Rural African Setting Research Articles

"Linkage to care" among people living with HIV - definition in the era of "universal test and treat" in a sub-Sahara African setting.

Prompt linkage to human immunodeficiency virus (HIV) care after diagnosis is of utmost importance for individual health and reduction of HIV transmission. Different definitions for “linkage to care” have challenged comparisons as a public health marker. Its meaning in the era of “universal test and treat” has transformed in all settings, but is most relevant in sub-Sahara Africa, where the burden of new HIV infection is still highest. For this narrative review on “linkage to care” definitions with a focus on sub-Saharan Africa, we searched PubMed/Medline between September and December 2020, restricted to the period 2000–2020 using Boolean operators: “HIV” AND (“linkage to care” OR “engagement in care”) and screened for institutional definitions of “linkage to care”. Additionally, as one example of a rural sub-Saharan African setting, we analysed linkage steps within the Chronic Diseases Clinic Ifakara (CDCI) and its associated Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) in rural Tanzania between 1 January 2017 and 31 March 2019. We analysed 81 articles that included “linkage to care” within different study settings and HIV organisations. Major differences in defining “linkage to care” exist, according to setting and location, patient populations and the timing of steps within the linkage process. We identified 16 different numerators and 10 denominators used to define linkage with time periods ranging from “same day as diagnosis” up to 12 months after diagnosis among 34 original articles from sub-Saharan Africa. At the CDCI, 1149/1671 (69%) newly diagnosed individuals were enrolled into care after diagnosis. Three months after enrolment into care, 94%, 86%, 85% and 71% of enrolled patients had a laboratory evaluation, a clinical evaluation, were initiated on treatment and had a first clinical follow-up visit after initiation of treatment, respectively. To address the inconsistency in defining “linkage to care” and in order to guarantee the comparability of “linkage to care” in the sub-Saharan Africa region, we support the definition from the European region with some adaptions. We suggest a priority list of care indicators if more than one care indicator is available for successful “linkage to care” in the era of “universal test and treat” for sub-Sahara Africa.

Usefulness of the English version of the Stress Overload Scale in a sample of employed South Africans

Amidst reports of high levels of stress in South Africa, it remained difficult to quantify psychological stress in the absence of locally validated measures. This study explored the English version of the Stress Overload Scale (SOS) in a South African sample. The first aim was to replicate the basic psychometric analysis of the original English version used in American samples, as well as the Setswana version used in a South African rural community setting. The second aim was to investigate criterion validity to determine its appropriateness for use in South Africa. A total of 2136 employed South Africans with at least 9 years of schooling participated in this study. Participants completed a range of mental health and well-being measures, both clinical and dispositional. Responses were analysed to examine both scale characteristics and validity indices related to the SOS. Little sociodemographic influence (age, gender and first language) was found, with analyses supporting validity across most indices. Furthermore, good predictive ability for mental (ill-) health was observed. This study, for the most part, replicated previous validation findings of the SOS. Validity was further confirmed by correlating the scale with measures of clinical mental health and dispositional well-being. Given the positive support to its validity, when used amongst employed South Africans with at least 9 years of education, the scale holds promise for application in local health-related research, for triage in primary healthcare contexts and for measuring outcomes of mental health interventions in therapeutic settings.

Is biological larviciding against malaria a starting point for integrated multi-disease control? Observations from a cluster randomized trial in rural Burkina Faso.

To evaluate the impact of anti-malaria biological larviciding with Bacillus thuringiensis israelensis on non-primary target mosquito species in a rural African setting. A total of 127 villages were distributed in three study arms, each with different larviciding options in public spaces: i) no treatment, ii) full or iii) guided intervention. Geographically close villages were grouped in clusters to avoid contamination between treated and untreated villages. Adult mosquitoes were captured in light traps inside and outside houses during the rainy seasons of a baseline and an intervention year. After enumeration, a negative binomial regression was used to determine the reductions achieved in the different mosquito species through larviciding. Malaria larviciding interventions showed only limited or no impact against Culex mosquitoes; by contrast, reductions of up to 34% were achieved against Aedes when all detected breeding sites were treated. Culex mosquitoes were captured in high abundance in semi-urban settings while more Aedes were found in rural villages. Future malaria larviciding programs should consider expanding onto the breeding habitats of other disease vectors, such as Aedes and Culex and evaluate their potential impact. Since the major cost components of such interventions are labor and transport, other disease vectors could be targeted at little additional cost.

