Evaluation of four interventions using behavioural economics insights to increase demand for voluntary medical male circumcision in South Africa through the MoyaApp: A quasi-experimental study

Background

While voluntary medical male circumcision (VMMC) reduces the risk of HIV transmission by 60%, circumcision coverage falls short of the UNAIDS 90% target. We investigated whether behaviourally informed message framing increased demand for VMMC.

Setting

Adult users of the MoyaApp, a data free application in South Africa, who viewed a form designed to generate interest in VMMC during August-November 2022.

Methods

A quasi-experimental study was conducted to evaluate four MoyaApp VMMC intervention forms against the Standard of Care (SOC) form. All forms enabled users to provide contact details for follow-up engagement by a call centre. The primary outcome was the proportion of forms submitted. Secondary outcomes included successful contact with the user, VMMC bookings/referrals and confirmed circumcision. Multivariable ordinary least-squares regression was used for the analysis.

Results

MoyaApp VMMC form viewers totalled 118,337 of which 6% submitted a form. Foot-in-the-Door form viewers were more likely (+1.3 percentage points, p<0.01) to submit a form compared to the SOC group (6.3%). Active Choice (-1.1 percentage points, p<0.01) and Reserved for You (-0.05 percentage points, p<0.05) form viewers were less likely to submit a form compared to SOC. Users submitting on Foot-in-the-Door were less likely to be booked/referred compared to SOC (-5 percentage points, p<0.05). There were no differences between the intervention and SOC forms for successful contact and circumcisions.

Conclusions

Message framing using behavioural insights was able to nudge men to engage with VMMC services. However, more work is needed to understand how to convert initial interest into bookings and circumcisions.

Trial registration

South African Clinical Trials Registry DOH-27-062022-7811Pan-African Clinical Trials Registry PACTR202112699416418.

Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020

Background

Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs’ progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)— including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria.

Methods

We conducted cross-sectional analyses on data obtained from Nigeria’s National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000–2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category.

Results

Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25–34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2^nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT.

Conclusions

Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.

Multimonth dispensing of up to 6 months of antiretroviral therapy in Malawi and Zambia (INTERVAL): a cluster-randomised, non-blinded, non-inferiority trial

BACKGROUND

Facility-based, multimonth dispensing of antiretroviral therapy (ART) for HIV could reduce burdens on patients and providers and improve retention in care. We assessed whether 6-monthly ART dispensing was non-inferior to standard of care and 3-monthly ART dispensing.

METHODS

We did a pragmatic, cluster-randomised, unblinded, non-inferiority trial (INTERVAL) at 30 health facilities in Malawi and Zambia. Eligible participants were aged 18 years or older, HIV-positive, and were clinically stable on ART. Before randomisation, health facilities (clusters) were matched on the basis of country, ART cohort size, facility type (ie, hospital vs health centre), and region or province. Matched clusters were randomly allocated (1:1:1) to standard of care, 3-monthly ART dispensing, or 6-monthly ART dispensing using a simple random allocation sequence. The primary outcome was retention in care at 12 months, defined as the proportion of patients with less than 60 consecutive days without ART during study follow-up, analysed by intention to treat. A 2·5% margin was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03101592.

FINDINGS

Between May 15, 2017, and April 30, 2018, 9118 participants were randomly assigned, of whom 8719 participants (n=3012, standard of care group; n=2726, 3-monthly ART dispensing group; n=2981, 6-monthly ART dispensing group) had primary outcome data available at 12 months and were included in the primary analysis. The median age of participants was 42·7 years (IQR 36·1-49·9) and 5774 (66·2%) of 8719 were women. The primary outcome was met by 2478 (82·3%) of 3012 participants in the standard of care group, 2356 (86·4%) of 2726 participants in the 3-monthly ART dispensing group, and 2729 (91·5%) of 2981 participants in the 6-monthly ART dispensing group. After adjusting for clustering, for retention in care at 12 months, the 6-monthly ART dispensing group was non-inferior to the standard of care group (percentage-point increase 9·1 [95% CI 0·9-17·2]) and to the 3-monthly ART dispensing group (5·0% [1·0-9·1]).

INTERPRETATION

Clinical visits with ART dispensing every 6 months was non-inferior to standard of care and 3-monthly ART dispensing. 6-monthly ART dispensing is a promising strategy for the expansion of ART provision and achievement of HIV treatment targets in resource-constrained settings.

FUNDING

US Agency for International Development.

Provider experiences with three- and six-month antiretroviral therapy dispensing for stable clients in Zambia

Multi-month dispensing of antiretroviral therapy (ART) has been taken to scale in many settings in sub-Saharan Africa with the benefits of improved client satisfaction and decreased client costs. Six-month ART dispensing may further increase these benefits; however, data are lacking. Within a cluster-randomized trial of three- versus six-month dispensing in Malawi and Zambia, we performed a sub-study to explore Zambian provider experiences with multi-month dispensing. We conducted 18 in-depth interviews with clinical officers and nurses dispensing ART as part of INTERVAL in Zambia. Interview questions focused on provider perceptions of client acceptability, views on client sharing and selling of ART, and perceptions on provider workload and clinic efficiency, with a focus on differences between three- and six-month dispensing. Interviews were analyzed using inductive thematic analysis to identify key themes and patterns within the data. Providers perceived significant benefits of multi-month dispensing, with advantages of six-month over three-month dispensing related to a reduced burden on clients, and for reductions in their own workload and clinic congestion. Among nearly all providers, the six-month dispensing strategy was perceived as ideal. Further research is needed to quantify clinical outcomes of six-month dispensing and feasibility of scaling-up this intervention in resource-limited settings.Clinical Trial Number: NCT03101592.

