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Ringwald B, Taegtmeyer M, Mwania V, Muthoki M, Munyao F, Digolo L, Otiso L, Wangui Ngunjiri AS, Karuga RN, Tolhurst R. Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya. Soc Sci Med 2023; 336:116247. [PMID: 37797544 PMCID: PMC10622644 DOI: 10.1016/j.socscimed.2023.116247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 08/03/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal urban settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies.
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Affiliation(s)
- Beate Ringwald
- ARISE Hub, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK; Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Miriam Taegtmeyer
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | | | - Mary Muthoki
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | - Faith Munyao
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | - Lina Digolo
- The Prevention Collaborative, P.O. Box 3794 00100, Nairobi, Kenya
| | - Lilian Otiso
- LVCT Health, P.O. Box 19835-00202, KNH, Nairobi, Kenya
| | | | | | - Rachel Tolhurst
- ARISE Hub, Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Mmotsa TM, Magasana V, Nsibande DF, Buthelezi M, Dassaye R, Rodriguez VJ, Jones DL, Goga AE, Ngandu NK. Mixed-methods cross-sectional study of the prevention of vertical HIV transmission program users unaware of male partner's HIV status, in six South African districts with a high antenatal HIV burden. BMC Public Health 2023; 23:1988. [PMID: 37828512 PMCID: PMC10571358 DOI: 10.1186/s12889-023-16921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 10/06/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Elimination of vertical HIV Transmission (VHT) and maternal deaths are global health priorities. Male involvement is one of the most important factors that influences women's decisions, including the uptake of Prevention of vertical HIV transmission (P-VHT). We sought to understand not knowing a male partner's HIV status (MPHIVs) amongst women using services to prevent vertical HIV transmission in six South African districts with high antenatal HIV burden. METHODS A mixed-methods cross-sectional study was conducted in six South African districts, and data collected through face-to-face interviews with women and focus group discussions (FGDs) with women or male partners. The quantitative data were analyzed using STATA SE-17.0 and an inductive approach was used for qualitative data analysis. RESULTS Overall, 28.7% of women were unaware of their MPHIVs, while 25.3% and 46.0% knew the MPHIVs was positive or negative, respectively. In multivariable logistic regression, single marital status and unplanned pregnancy increased the odds of not knowing a MPHIVs while a woman's disclosure of her HIV status to the male partner reduced the odds. FDGs highlighted complexities around MPHIVs disclosure, e.g., reluctance to test for HIV and potential interventions including healthcare worker (HCW) assisted HIV disclosure. CONCLUSION User-informed interventions to address MPHIVs non-disclosure amongst women of child-bearing age, particularly those at risk of unstable sexual partners and unplanned pregnancies, should be strengthened.
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Affiliation(s)
- Tshiamo M Mmotsa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Vuyolwethu Magasana
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Duduzile F Nsibande
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mbongeleni Buthelezi
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Reshmi Dassaye
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Psychology (Clinical/Community Division), University of Illinois at Urbana-Champaign, Champaign, IL, United States of America
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ameena E Goga
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Nobubelo K Ngandu
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
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Moss C, Smith SJ, Kim K, Hua N, Noronha N, Kavenagh M, Wekerle C. A global systematic scoping review of literature on the sexual exploitation of boys. CHILD ABUSE & NEGLECT 2023; 142:106244. [PMID: 37244784 DOI: 10.1016/j.chiabu.2023.106244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 04/26/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Sexual exploitation of children (SEC) is a widespread crime which impacts the child victim across developmental, health and well-being domains. As victims, boys have received much less clinical and research attention. While context-specific factors likely shape the SEC risk, under-recognized gender norms can deny boys' vulnerability. Professional failures to recognize and respond adequately to boys' sexual exploitation may prevent access to support. OBJECTIVE This systematic scoping review updates and broadens a previous review of literature addressing prevalence, victim/offender/facilitator characteristics, control mechanisms, as well as the health correlates and outcomes regarding sexual exploitation of boys. This review included international peer-reviewed and gray literature from 38 countries in 14 languages. PARTICIPANTS AND SETTING Studies from the years 2000 to 2022 that included samples of boys under age 18, or sex-disaggregated data for children under 