A cross-cultural investigation of the conceptualisation of frailty in northern Tanzania

AbstractFrailty prevalence is higher in low- and middle-income countries (LMICs) compared with high-income countries when measured by biomedical frailty models, the most widely used being the frailty phenotype. Frailty in older people is becoming of global public health interest as a means of promoting health in old age in LMICs. As yet, little work has been done to establish to what extent the concept of frailty, as conceived according to ‘western’ biomedicine, has cross-cultural resonance for a low-income rural African setting. This study aimed to investigate the meaning of frailty contextually, using the biomedical concept of the frailty phenotype as a framework. Qualitative interviews were conducted with a purposive sample of older adults, their care-givers and community representatives in rural northern Tanzania. Thirty interview transcripts were transcribed, translated from Kiswahili to English and thematically analysed. Results reveal that despite superficial similarities in the understanding of frailty, to a great extent the physical changes highlighted by the frailty phenotype were naturalised, except when these were felt to be due to a scarcity of resources. Frailty was conceptualised as less of a physical problem of the individual, but rather, as a social problem of the community, suggesting that the frailty construct may be usefully applied cross-culturally when taking a social equity focus to the health of older people in LMICs.

Livelihood outcomes in a cohort of youth with disabilities following participation in an economic empowerment programme in rural Uganda

BackgroundLittle evidence exists on the livelihoods of young people with disabilities in low- and middle-income settings. ObjectiveThis study examined employability and livelihood outcomes among a cohort of youth with disabilities who participated in an economic empowerment programme in rural Uganda. MethodsProspective cohort of youth with disabilities participating in an economic empowerment programme in rural Uganda. Livelihood outcomes of participants were assessed through structured interviews at baseline (n = 297) and again at 12 months (n = 252) and analysed using chi-squared tests and generalized estimating equations. ResultsOf 297 participants at baseline, 144 (48%) were women and the mean age was 21.7 years. At 12 months follow-up, participants were significantly more likely to have a job (OR 3.04, 95% CI 2.10–4.39); to have accessed finance (OR 5.52, 95% CI 3.18–9.56); and experienced community support (OR 2.23, 95% CI 1.51–3.29) compared with baseline. There were no statistically significant changes in having enough money for food or in having experienced community discrimination. ConclusionsThe findings suggest that targeted vocational skills training, apprenticeships scheme and a start-up financial package may improve the livelihoods of young people living with disabilities in rural African settings.

Brief problem-solving therapy for antenatal depressive symptoms in primary care in rural Ethiopia: protocol for a randomised, controlled feasibility trial

BackgroundDespite a high prevalence of antenatal depression in low- and middle-income countries, there is very little evidence for contextually adapted psychological interventions delivered in rural African settings. The aims of this study are (1) to examine the feasibility of procedures for a future fully powered efficacy trial of contextually adapted brief problem solving therapy (PST) for antenatal depression in rural Ethiopia, and (2) to investigate the acceptability, fidelity and feasibility of delivery of PST in routine antenatal care.MethodsDesign: A randomised, controlled, feasibility trial and mixed method process evaluation. Participants: Consecutive women attending antenatal clinics in two primary care facilities in rural Ethiopian districts. Eligibility criteria: (1) disabling levels of depressive symptoms (Patient Health Questionnaire (PHQ-9) score of five or more and positive for the 10th disability item); (2) gestational age 12–34 weeks; (3) aged 16 years and above; (4) planning to live in the study area for at least 6 months; (5) no severe medical or psychiatric conditions. Intervention: Four sessions of adapted PST delivered by trained and supervised antenatal care staff over a maximum period of eight weeks. Control: enhanced usual care (EUC). Sample size: n = 50. Randomisation: individual randomisation stratified by intimate partner violence (IPV). Allocation: central phone allocation. Outcome assessors and statistician masked to allocation status. Primary feasibility trial outcome: dropout rate. Primary future efficacy trial outcome: change in PHQ-9 score, assessed 9 weeks after recruitment. Secondary outcomes: anxiety symptoms, trauma symptoms, intimate partner violence, disability, healthcare costs at 9 weeks; postnatal outcomes (perinatal and neonatal complications, onset of breast feeding, child health) assessed 4–6 weeks postnatal. Other trial feasibility indicators: recruitment, number and duration of sessions attended. Audio-recording of randomly selected sessions and in-depth interviews with purposively selected participants, healthcare providers and supervisors will be analysed thematically to explore the acceptability and feasibility of the trial procedures and fidelity of the delivery of PST.DiscussionThe findings of the study will be used to inform the design of a fully powered efficacy trial of brief PST for antenatal depression in routine care in rural Ethiopia.Trial registrationThe protocol was registered in the Pan-African clinical trials registry, (PACTR): registration number: PACTR202008712234907 on 18/08/2020; URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9578.