Temporal trends in the epidemiology of cervical cancer in South Africa (1994-2012)

Cervical cancer (CC) is the leading cause of cancer death among female South Africans (SA). Improved access to reproductive health services following multi-ethnic democracy in 1994, HIV epidemic, and the initiation of CC population-based screening in early 2000s have influenced the epidemiology of CC in SA. We therefore evaluated the trends in CC age-standardised incidence (ASIR) (1994-2009) and mortality rates (ASMR) (2004-2012) using data from the South African National Cancer Registry and the Statistics South Africa, respectively. Five-year relative survival rates and average per cent change (AAPC) stratified by ethnicity and age-groups was determined. The average annual CC cases and mortalities were 4,694 (75,099 cases/16 years) and 2,789 (25,101 deaths/9 years), respectively. The ASIR was 22.1/100,000 in 1994 and 23.3/100,000 in 2009, with an average annual decline in incidence of 0.9% per annum (AAPC = -0.9%, p-value < 0.001). The ASMR decreased slightly by 0.6% per annum from 13.9/100,000 in 2004 to 13.1/100,000 in 2012 (AAPC = -0.6%, p-value < 0.001). In 2012, ASMR was 5.8-fold higher in Blacks than in Whites. The 5-year survival rates were higher in Whites and Indians/Asians (60-80%) than in Blacks and Coloureds (40-50%). The incidence rate increased (AAPC range: 1.1-3.1%, p-value < 0.001) among young women (25-34 years) from 2000 to 2009. Despite interventions, there were minimal changes in overall epidemiology of CC in SA but there were increased CC rates among young women and ethnic disparities in CC burden. A review of the CC national policy and directed CC prevention and treatment are required to positively impact the burden of CC in SA.

Assessment of adolescent and youth friendly services in primary healthcare facilities in two provinces in South Africa

Background

Health services for adolescents are increasingly recognised as a priority in low- and middle-income countries (LMICs). The Adolescent and Youth Friendly Service (AYFS) approach has been promoted in South Africa by the National Department of Health and partners, as a means of standardising the quality of adolescent health services in the country. The objective of this paper is to detail the evaluation of AYFS against defined standards to inform initiatives for strengthening these services.

Methods

A cross-sectional assessment of AYFS was carried out in 14 healthcare facilities in a sub-district of Gauteng Province and 16 in a sub-district in North West Province, South Africa. Data on adolescent care and service management systems were collected through interviews with healthcare providers, non-clinical staff and document review. Responses were scored using a tool based on national and World Health Organisation criteria for ten AYFS standards.

Results

Mean scores for the ten standards showed substantial variation across facilities in the two sub-Districts, with Gauteng Province scoring lower than the North West for 9 standards. The sub-district median for Gauteng was 38% and the North West 48%. In both provinces standards related to the general service delivery, such as Standards 4 and 5, scored above 75%. Assessment of services specifically addressing sexual, reproductive and mental health (Standard 3) showed that almost all these services were scored above 50%. Exploration of services related to psycho-social and physical assessments (Standard 8) demonstrated differences in the healthcare facilities’ management of adolescents’ presenting complaints and their comprehensive management including psycho-social status and risk profile. Additionally, none of the facilities in either sub-district was able to meet the minimum criteria for the five standards required for AYFS recognition.

Conclusion

Facilities had the essential components for general service delivery in place, but adolescent-specific service provision was lacking. AYFS is a government priority, but additional support for facilities is needed to achieve the agreed standards. Meeting these standards could make a major contribution to securing adolescents’ health, especially in preventing unintended pregnancies and HIV as well as improving psycho-social management.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3623-7) contains supplementary material, which is available to authorized users.

Outcomes of community-based differentiated models of multi-month dispensing of antiretroviral medication among stable HIV-infected patients in Lesotho: a cluster randomised non-inferiority trial protocol

BACKGROUND

Current World Health Organization (WHO) guidelines recommend early initiation of HIV positive patients on antiretroviral therapy (ART) irrespective of their clinical or immunological status known as the test and start approach. Lesotho, like many other countries introduced this approach in 2016 as a strategy to reach epidemic control. There will be rapidly growing number of HIV-infected individuals initiating treatment leading to practical challenges on health systems such as congestion, long waiting time for patients and limited time to provide quality services to patients. Differentiated models of ART delivery is an innovative solution that helps to increase access to care, while reducing the burden on existing health systems. Ultimately this model will help to achieve retention and viral suppression. We describe a demonstration study designed to evaluate a community-based differentiated model of multi-month dispensing (MMD) approaches of ART among stable HIV patients in Lesotho.

METHODS

This study will be a three-arm cluster randomised trial, which will enrol approximately 5760 HIV-infected individuals who are stable on ART in 30 selected clusters. The clusters, which are health facilities, will be randomly assigned into the following differentiated model of care arms: (i) 3 monthly ART supply at facilities (Control), (ii) 3 monthly ART supply through community ART groups (CAGs) and (iii) 6 monthly ART supply through community ART distribution points (CAD). Primary outcomes are retention in care and virologic suppression, and secondary outcomes include feasibility and cost effectiveness.

DISCUSSION

Important lessons will be learnt to allow for improved implementation of such demonstration projects, including various needs for reliable supply of medication, access to quality clinical data including access to viral loads (VLs) results, frameworks to support lay worker cadre, involvement of community stakeholders, and reliable data systems including records of key indicators. MMD will have positive implications including improved retention, virologic suppression, convenience and access to medication.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03438370 . Accepted on 16 February 2018.