18, were included. Case studies, systematic reviews, and those reporting on retrospective experiences by adults over 18 were excluded. A total of 254,744 boys were represented across 81 studies. METHODS A systematic scoping review considered qualitative and quantitative peer-reviewed publications from eight, English-language databases. English and non-English non-peer reviewed publications ('gray literature') was identified by both ECPAT International's global network of member organizations and citation chaining. RESULTS Overall, 81 peer-reviewed (n = 51) and gray literature (n = 30) documents from 38 countries were included. In total, 254,744 youth participated in peer-reviewed studies (N = 217,726) and gray literature (N = 37,018). General prevalence of sexual exploitation of boys was reported at up to 5 %, with higher rates noted in specifically vulnerable sub-populations (e.g., 10 %, trans youth; 26 %, street-connected youth). The literature indicates that sexual exploitation of boys is reported as occurring primarily between 12 and 18 years old. Multi-level factors are linked to SEC, including individual (e.g., disability status), relationship (e.g., child maltreatment, dating violence), community (e.g., community violence), and societal domains (e.g., discriminatory beliefs). SEC victimization is linked with youth mental and physical health concerns, particularly sexual health. Post-traumatic stress symptomatology or disorder was rarely evaluated. Evidence-based treatments were not available, which may be related to a lack of gender-based theoretical models for understanding SEC specifically. CONCLUSION The sexual exploitation of boys is a prevalent public health, child rights, and clinical issue. All young people experiencing sexual exploitation face sex- and gender-specific challenges, and this remains the case for boys with indications including family rejection, implicit community tolerance for abuse to service accessibility barriers. Actioning our duty to care for all children requires gender- and trauma-informed lenses. Ongoing surveillance of all forms of violence against children, with gender disaggregation, is essential for practice and policy advancement.
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Affiliation(s)
- Corinne Moss
- McMaster University, Department of Pediatrics, Hamilton, ON, Canada.
| | - Savanah Jordan Smith
- McMaster University, Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, Hamilton, ON, Canada
| | - Katherine Kim
- University of Toronto, Temerty Faculty of Medicine, Toronto, ON, Canada
| | - Nicholas Hua
- McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada
| | - Noella Noronha
- McMaster University, Department of Health Research Methods, Evidence and Impact, Hamilton, ON, Canada; McMaster University, School of Interdisciplinary Science, Hamilton, ON, Canada
| | | | - Christine Wekerle
- McMaster University, Department of Pediatrics, Hamilton, ON, Canada; McMaster University, Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, Hamilton, ON, Canada
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Ouahid H, Mansouri A, Sebbani M, Nouari N, Khachay FE, Cherkaoui M, Amine M, Adarmouch L. Gender norms and access to sexual and reproductive health services among women in the Marrakech-Safi region of Morocco: a qualitative study. BMC Pregnancy Childbirth 2023; 23:407. [PMID: 37268874 DOI: 10.1186/s12884-023-05724-0] [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: 12/15/2022] [Accepted: 05/20/2023] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Improving access to sexual and reproductive health remains a public health challenge, especially for women, whose access is affected by several determinants, such as gender inequality, which is the underlying barrier to all other determinants. Many actions have been carried out, but much remains to be done before all women and girls can exercise their rights. This study aimed to explore how gender norms influence access to sexual and reproductive health services. METHOD A qualitative study was conducted from November 2021 to July 2022. The inclusion criteria were women and men aged over 18 years old, living in the urban and rural areas of the Marrakech-Safi region in Morocco. A purposive sampling method was used to select participants. Data were obtained through semi-structured interviews and focus groups with selected participants. The data were coded and classified using thematic content analysis. RESULTS The study highlighted inequitable, restrictive gender norms that lead to stigmatization and affect the sexual and reproductive healthcare-seeking behavior and access of girls and women in the Marrakech-Safi region. These most common gender norms for women include parental refusal, stigmatization, and social exclusion of girls from sexual and reproductive health education services; strong decision-making power of family members over contraceptive use and women's adherence to pregnancy monitoring and access to supervised delivery; and culturally constructed role allocation, assigning a reproductive role to women and making them responsible for the health of new-borns. CONCLUSION Sexual and reproductive health projects must strive to be gender sensitive. Gender-blind projects are missed opportunities to improve health outcomes and advance gender equality.