Factors affecting the uptake of preventive chemotherapy treatment for schistosomiasis in Sub-Saharan Africa: A systematic review.

BackgroundSchistosomiasis affects nearly 220 million people worldwide, mainly in Sub-Saharan Africa (SSA). Preventive chemotherapy (PC) treatment, through regular mass-drug administration (MDA) of Praziquantel tablets remains the control measure of choice by Ministries of Health. Current guidelines recommend that 75% of school-aged children receive treatment. Many programmes, however, struggle to achieve this target. Given the risk of high reinfection rates, attaining sustained high levels of treatment coverage is essential. This study provides a comprehensive review of the barriers and facilitators operating at different levels of analysis, from the individual to the policy level, conditioning the uptake of PC for schistosomiasis in SSA.Methodology/Principal findingsA systematic literature search was conducted in several databases for publications released between January 2002 and 2019 that examined factors conditioning the uptake of Praziquantel in the context of MDA campaigns in SSA. A total of 2,258 unique abstracts were identified, of which 65 were selected for full text review and 30 met all eligibility criteria. Joanna Briggs Institute’s Critical Appraisal and the Mixed-Methods Assessment tools were used to assess the strength of the evidence. This review was registered with PROSPERO (CRD42017058525).A meta-synthesis approach was used. Results indicated publication bias, with the literature focusing on East African rural settings and evidence at the individual and programmatic levels. The main influencing factors identified included material wellbeing, drug properties, knowledge and attitudes towards schistosomiasis and MDAs, fears of side effects, gender values, community and health systems support, alongside programme design features, like training, sensitisation, and provision of incentives for drug-distributors. The effect of these factors on determining Praziquantel uptake were explored in detail.Conclusions/SignificanceMultiple determinants of treatment uptake were found in each level of analysis examined. Some of them interact with each other, thus affecting outcomes directly and indirectly. The promotion of context-based transdisciplinary research on the complex dynamics of treatment uptake is not only desirable, but essential, to design effective strategies to attain high levels of treatment coverage.

A Critique of the Democratic Functionality of the School Disciplinary Committee Structures within a South African Rural Setting

The South Africans Schools Act mandates institutional policy duty bearers such as the school governing bodies (SGBs) and school disciplinary committees (SDCs) through which education stakeholders such as school principals, teachers, parents and learners to democratically formulate and implement school policies. The effectiveness of these bodies in carrying out their responsibilities in most cases is left to speculation. Based on a case study of high schools in a rural district setting in South Africa, this paper reports on the extent to which SDCs are democratically constituted and function in conducting their responsibilities. A qualitative approach was employed to gather data from a purposeful sample of 53 participants at two secondary schools that comprised 10 SGB members, 10 school management team (SMT) members, 9 SDC members, 10 Representative Council of Learners (RCL), 4 class teachers and 10 previously disciplined learners (PDLs). Focus group and individual interviews were the primary data gathering instruments but were complemented by document analysis to cross-check participants’ narratives where necessary. Results indicated that the discharge of the SDC responsibilities was largely undemocratic in both composition and functioning, and therefore unjust in disciplining learners who acted outside school rules. On the basis of our findings, we recommend that the policy duty bearers in school institutional management structures such as the SMT, SGB, RCL and SDC should first be inducted on school policies, roles and responsibilities on assumption of duty.
 
 Received: 28 June 2020 / Accepted: 18 November 2020 / Published: 17 January 2021

Carriage Dynamics of Pneumococcal Serotypes in Naturally Colonized Infants in a Rural African Setting During the First Year of Life.