Access to HIV care and treatment for migrants between Lesotho and South Africa: a mixed methods study

Background

HIV treatment and care for migrants is affected by their mobility and interaction with HIV treatment programs and health care systems in different countries. To assess healthcare needs, preferences and accessibility barriers of HIV-infected migrant populations in high HIV burden, borderland districts of Lesotho.

Methods

We selected 15 health facilities accessed by high patient volumes in three districts of Maseru, Leribe and Mafeteng. We used a mixed methods approach by administering a survey questionnaire to consenting HIV infected individuals on anti-retroviral therapy (ART) and utilizing a purposive sampling procedure to recruit health care providers for qualitative in-depth interviews across facilities.

Results

Out of 524 HIV-infected migrants enrolled in the study, 315 (60.1%) were from urban and 209 (39.9%) from rural sites. Of these, 344 (65.6%) were women, 375 (71.6%) were aged between 26 and 45 years and 240 (45.8%) were domestic workers. A total of 486 (92.7%) preferred to collect their medications primarily in Lesotho compared to South Africa. From 506 who responded to the question on preferred dispensing intervals, 63.1% (n = 319) preferred 5–6 month ARV refills, 30.2% (n = 153) chose 3–4 month refills and only 6.7% (n = 34) opted for the standard-of-care 1–2 month refills. A total of 126 (24.4%) defaulted on their treatment and the primary reason for defaulting was failure to get to Lesotho to collect medication (59.5%, 75/126). Treatment default rates were higher in urban than rural areas (28.3% versus 18.4%, p = 0.011). Service providers indicated a lack of transfer letters as the major drawback in facilitating care and treatment for migrants, followed by discrimination based on nationality or language. Service providers indicated that most patients preferred all treatment services to be rendered in Lesotho, as they perceive the treatment provided in South Africa to be different often less strong or with more serious side effects.

Conclusion

Existing healthcare systems in both South Africa and Lesotho experience challenges in providing proper care and treatment for HIV infected migrants. A need for a differentiated model of ART delivery to HIV infected migrants that allows for multi-month scripting and dispensing is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5594-3) contains supplementary material, which is available to authorized users.

Prevalence, incidence and correlates of low risk HPV infection and anogenital warts in a cohort of women living with HIV in Burkina Faso and South Africa

OBJECTIVE

To report the prevalence and incidence of low-risk human papillomavirus infection (LR-HPV) and anogenital warts (AGW) among women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA), and to explore HIV-related factors associated with these outcomes.

METHODS

We enrolled 1238 WLHIV (BF = 615; SA = 623) aged 25-50 years and followed them at three time points (6, 12 and 16 months) after enrolment. Presence of AGW was assessed during gynaecological examination. Cervico-vaginal swabs for enrolment and month 16 follow-up visits were tested for HPV infection by Inno-LiPA® genotyping. Logistic regression was used to assess risk factors for prevalent infection or AGW. Cox regression was used to assess risk factors for incident AGW.

RESULTS

Women in SA were more likely than those in BF to have prevalent LR-HPV infection (BF: 27.1% vs. SA: 40.9%; p<0.001) and incident LR-HPV infection (BF: 25.8% vs. SA: 31.6%, p = 0.05). Prevalence of persistent LR-HPV was similar in the two countries (BF: 33.3% vs. SA: 30.4%; p = 0.54), as were prevalence and incidence of AGW (Prevalence: BF: 7.5% vs. SA: 5.7%; p = 0.21; Incidence: BF: 2.47 vs. SA: 2.33 per 100 person-years; p = 0.41). HPV6 was associated with incident AGW (BF: adjusted Hazard Ratio (aHR) = 4.88; 95%CI: 1.36-17.45; SA: aHR = 5.02; 95%CI: 1.40-17.99). Prevalent LR-HPV (BF: adjusted Odds Ratio [aOR = 1.86]; 95%CI: 1.01-3.41; SA: aOR = 1.75; 95%CI: 0.88-3.48); persistent LR-HPV (BF: aOR = 1.92; 95%CI: 0.44-8.44; SA: aOR = 2.81; 95%CI: 1.07-7.41) and prevalent AGW (BF: aOR = 1.53; 95%CI: 0.61-3.87; SA: aOR = 4.11; 95%CI: 1.20-14.10) were each associated with low CD4+ counts (i.e. <200 vs. >500 cells/μL). Duration of ART and HIV plasma viral load were not associated with any LR-HPV infection or AGW outcomes.

CONCLUSION

LR-HPV infection and AGW are common in WLHIV in sub-Saharan Africa. Type-specific HPV vaccines and effective ART with immunological reconstitution could reduce the burden of AGW in this population.

Different adiposity indices and their association with blood pressure and hypertension in middle-aged urban black South African men and women: findings from the AWI-GEN South African Soweto Site

Background

To report associations between different adiposity indices [anthropometric and dual-energy X-ray absorptiometry (DXA) measures] and blood pressure (BP) and hypertension in urban black South African adults.

Methods

Anthropometric and DXA whole body measures were performed on 1026 men and 982 women. Participants were classified as being hypertensive if they had a systolic BP (SBP) ≥ 140 mmHg and/or diastolic (DBP) ≥ 90 mmHg. Within each gender the relationship of adiposity with BP and hypertension risk was assessed using linear and logistic regression models respectively. Bivariate models were computed for each body composition variable. Furthermore, we computed a multiple regression model to illustrates how body composition parameters are associated with the outcome variables independent of each other.