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Affiliation(s)
- Hajar Ouahid
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco.
| | - Adil Mansouri
- Clinical Research Department, Mohammed VI University Hospital, Marrakech, Morocco
| | - Majda Sebbani
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
- Clinical Research Department, Mohammed VI University Hospital, Marrakech, Morocco
- Department of Public Health, Community Medicine and Epidemiology, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - Nadia Nouari
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - Fatima Ezzahra Khachay
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - Mohamed Cherkaoui
- Laboratory of Pharmacology, Neurobiology, Anthropobiology, and Environment, Faculty of Sciences Semlalia, Cadi Ayyad University, Marrakech, Morocco
| | - Mohamed Amine
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
- Clinical Research Department, Mohammed VI University Hospital, Marrakech, Morocco
- Department of Public Health, Community Medicine and Epidemiology, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
| | - Latifa Adarmouch
- Bioscience and Health Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
- Clinical Research Department, Mohammed VI University Hospital, Marrakech, Morocco
- Department of Public Health, Community Medicine and Epidemiology, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Marrakech, Morocco
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Men's Endorsement of Intimate Partner Violence and HIV Testing Behavior Across Sub-Saharan Africa. AIDS Behav 2023; 27:454-461. [PMID: 36048291 DOI: 10.1007/s10461-022-03780-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/01/2022]
Abstract
Despite an upward trend in HIV testing across sub-Saharan Africa, men continue to lag women in the use of HIV testing services. Inequitable gender attitudes held by some men may be implicated in their suboptimal HIV testing behaviors. We sought to ascertain the relationship between men?s endorsement of intimate partner violence (IPV), which is one manifestation of inequitable gender attitudes, and their lifetime and recent HIV testing, using nationally representative Demographic and Health Survey data from 23 sub-Saharan African countries. In a pooled analysis, we found that a unit increase in the IPV index scale is associated with 8% lower odds of lifetime HIV testing, and 6% lower odds of recent HIV testing. The strength of this relationship, however, varied across countries and regions. Our findings suggest that efforts to increase men?s HIV testing in the region should address the inequitable gender attitudes underpinning men?s endorsement of IPV, but that it is important to consider contextual variation.
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Community Mobilization is Associated with HIV Testing Behaviors and Their Psychosocial Antecedents Among Zambian Adults: Results from a Population-Based Study. AIDS Behav 2022; 27:1682-1693. [PMID: 36307741 PMCID: PMC10140187 DOI: 10.1007/s10461-022-03900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 12/31/2022]
Abstract
Community mobilization (CM) is a vital yet under-explored avenue for increasing HIV testing in generalized HIV epidemic settings. Using multi-stage cluster sampling, a population-based sample of 3535 Zambian adults (mean age: 28 years, 50% women) were recruited from 14 districts to complete a household survey. Exploratory factor analysis (EFA) was used to re-validate a 23-item, 5-factor CM scale. Multivariable logistic and Poisson regression were then used to identify associations of CM with HIV testing behaviors and their psychosocial antecedents. A 21-item, 3-factor ("Leadership", "Collective Action Capacity", and "Social Cohesion") CM solution emerged from EFA (Cronbach's α 0.88). Among men and in rural settings, higher CM was significantly (p < 0.05) associated with elevated odds of HIV testing and more past-year HIV testing discussion sources, controlling for socio-demographics and sexual behaviors. Results underscore the importance of prioritizing CM to cultivate more favorable environments for HIV testing uptake, especially for men and rural residents.