Streptococcus pneumoniae (the pneumococcus) carriage precedes invasive disease and influences population-wide strain dynamics, but limited data exist on temporal carriage patterns of serotypes due to the prohibitive costs of longitudinal studies. Here, we report carriage prevalence, clearance and acquisition rates of pneumococcal serotypes sampled from newborn infants bi-weekly from weeks 1 to 27, and then bi-monthly from weeks 35 to 52 in the Gambia. We used sweep latex agglutination and whole genome sequencing to serotype the isolates. We show rapid pneumococcal acquisition with nearly 31% of the infants colonized by the end of first week after birth and quickly exceeding 95% after 2 months. Co-colonization with multiple serotypes was consistently observed in over 40% of the infants at each sampling point during the first year of life. Overall, the mean acquisition time and carriage duration regardless of serotype was 38 and 24 days, respectively, but varied considerably between serotypes comparable to observations from other regions. Our data will inform disease prevention and control measures including providing baseline data for parameterising infectious disease mathematical models including those assessing the impact of clinical interventions such as pneumococcal conjugate vaccines.

Association between cardiometabolic health and objectively-measured, free-living sleep parameters: a pilot study in a rural African setting

ObjectivesTo investigate the relationship between objectively-measured, free-living sleep quantity and quality, and cardiometabolic health, in a rural African setting in 139 adults (≥40 years, female: n = 99, male: n = 40). Wrist-mounted, tri-axial accelerometry data was collected over 9 days. Measures of sleep quantity and quality, and physical activity were extracted from valid minute-by-minute data. Self-reported data included behavioural, health and socio-demographic variables. Biological data included body composition, resting blood pressure and fasting blood glucose, insulin and lipids. Logistic regression models were constructed with insulin resistance (IR) and cardiometabolic (CM) risk, as dependent variables, adjusting for socio-demographic, behavioural and biological factors.ResultsNocturnal sleep time was longer in females (p = 0.054) and sleep quality was better in males (p ≤ 0.017). Few participants slept > 9 h/night (4–5%), and 46–50% slept < 7 h/night. IR and CM risk was higher in females (p ≤ 0.006). In adjusted models, sleep variables were independently associated with IR (p < 0.05). Sleep quantity was non-linearly associated with CM risk (p ≤ 0.0398), and linearly associated with IR (p ≤ 0.0444). Sleep quality was linearly related with CM risk and IR (p ≤ 0.0201). In several models, sleep quantity and sleep quality measures were concurrently and significantly associated with IR (p ≤ 0.044).

Rethinking Cultural Factors Through a Structural Health Vulnerability Approach: A Critical Perspective of a Family Planning Evaluation in Rural Uganda

Many evaluations of family planning (FP) programs use a behavioral approach and point to the unequal power dynamics between women and men, often resulting in a lack of opportunities for women to be involved in decision-making. Such gender inequities are often simplified and presented as aspects of a generalized African culture. In this commentary, we argue that using a structural health vulnerability approach could be beneficial for FP program evaluations, switching from a cultural perception to a social justice understanding of barriers to FP. We support our argument by drawing from our experience in Uganda, where we conducted a qualitative evaluation of a FP program and identified sociocultural factors limiting women’s access to contraception. With hindsight, we believe that a critical approach could have been used to bring a new perspective, moving away from an oversimplified culturalist explanation of a limited access to FP. By presenting cases of Ugandan women, we demonstrate the relevance of considering structural vulnerabilities. We show that this critical approach allows us to analyze the oppressive structures, such as poverty and gender inequality, and social injustices that perpetuate situations of vulnerability for women. Anchored in intersectionality, a structural health vulnerability approach could therefore be used to assess FP programs through a lens of social justice. Researchers interested in applying a critical perspective towards global health could benefit from this approach. Doing so, we could better understand the complexities of women’s reproductive health in rural African settings, identifying locally relevant structural interventions to improve FP access.