Results

The males were significantly taller and had a higher fat free soft tissue mass (FFSTM), DBP and socio-economic status, and were more likely to use tobacco and be hypertensive (48.0% vs. 38.8%). The females had higher body mass index (BMI), waist circumference (WC), fat mass (FM), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), FM/FFSTM ratio and body fat % than males. All body composition parameters were positively associated with hypertension. In both males and females, the FM/FFSTM ratio associated the strongest with hypertension illustrating the following odds ratios [males: 70.37 (18.47, 268.16) p ≤ 0.001; females 2.48 (0.86,7.21) p = 0.09]. The multiple regression model, indicated that the VAT and WC significantly associated with both SBP and DBP in the men and women respectively, whilst WC was the only significant predictor for hypertension.

Conclusions

All body composition parameters were associated with hypertension and FM/FFSTM ratio showed the strongest relationship. It was reassuring that WC remains a useful measure of central adiposity that can be used as a risk indicator for hypertension if more sophisticated measures are not available. Furthermore, our data in part, implies that reducing abdominal adiposity in aging adults could contribute to reducing the risk of elevated blood pressure and hypertension.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5443-4) contains supplementary material, which is available to authorized users.

Economic growth and obesity in South African adults: an ecological analysis between 1994 and 2014

Background

To assess the trend associations between South Africa's economic growth using various economic growth indicators (EGIs) with adult obesity prevalence over a specified period of time. Data for obesity levels reported were obtained from national surveys conducted in South African adults in 1998, 2003 and 2012. EGIs incorporated in the current analysis were obtained from the World Bank and IHS Global insight databases. Obesity prevalence is presented by gender, urbanisation level and ethnicity. EGIs congruent to the time points where obesity data are available are presented. Unadjusted time trend plots were applied to assess associations between obesity prevalence and EGIs by gender, urbanisation level and ethnicity. Females present higher levels of obesity relative to males for all time points. For both males and females, an overall increase in prevalence was observed in both rural and urban settings over-time, with urban dwellers presenting higher obesity levels. An overall increase in Gross Domestic Product (GDP) per capita and Household Final Consumption Expenditure (HFCE) per capita was observed. The Gini coefficient for all ethnicities except the White population increased between 1998 and 2003 but declined by 2012. Overtime per capita GDP and HFCE increased with increasing obesity prevalence in both genders. The trend association between the Gini coefficient for all ethnicities and obesity prevalence was similar for both genders in that as the Gini coefficient increased obesity prevalence declined, and when the coefficient decreased obesity prevalence increased. Trend associations exist between South Africa's economic growth and adult obesity.

Breast cancer trends differ by ethnicity: a report from the South African National Cancer Registry (1994-2009)

Background

To describe breast cancer (BC) incidence and mortality by ethnicity in South Africa (SA).

Methods

Sources of data included the South African National Cancer Registry (NCR) pathology-based reports (1994–2009) and Statistics South Africa (SSA) mortality data (1997–2009). Numbers of cases, age-standardised incidence rates (ASIR) and lifetime risk (LR) were extracted from the NCR database for 1994–2009. Age-specific incidence rates were calculated for five-year age categories. The direct method of standardisation was employed to calculate age-standardised mortality rates (ASMR) using mortality data.

Results

Between 1994 and 2009, there were 85 561 female BC. For the Black, Coloured and Asian groups, increases in ASIR and LR were observed between 1994 and 2009. In 2009, the ASIR for the total population, Blacks, Whites, Coloureds and Asians were 26.9, 18.7, 50.2, 40.9 and 51.2 per 100 000, respectively. For Asians, an increase in proportion of BC as a percentage of all female cancers was observed between 1994 and 2002 (11.1%) and continued to increase to 2009 (a further 4.5%). Whites and Asians presented higher incidences of BC at earlier ages compared with Blacks and Coloureds in 2009. In 1998, there were 1618 BC deaths in SA compared with 2784 deaths in 2009. ASMR between 1997 and 2004 increased but stabilised thereafter.

Conclusion

This paper demonstrated that SA BC incidence rates are similar to other countries in the region, but lower than other countries with similar health systems. Ethnic differences in BC trends were observed. However, the reasons for observed ethnic differences are unclear.

Oropharyngeal HPV infection: prevalence and sampling methods among HIV-infected men in South Africa

Worldwide, 96,000 cases of oropharyngeal cancer (OPC) occurred in 2012. Human papillomavirus (HPV) is a risk factor for OPC. Data on oropharyngeal HPV infection are limited. There is no consensus on the best sampling method for detecting the infection. We describe the prevalence of oropharyngeal HPV infection among HIV-infected men and compare the performance of oral rinses and swabs in detecting oropharyngeal HPV infection. Paired oral rinses and swabs for 181 men were tested for HPV DNA using the Roche Linear Array. Performance was determined by the number of infections detected and the percentage of samples with adequate DNA extraction. Agreement between sampling methods was assessed by the kappa statistic. Prevalence of oropharyngeal HPV infection with rinse samples was 1.8% (three infections) and 0.6% (one infection) with swabs (p = 0.06). Adequate cellular DNA extraction was more likely with rinse (93.4%) than swab samples (89.0%, p = 0.05). There was moderate agreement between the methods (kappa = 0.49). The prevalence of oropharyngeal HPV DNA infection among this predominantly heterosexual sample of men living with HIV was low and consistent with the infrequent oral sex practices. Oral rinse performed better than oral swab in detecting oropharyngeal HPV DNA infection and might contribute to screening for OPCs.

Intersections between polyvictimisation and mental health among adolescents in five urban disadvantaged settings: the role of gender

BACKGROUND

Polyvictimisation (PV) - exposure to violence across multiple contexts - causes considerable morbidity and mortality among adolescents. Despite high levels of violence in urban disadvantaged settings, gender differences in associations between PV and mental health have not been well established.

