and older adults reported positive spillover effects for older adults across five main tiers: caregiving, financial support, physical and mental health, living arrangements and household relationships, and stigma and reputation. Spillover challenges included financial costs and caregiving responsibilities following ART initiation of young or middle-aged adults, although these additional caregiving responsibilities were generally not perceived as particularly burdensome. Conclusions ART is likely to benefit older adults in South Africa whose families are affected by HIV. This study identified a wide range of perceived spillover effects from ART in younger adults to older adults, including improvements to upward intergenerational support. These qualitative findings offer a guide to researchers, policymakers, and donors to capitalise on the broader societal effects of a large-scale health intervention to further support family structures and meet the needs of a growing older population.
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Affiliation(s)
- Henning Schröder
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Palesa Mataboge
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shannon A McMahon
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - F Xavier Gómez-Olivé
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Enid J Schatz
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Health, College of Health Sciences, University of Missouri, Columbia, Missouri, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
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Schröder H, Yapa HM, Gómez-Olivé FX, Thirumurthy H, Seeley J, Bärnighausen T, De Neve JW. Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research. BMJ Glob Health 2023; 8:bmjgh-2022-011079. [PMID: 37068847 PMCID: PMC10111905 DOI: 10.1136/bmjgh-2022-011079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/24/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research. METHODS We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies. FINDINGS We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART. CONCLUSIONS ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.
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Affiliation(s)
- Henning Schröder
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - H Manisha Yapa
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- The Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janet Seeley
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, South Africa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, Durban, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
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Micklesfield LK, Kolkenbeck-Ruh A, Mukoma G, Prioreschi A, Said-Mohamed R, Ware LJ, Motlhatlhedi M, Wrottesley SV, Norris SA. The Healthy Aging Adult South Africa report card: a systematic review of the evidence between 2013 and 2020 for middle-aged South African men and women. Cardiovasc J Afr 2022; 33:200-219. [PMID: 35789240 PMCID: PMC9650148 DOI: 10.5830/cvja-2022-015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 03/14/2022] [Indexed: 10/03/2023] Open
Abstract
Due to the increasing non-communicable disease burden in Africa, several strategies that target the major lifestyle and physiological risk factors have been implemented to combat such diseases. The Healthy Aging Adult South Africa report card systematically reviews national and regional prevalence data of middle-aged South African adults (45-65 years) published between 2013 and 2020 on diet, physical activity, tobacco use and alcohol consumption, obesity, hypertension, dyslipidaemia and diabetes mellitus. Each indicator was assigned two grades, (1) based on the availability of prevalence data, and (2) based on whether policies have been proposed and implemented for the respective indicators. Alcohol consumption, obesity, hypertension and diabetes received an A grade for the availability of prevalence data. Tobacco use and diet received an A grade for policy and implementation. Gaps have been identified that need to be filled by future research focusing on continued surveillance of all indicators in order to inform and implement effective policies.
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Affiliation(s)
- Lisa K Micklesfield
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Andrea Kolkenbeck-Ruh
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gudani Mukoma
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alessandra Prioreschi
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rihlat Said-Mohamed
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa J Ware
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Molebogeng Motlhatlhedi
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie V Wrottesley
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane A Norris
- SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Ludwig JO, Davies NM, Bor J, De Neve JW. Causal effect of children's secondary education on parental health outcomes: findings from a natural experiment in Botswana. BMJ Open 2021; 11:e043247. [PMID: 33436473 PMCID: PMC7805356 DOI: 10.1136/bmjopen-2020-043247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES A growing literature highlights the intergenerational transmission of human capital from parents to children. However, far less is known about 'upward transmission' from children to parents. In this study, we use a 1996 Botswana education policy reform as a natural experiment to identify the causal effect of children's secondary schooling on their parents' health. SETTING Botswana's decennial census (2001 and 2011). Data were obtained through the Integrated Public Use Microdata Series and are 10% random samples of the complete population in each of these census years. PARTICIPANTS Survey respondents who were citizens born in Botswana, at least 18 years old at the time of the census and born in or after 1975 (n=89 721). PRIMARY AND SECONDARY OUTCOME MEASURES Parental survival and disability at the time of the census, separately for mothers and fathers. RESULTS The 1996 reform caused a large increase in grade 10 enrolment, inducing an additional 0.4 years of schooling for the first cohorts affected (95% CI 0.3 to 0.5, p<0.001). The reform, however, had no effect on parental survival and disability by the time exposed child cohorts reach age 30. Results were robust to a wide array of sensitivity analyses. CONCLUSIONS This study found little evidence that parents' survival and disability were affected by their offspring's educational attainment in Botswana. Parents' health may not be necessarily affected by increasing their offspring's educational attainment.
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Affiliation(s)
- Jan Ole Ludwig
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Neil M Davies
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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