Experiences of Educational Researchers in the Use of the Case Study Design During the Covid-19 Pandemic: Lessons From a South African Rural Setting

This article explores the usefulness of the case study design in the creation of educational knowledge during uncertain times such as wars, disease outbreaks, famine, and pandemics, including Covid-19 pandemic. This is done at a time when others still doubt its contribution to the creation of knowledge. They criticize it for among other things, its lack of robustness and, its dependency on single case occurrences. In the current Covid-19 pandemic circumstances, further advantages of its application may be highlighted. Thus, the question is: to what extent does a case study design contribute toward knowledge creation during uncertain times? This article reflects on the experiences of educational researchers in using the case study design and its contribution to the creation of knowledge during the Covid-19 pandemic in a rural South African setting. Data was generated through semi-structured interviews with four researchers who were purposively selected to participate in the study and was analyzed by developing categories and themes. Despite the constraints imposed by the pandemic, such as the inaccessibility of participants during data creation, the case study design proved to be a suitable alternative approach. The article argues that the use of the case study design is appropriate during uncertain times because of its flexibility and plausibleness. This includes, the understanding of the dynamic nature of the Covid-19 pandemic, and its management. For example, the case study design enables researchers to highlight the unique nature of different contexts created by the Covid-19 pandemic. It might also assist researchers in assessing and constructing additional data while observing social distancing. The implication of the study is that researchers need to consider the use of the case design in dealing with emergent issues. It may also help policy makers in the understanding and management of future public health advocacy campaigns regarding Covid-19 pandemic.

Multilingualism and the heteroglossia of ideologies in Lower Fungom (Cameroon)

Located at the northwestern edge of the Cameroonian Grassfields, Lower Fungom is a rural, linguistically highly diverse region (pop. ca. 12,000) where individual multilingualism in three local languages plus Cameroonian Pidgin English (henceforth CPE) is the norm, with a minority also speaking Cameroonian English. This article focuses on the different types of identity that can be projected via the use of English, CPE, and the local languages. Data come from language documentation projects and include self-reports, ethnographic observations, and analysis of language use. Such a diverse dataset allows us to uncover and discuss a number of aspects of the local language ideologies. Key here is the recognition that only exoglossic languages allow the representation of different identities qua membership in stereotypical categories – such as the case of English, which calls up stereotypes connected with authority and prestige – whereas the use of local languages is associated with village affiliation and, hence, relational rather than categorical identities. This ideological layer is not regimented by any form of prestige- or domain-based compartmentalization and, therefore, can hardly be captured by classical theories such as Fishman’s (1967) extended diglossia theory, whose limits in doing research on African rural settings are highlighted. Also, inspired by Jenks and Lee (2016), this article suggests the existence of a heteroglossia of ideologies of personal identity (relational vs. categorical) most likely determined by the relatively recent entry of English in the local language ecology.

Aging in Rural Communities: Advocacy Does Matter

Disparities in health care information and access often experienced by rural residents exacerbate health risks of older adults. The purpose of this symposium is to highlight efforts in varied rural settings to develop new information that contributes to identifying, assessing, and addressing the causes of these disparities, thus informing and strengthening advocacy and intervention. Mi and Ma address an unmet need for the description of challenges related to the extensive migration of Chinese rural workers and their families (46 million increase since 2011) that has exacerbated disparity of Social Security access. They describe barriers to establishing eligibility of these newly urban families for social services as they change from rural farmers to urban householders. Asman and Sisofo discuss barriers to working successfully with an alliance of diverse city, county, and state organizations to meet perceived needs of three categories of rural older adults: 1)active but denies aging, 2)adapting to aging and achieving satisfaction; and 3)dependent aging. Using a novel measure to determine true needs of their rural older communities resulted in benchmarks, which the alliance used in creating their strategic plan. Ford and colleagues tested a church-based program in a rural African American setting to facilitate chronic disease management. They tested the efficacy of utilizing online resources in underserved settings. Wiese and Williams investigated stakeholder perceptions/knowledge regarding dementia at six diverse rural sites. Although 71% of participants believed heart disease and poor diet increased dementia risk and were willing to be screened, only 15% had been tested for memory loss.

Diagnostic categories of mental illness in a rural African setting - the mhGAP experience in Edawu (Nigeria)

Mental health remains largely neglected in most low and middle income countries. There is undoubted need to build resources and consolidate training for staff, which is relevant to the mental health needs of the communities in Africa and practically feasible. In this study we present descriptive statistics of diagnostic categories in the patient group attending the outpatient clinics of Edawu---a community mental health center in rural Nigeria. The data shows disproportionately low numbers of clinical contacts for depression. The possible reasons are discussed and strategies including the use of the World Health Organization (WHO) mhGAP Intervention Guide are suggested for the way forward. The study also emphasizes on the potential of the mhGAP intervention guide not only as a tool of assessment and delivery of mental health services but also as a possible instrument of research with available resources.