METHODS

We analysed data from a survey with 2393 adolescents aged 15-19 years, recruited using respondent-driven sampling from urban disadvantaged settings in Baltimore (USA), Delhi (India), Ibadan (Nigeria), Johannesburg (South Africa) and Shanghai (China). PV was defined as exposure to two or more types of violence in the past 12 months with family, peers, in the community, or from intimate partners and non-partner sexual violence. Weighted logistic regression models are presented by gender to evaluate whether PV is associated with posttraumatic stress, depression, suicidal thoughts and perceived health status.

RESULTS

PV was extremely common overall, but ranged widely, from 74.5% of boys and 82.0% of girls in Johannesburg, to 25.8 and 23.9% respectively in Shanghai. Community violence was the predominant violence type, affecting 72.8-93.7% across the sites. More than half of girls (53.7%) and 45.9% of boys had at least one adverse mental health outcome. Compared to those that did not report violence, boys exposed to PV had 11.4 higher odds of having a negative perception of health (95%CI adjusted OR = 2.45-53.2), whilst this figure was 2.58 times in girls (95%CI = 1.62-4.12). Among girls, PV was associated with suicidal thoughts (adjusted OR = 4.68; 95%CI = 2.29-9.54), posttraumatic stress (aOR = 4.53; 95%CI = 2.44-8.41) and depression (aOR = 2.65; 95%CI = 1.25-5.63). Among boys, an association was only detected between PV and depression (aOR = 1.82; 95%CI = 1.00-3.33).

CONCLUSION

The findings demonstrate that PV is common among both sexes in urban disadvantaged settings across the world, and that it is associated with poor mental health outcomes in girls, and with poor health status in both girls and boys. Clearly, prevention interventions are failing to address violence exposure across multiple contexts, but especially within community settings and in Johannesburg. Interventions are needed to identify adolescents exposed to PV and link them to care, with services targeting a range of mental health conditions among girls and perhaps focusing on depression among boys.

Prevalence of anogenital HPV infection, related disease and risk factors among HIV-infected men in inner-city Johannesburg, South Africa: baseline findings from a cohort study

BACKGROUND

Persistent high-risk human papillomavirus (HR-HPV) infection is associated with the development of anogenital cancers, particularly in men living with HIV (MLWH). We describe the prevalence of anogenital HPV infection, abnormal anal cytology and anogenital warts (AGWs) in MLWH in Johannesburg, and explore whether HPV infection and receipt of antiretroviral treatment is associated with detection of abnormal anal cytology and AGWs.

METHODS

We enrolled a cohort of 304 sexually-active MLWH ≥18 years, who completed a questionnaire and physical examination. Genital swabs were collected from all men and intra-anal swabs from 250 (82%). Swabs were tested for HPV DNA and genotypes, and anal smears graded using the Bethesda classification. Factors associated with anogenital disease were assessed by logistic regression models.

RESULTS

Two thirds were receiving antiretroviral treatment, for a median 33 months (IQR = 15-58) and 54% were HIV-virologically suppressed. Only 5% reported ever having sex with men. Among 283 genital swabs with valid results, 79% had any HPV, 52% had HR-HPV and 27% had >1 HR-HPV infection. By comparison, 39% of the 227 valid intra-anal swabs had detectable HPV, 25% had any HR-HPV and 7% >1 HR infection. While most anal smears were normal (51%), 20% had ASCUS and 29% were LSIL. No cases had HSIL or cancer. Infection with >1 HR type (adjusted OR [aOR] = 2.39; 95%CI = 1.02-5.58) and alpha-9 types (aOR = 3.98; 95%CI = 1.42-11.16) were associated with having abnormal cytology. Prevalence of AGWs was 12%. Infection with any LR type (aOR = 41.28; 95%CI = 13.57-125.62), >1 LR type (aOR = 4.14; 95%CI = 1.60-10.69), being <6 months on antiretroviral treatment (aOR = 6.90; 95%CI = 1.63-29.20) and having a CD4+ count <200 cells/μL (aOR = 5.48; 95%CI: 1.60-18.78) were associated with having AGWs.

CONCLUSIONS

In this population, anogenital HR-HPV infection and associated low-grade disease is common, but severe anal dysplasia was not detected. Findings reinforce the need for HPV vaccination in men for preventing both AGWs and HR-HPV infection. Given the absence of anal HSILs, however, the findings do not support the use of anal screening programmes in this population.

Inventory on the dietary assessment tools available and needed in africa: a prerequisite for setting up a common methodological research infrastructure for nutritional surveillance, research, and prevention of diet-related non-communicable diseases

OBJECTIVE

To carry out an inventory on the availability, challenges, and needs of dietary assessment (DA) methods in Africa as a pre-requisite to provide evidence, and set directions (strategies) for implementing common dietary methods and support web-research infrastructure across countries.

METHODS

The inventory was performed within the framework of the "Africa's Study on Physical Activity and Dietary Assessment Methods" (AS-PADAM) project. It involves international institutional and African networks. An inventory questionnaire was developed and disseminated through the networks. Eighteen countries responded to the dietary inventory questionnaire.

RESULTS

Various DA tools were reported in Africa; 24-Hour Dietary Recall and Food Frequency Questionnaire were the most commonly used tools. Few tools were validated and tested for reliability. Face-to-face interview was the common method of administration. No computerized software or other new (web) technologies were reported. No tools were standardized across countries.