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Lippman SA, Pettifor A, Dufour MSK, Kabudula CW, Twine R, Peacock D, Mathebula R, Julien A, West R, Neilands TB, Wagner R, Gottert A, Gómez-Olivé FX, Rebombo D, Haberland N, Pulerwitz J, Majuba LP, Tollman S, Kahn K. A community mobilisation intervention to improve engagement in HIV testing, linkage to care, and retention in care in South Africa: a cluster-randomised controlled trial. Lancet HIV 2022; 9:e617-e626. [PMID: 36055294 PMCID: PMC10617423 DOI: 10.1016/s2352-3018(22)00192-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Community mobilisation, engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. In South Africa, current rates fall below those needed for epidemic control. We assessed whether community mobilisation increased HIV testing, linkage to care, and retention in care over time in intervention relative to control communities. METHODS We conducted a cluster-randomised controlled trial in villages in the Agincourt sub-district of the rural Mpumalanga Province in South Africa. 15 villages were randomly assigned to either a community mobilisation intervention engaging residents to address social barriers to HIV testing and treatment (intervention arm) or to a control arm using balanced randomisation. Villages were eligible if they had been fully enumerated in 2014, had not been included in previous mobilisation activities, and included over 500 permanent adult residents aged 18-49 years. Primary outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among residents of the intervention and control communities over the 3-year study period. Intention-to-treat analyses employed generalised estimating equations stratified by sex. This trial is registered with ClinicalTrials.gov, NCT02197793. FINDINGS Between Aug 1, 2015, and July 31, 2018, residents in eight intervention communities (n=20 544 residents) and seven control communities (n=17 848) contributed data; 92 residents contributed to both arms. Among men, HIV testing increased quarterly by 12·1% (relative change [RC] 1·121, 95% CI 1·099 to 1·143, p<0·0001) in the intervention communities and 9·5% (1·095, 1·075 to 1·114, p=0·011) in the control communities; although increases in testing were greater in the intervention villages, differences did not reach significance (exponentiated interaction coefficient 1·024, 95% CI 0·997 to 1·052, p=0·078). Among women, HIV testing increased quarterly by 10·6% (RC 1·106, 95% CI 1·097 to 1·114, p<0·0001) in the intervention communities and 9·3% (1·093, 1·084 to 1·102, p=0·053) in the control communities; increases were greater in intervention communities (exponentiated interaction coefficient 1·012, 95% CI 1·001 to 1·023, p=0·043). Quarterly linkage increased significantly among women in the intervention communities (RC 1·013, 95% CI 1·002 to 1·023, p=0·018) only. Quarterly linkage fell among men in both arms, but decreased significantly among men in the control communities (0·977, 0·954 to 1·002, p=0·043). Quarterly retention fell among women in both arms; however, reductions were tempered among women in the intervention communities (exponentiated interaction coefficient 1·003, 95% CI <1·000 to 1·006, p=0·062). Retention fell significantly among men in both arms with difference in rates of decline. INTERPRETATION Community mobilisation was associated with modest improvements in select trial outcomes. The sum of these incremental, quarterly improvements achieved by addressing social barriers to HIV care engagement can impact epidemic control. However, achieving optimal impacts will probably require integrated efforts addressing both social barriers through community mobilisation and provision of improved service delivery. FUNDING US National Institutes of Health, National Institute of Mental Health, and United States President's Emergency Plan for AIDS Relief through Right to Care and Project SOAR.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA USA; MRC/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.
| | - Audrey Pettifor
- MRC/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; Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Mi-Suk Kang Dufour
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA USA; Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Chodziwadziwa Whiteson Kabudula
- MRC/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
| | - Rhian Twine
- MRC/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
| | | | | | - Aimée Julien
- MRC/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; Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca West
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA USA
| | - Torsten B Neilands
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA USA
| | - Ryan Wagner
- MRC/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
| | - Ann Gottert
- Population Council/Project SOAR, Washington, DC, USA
| | - F Xavier Gómez-Olivé
- MRC/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
| | | | | | | | | | - Stephen Tollman
- MRC/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; Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Kathleen Kahn
- MRC/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; Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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