CONCLUSIONS

The lack of comparable DA methods across represented countries is a major obstacle to implement comprehensive and joint nutrition-related programmes for surveillance, programme evaluation, research, and prevention. There is a need to develop new or adapt existing DA methods across countries by employing related research infrastructure that has been validated and standardized in other settings, with the view to standardizing methods for wider use.

Main nutrient patterns are associated with prospective weight change in adults from 10 European countries

PURPOSE

Various food patterns have been associated with weight change in adults, but it is unknown which combinations of nutrients may account for such observations. We investigated associations between main nutrient patterns and prospective weight change in adults.

METHODS

This study includes 235,880 participants, 25-70 years old, recruited between 1992 and 2000 in 10 European countries. Intakes of 23 nutrients were estimated from country-specific validated dietary questionnaires using the harmonized EPIC Nutrient DataBase. Four nutrient patterns, explaining 67 % of the total variance of nutrient intakes, were previously identified from principal component analysis. Body weight was measured at recruitment and self-reported 5 years later. The relationship between nutrient patterns and annual weight change was examined separately for men and women using linear mixed models with random effect according to center controlling for confounders.

RESULTS

Mean weight gain was 460 g/year (SD 950) and 420 g/year (SD 940) for men and women, respectively. The annual differences in weight gain per one SD increase in the pattern scores were as follows: principal component (PC) 1, characterized by nutrients from plant food sources, was inversely associated with weight gain in men (-22 g/year; 95 % CI -33 to -10) and women (-18 g/year; 95 % CI -26 to -11). In contrast, PC4, characterized by protein, vitamin B2, phosphorus, and calcium, was associated with a weight gain of +41 g/year (95 % CI +2 to +80) and +88 g/year (95 % CI +36 to +140) in men and women, respectively. Associations with PC2, a pattern driven by many micro-nutrients, and with PC3, a pattern driven by vitamin D, were less consistent and/or non-significant.

CONCLUSIONS

We identified two main nutrient patterns that are associated with moderate but significant long-term differences in weight gain in adults.

Perceptions of diet, physical activity, and obesity-related health among black daughter-mother pairs in Soweto, South Africa: a qualitative study

BACKGROUND

The prevalence of overweight and obesity is on the rise in South Africa, particularly among females living in urban environments. The purpose of this qualitative study was to explore the emic perspectives of black young adult daughter and mother pairs living in Soweto, South Africa on diet, physical activity, and obesity-related health within their social and cultural context.

METHODS

Purposeful sampling was used to recruit daughters with a normal body mass index (BMI) who have obese mothers. Individual semi-structured in-depth interviews were conducted with 17 daughters (age 24 years) and 15 of their mothers in Soweto, South Africa. Interview questions related to: a) eating and physical activity behaviors and perceptions, b) perceptions of social and community level factors, c) cultural beliefs about diet and body image, and d) intergenerational relationships. Data were analyzed using four-phases of thematic analysis and the constant comparison approach.

RESULTS

Daughters and mothers had similar ideas of the definition of healthy food and the importance of eating healthy, but mothers were more likely to report eating healthy because of their age, adverse health experiences, and a desire to live longer. Daughters and mothers engaged in physical activity for reasons related to weight maintenance and feeling better, but mothers reported being more likely to start exercising as a result of a health concern. Daughters and mothers had comparable views of what makes a person healthy. Daughters and mothers relied on each other for food purchasing and food preparation.

CONCLUSION

Daughters and mothers shared some similar perceptions of diet, physical activity, and health that were rooted in their daily life in Soweto. However, mothers generally reported being more likely to exhibit healthy eating and physical activity behaviors despite being obese. The mothers may have adopted these perceptions and behaviors later in life linked to ageing and ill-health. It is possible that through exposure, their daughters have assimilated these perceptions earlier in childhood or adolescence. It is important to focus health promotion efforts around preventing the otherwise expected increase of obesity among the young adult generation.

Association of socioeconomic status change between infancy and adolescence, and blood pressure, in South African young adults: Birth to Twenty Cohort

OBJECTIVE

Social epidemiology models suggest that socioeconomic status (SES) mobility across the life course affects blood pressure. The aim of this study was to investigate the association between SES change between infancy and adolescence, and blood pressure, in young adults, and the impact of early growth on this relationship.

SETTING

Data for this study were obtained from a 'Birth to Twenty' cohort in Soweto, Johannesburg, in South Africa.

PARTICIPANTS

The study included 838 Black participants aged 18 years who had household SES measures in infancy and at adolescence, anthropometry at 0, 2, 4 and 18 years of age and blood pressure at the age of 18 years.

METHODS

We computed SES change using asset-based household SES in infancy and during adolescence as an exposure variable, and blood pressure and hypertension status as outcomes. Multivariate linear and logistic regressions were used to investigate the associations between SES change from infancy to adolescence, and age, height and sex-specific blood pressure and hypertension prevalence after adjusting for confounders.

RESULTS

Compared to a persistent low SES, an upward SES change from low to high SES tertile between infancy and adolescence was significantly associated with lower systolic blood pressure (SBP) at the age of 18 years (β=-4.85; 95% CI -8.22 to -1.48; p<0.01; r(2)=0.1804) after adjusting for SES in infancy, small-for-gestational-age (SGA) and weight gain. Associations between SES change and SBP were partly explained by weight gain between birth and the age of 18 years. There was no association between SES mobility and diastolic blood pressure, mean arterial pressure or hypertension status.

CONCLUSIONS

Our study confirms that upward SES change has a protective effect on SBP by the time participants reach young adulthood. Socioeconomic policies and interventions that address inequality may have the potential to reduce cardiovascular disease burden related to BP in later life.

Dietary Patterns in Adults with Type 2 Diabetes Predict Cardiometabolic Risk Factors

OBJECTIVES

Examining the diets of people living with type 2 diabetes may improve understanding of how diet affects disease progression. We derived dietary patterns in adults living with type 2 diabetes and explored associations among patterns, sociodemographic variables and cardiometabolic risk factors.

METHODS

Dietary patterns were derived from food frequency questionnaires (FFQs) in 196 adults with type 2 diabetes using principal components analysis (PCA). Multilinear regression models were fitted for the differing dietary pattern scores so as to estimate the marginal contribution of each variable explaining variations in diet. Differences in clinical variables across dietary patterns, adjusting for sex, smoking and total energy intake, were assessed.

RESULTS

Three principal components (PCs), or patterns, were identified, explaining 56.5% of the total variance in diet: (PC1) fried foods, cakes and ice cream; (PC2) fish and vegetables; and (PC3) pasta, potatoes and breads. Female sex, current smoker and total energy were significant associated with patterns. Total energy accounted for the greatest amount of variance in each pattern (11.2% for fried foods, cakes and ice cream, 3.89% for fish and vegetables and 9.21% for pasta, potatoes and breads). After adjustment for sex, smoking and total energy, the pasta, potatoes and breads pattern was inversely associated with systolic blood pressure and low-density lipoprotein-cholesterol.

CONCLUSIONS

Of the 3 distinct diet patterns characterized, the carbohydrate-based pattern was most closely associated with cardiometabolic risk factors. To better understand and improve self-management by people living with type 2 diabetes through dietary modifications, further improvements in measuring and assessing diet using comparable instruments and comparisons with apparently healthy populations is required.

Association of alcohol consumption with specific biomarkers: a cross-sectional study in South Africa

Alcohol consumption plays an important role in the health transition associated with urbanization in developing countries. Thus, reliable tools for assessing alcohol intake levels are necessary. We compared two biological markers of alcohol consumption and self-reported alcohol intakes in participants from urban and rural South African communities. This cross-sectional epidemiological survey was part of the North West Province, South African leg of the 12-year International Prospective Urban and Rural Epidemiology (PURE) study which investigates the health transition in urban and rural subjects. A total of 2,010 apparently healthy African volunteers (35 years and older) were recruited from a sample of 6,000 randomly-selected households. Alcohol consumption was assessed through self-reports (24-hour recalls and quantitative food frequency questionnaire) and by two biological markers: percentage carbohydrate-deficient transferrin (%CDT) and gamma-glutamyl transferase (GGT). Of the 716 men and 1,192 women volunteers, 64% and 33% respectively reported regular alcohol consumption. Reported mean habitual intakes of drinker men and women were 29.9 (± 30.0) and 23.3 (± 29.1) g of pure alcohol per day. Reported habitual intake of the whole group correlated positively and significantly with both %CDT (R=0.32; p ≤ 0.01) and GGT (R=0.43; p ≤ 0.01). The correlation between the two biomarkers was low (0.211; p ≤ 0.01). GGT and %CDT values should be interpreted with care in Africans as self-reported non-drinker men and women had elevated levels of GGT (19% and 26%) and %CDT (48% and 38%). A need exists for a more specific biological marker for alcohol consumption in black Africans.

Mechanisms of stress, energy homeostasis and insulin resistance in European adolescents--the HELENA study

BACKGROUND AND AIMS

Stress is hypothesized to facilitate the development of obesity, whose the foundations are already set during childhood and adolescence. We investigated the relationship between the stress-system, selected mechanisms of energy homeostasis and insulin resistance (IR) in a sample of European adolescents.

METHODS AND RESULTS

Within HELENA-CSS, 723 adolescents (12.5-17.5 years) from 10 European cities provided all the necessary data for this study. Fasting blood samples were collected for cortisol, leptin, insulin and glucose analysis. HOMA-IR was calculated from insulin and glucose concentrations. Adolescents' body fat (BF) %, age and duration of exclusive breastfeeding were assessed. For boys and girls separately, the relationship of cortisol with leptin, insulin, glucose and HOMA-IR was examined by computing Pearson correlation coefficients and Hierarchical Linear Models (HLMs), with 'city' as cluster unit, adjusting for age, BF% and duration of exclusive breastfeeding. In boys, Pearson correlation coefficients illustrated positive correlations of cortisol with insulin (r = 0.144; p = 0.013), glucose (r = 0.315; p < 0.001) and HOMA-IR (r = 0.180; p = 0.002), whilst in girls, this positive relationship was observed for leptin (r = 0.147; p = 0.002), insulin (r = 0.095; p = 0.050) and HOMA-IR (r = 0.099; p = 0.041), but not for glucose (r = 0.054; p = 0.265). Observed associations were independent of adolescents' age, BF% and duration of exclusive breastfeeding after computing HLMs.

CONCLUSION

This study suggests that the stress-system is positively related to mechanisms of energy homeostasis and IR in European adolescents, and reveals a potential small gender difference in this relationship. The hypothesis that stress might facilitate the development of obesity during adolescence is supported.

Nutrient patterns and their food sources in an International Study Setting: report from the EPIC study

BACKGROUND

Compared to food patterns, nutrient patterns have been rarely used particularly at international level. We studied, in the context of a multi-center study with heterogeneous data, the methodological challenges regarding pattern analyses.

METHODOLOGY/PRINCIPAL FINDINGS

We identified nutrient patterns from food frequency questionnaires (FFQ) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study and used 24-hour dietary recall (24-HDR) data to validate and describe the nutrient patterns and their related food sources. Associations between lifestyle factors and the nutrient patterns were also examined. Principal component analysis (PCA) was applied on 23 nutrients derived from country-specific FFQ combining data from all EPIC centers (N = 477,312). Harmonized 24-HDRs available for a representative sample of the EPIC populations (N = 34,436) provided accurate mean group estimates of nutrients and foods by quintiles of pattern scores, presented graphically. An overall PCA combining all data captured a good proportion of the variance explained in each EPIC center. Four nutrient patterns were identified explaining 67% of the total variance: Principle component (PC) 1 was characterized by a high contribution of nutrients from plant food sources and a low contribution of nutrients from animal food sources; PC2 by a high contribution of micro-nutrients and proteins; PC3 was characterized by polyunsaturated fatty acids and vitamin D; PC4 was characterized by calcium, proteins, riboflavin, and phosphorus. The nutrients with high loadings on a particular pattern as derived from country-specific FFQ also showed high deviations in their mean EPIC intakes by quintiles of pattern scores when estimated from 24-HDR. Center and energy intake explained most of the variability in pattern scores.

CONCLUSION/SIGNIFICANCE

The use of 24-HDR enabled internal validation and facilitated the interpretation of the nutrient patterns derived from FFQs in term of food sources. These outcomes open research opportunities and perspectives of using nutrient patterns in future studies particularly at international level.

Validity of instruction leaflets for parents to measure their child's weight and height at home: results obtained from a randomised controlled trial

OBJECTIVES

To compare the validity of parent-reported height, weight and body mass index (BMI) values of children (aged 4-10 years), when measured at home by means of newly developed instruction leaflets in comparison with simple estimated parental reports.

DESIGN

Randomised controlled trial with control and intervention group using simple randomisation.

SETTING

Belgian children and their parents recruited via schools (multistage cluster sampling design).

PARTICIPANTS

164 Belgian children (53% male; participation rate 62%).

INTERVENTION

Parents completed a questionnaire including questions about the height and weight of their child. Parents in the intervention group received instruction leaflets to measure their child's weight and height. Classes were randomly allocated to the intervention and control groups. Nurses measured height and weight following standardised procedures up to 2 weeks after parental reports.

OUTCOME MEASURES

Weight, height and BMI category of the child were derived from the index measurements and the parental reports.

RESULTS

Mean parent-reported weight was slightly more underestimated in the intervention group than in the control group relative to the index weights. However, for all three parameters (weight, height and BMI), correlations between parental reports and nurse measurements were higher in the intervention group. Sensitivity for underweight and overweight/obesity was respectively, 75% and 60% in the intervention group, and 67% and 43% in the control group. Weighed κ for classifying children in the correct BMI category was 0.30 in the control group and was 0.51 in the intervention group.

CONCLUSIONS

Although mean parent-reported weight was slightly more underestimated in the intervention than in the control group, correlations were higher and there was considerably less misclassification into valid BMI categories for the intervention group. This pattern suggests that most of the parental deviations from the index measurements were probably due to random errors of measurement and that diagnostic measures could improve by encouraging parents to measure their children's weight and height at home by means of instruction leaflets.

Social drift of cardiovascular disease risk factors in Africans from the North West Province of South Africa: the PURE study

Objective

This study examined whether the association between socio-economic status (SES) and cardiovascular disease (CVD) risk factors in black South Africans from the North West Province had shifted from the more affluent groups with higher SES to the less affluent, lower SES groups over a period of nine years.

Method

Cross-sectional baseline data of 2 010 urban and rural subjects (35 years and older) participating in the Prospective Urban and Rural (PURE) study and collected in 2005 were analysed to examine the relationship of level of education, employment and urban or rural residence with dietary intakes and other CVD risk factors. These relationships were compared to those found nine years earlier in the Transition and Health during the Urbanisation of South Africans (THUSA) study conducted in the same area.

Results

The results showed that urban women had higher body mass index (BMI), serum triglyceride and fasting glucose levels compared to rural women and that both urban men and women had higher blood pressures and followed a more Westernised diet. However, rural men and women had higher plasma fibrinogen levels. The more highly educated subjects (which included both urban and rural subjects) were younger than those with no or only primary school education. Few of the risk factors differed significantly between education groups, except that more highly educated men and women had lower BMIs, and women had lower blood pressure and triglyceride levels. These women also followed a more prudent diet than those with only primary school education. Employed men and women had higher BMIs, higher energy intakes but lower plasma fibrinogen levels, and employed women had lower triglyceride levels. No significant differences in total serum cholesterol values were observed.

Conclusion

These results suggest a drift of CVD risk factors from groups with higher SES to groups with a lower SES from 1996 to 2005, indicating that interventions to prevent CVD should also be targeted at Africans living in rural areas, those with low educational levels, and the unemployed.

The relationship between indices of iron status and selected anthropometric cardiovascular disease risk markers in an African population: the THUSA study

There is evidence that certain indices of iron status are associated with anthropometric measures, which are used independently as markers of cardiovascular disease (CVD) risk. This study examined whether this association exists in an African population. The study was a cross-sectional comparative study that examined a total of 1 854 African participants. Ferritin was positively associated with body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), percentage body fat and subscapular skinfold thickness. Serum ferritin concentration was higher in the high-WHR category than the normal-WHR category for both genders. Additionally, WC and WHR increased with increasing ferritin concentrations in both genders. Serum iron was lower in the obese than the normal-weight and pre-obese women only. In this population-based study, increased serum ferritin concentrations associated positively with increased WHR and WC, indicating that individuals or populations at risk of iron overload as defined by high serum ferritin concentrations may be at a greater risk of developing CVD.