Clustering of health risk behaviors among adolescents in Kilifi, Kenya, a rural Sub-Saharan African setting.

BackgroundAdolescents tend to experience heightened vulnerability to risky and reckless behavior. Adolescents living in rural settings may often experience poverty and a host of risk factors which can increase their vulnerability to various forms of health risk behavior (HRB). Understanding HRB clustering and its underlying factors among adolescents is important for intervention planning and health promotion. This study examines the co-occurrence of injury and violence, substance use, hygiene, physical activity, and diet-related risk behaviors among adolescents in a rural setting on the Kenyan coast. Specifically, the study objectives were to identify clusters of HRB; based on five categories of health risk behavior, and to identify the factors associated with HRB clustering.MethodsA cross-sectional survey was conducted of a random sample of 1060 adolescents aged 13–19 years living within the area covered by the Kilifi Health and Demographic Surveillance System. Participants completed a questionnaire on health behaviors which was administered via an Audio Computer-Assisted Self–Interview. Latent class analysis on 13 behavioral factors (injury and violence, hygiene, alcohol tobacco and drug use, physical activity, and dietary related behavior) was used to identify clustering and stepwise ordinal logistic regression with nonparametric bootstrapping identified the factors associated with clustering. The variables of age, sex, education level, school attendance, mental health, form of residence and level of parental monitoring were included in the initial stepwise regression model.ResultsWe identified 3 behavioral clusters (Cluster 1: Low-risk takers (22.9%); Cluster 2: Moderate risk-takers (67.8%); Cluster 3: High risk-takers (9.3%)). Relative to the cluster 1, membership of higher risk clusters (i.e. moderate or high risk-takers) was strongly associated with older age (p<0.001), being male (p<0.001), depressive symptoms (p = 0.005), school non-attendance (p = 0.001) and a low level of parental monitoring (p<0.001).ConclusionThere is clustering of health risk behaviors that underlies communicable and non-communicable diseases among adolescents in rural coastal Kenya. This suggests the urgent need for targeted multi-component health behavior interventions that simultaneously address all aspects of adolescent health and well-being, including the mental health needs of adolescents.

Cultural implications for learners’ effectiveness as governors of schools in rural South Africa

The South African Schools Act, 84 of 1996, articulates the establishment of School Governing Bodies, which authorises stakeholders such as parents, educators and learners to participate actively in decision-making processes pertaining to school governance. The Act further stipulates that learners, through the Representative Council of Learners, should be afforded full opportunity to participate in crucial decisions by the broader governing body. The reason for undertaking the study reported on here was triggered by the concern raised by various authors about the high level of ineffectiveness of learners as governors of schools in South Africa. This study explored and analysed the significance of culture in relation to learners’ effectiveness as governors of schools in rural South Africa. A qualitative research approach, based on a purposive sampling method and interviews, was espoused by engaging members of the Representative Council of Learners in certain selected high schools of the Harry Gwala district in KwaZulu-Natal. The findings of the empirical study investigation divulged that culture was one of the main impediments to learners’ effective school governance in the rural South African setting. The study recommends the intervention of the Department of Education, with the view of creating an environment conducive to active learner participation in school governance in rural areas.

Directed and target focused multi-sectoral adolescent HIV prevention: Insights from implementation of the 'DREAMS Partnership' in rural South Africa.

IntroductionThe “DREAMS Partnership” promotes a multi‐sectoral approach to reduce adolescent girls and young women's (AGYW) vulnerability to HIV in sub‐Saharan Africa. Despite widespread calls to combine structural, behavioural and biomedical HIV prevention interventions, this has not been delivered at scale. In this commentary, we reflect on the two‐year rollout of DREAMS in a high HIV incidence, rural and poor community in northern KwaZulu‐Natal, South Africa to critically appraise the capacity for a centrally co‐ordinated and AGYW‐focused approach to combination HIV prevention to support sustainable development for adolescents.DiscussionDREAMS employed a directed target‐focused approach in which local implementing partners were resourced to deliver defined packages to AGYW in selected geographical areas over two years. We argue that this approach, with high‐level oversight by government and funders, enabled the rapid roll‐out of ambitious multi‐sectoral HIV prevention for AGYW. It was most successful at delivering multiple interventions for AGYW when it built on existing infrastructure and competencies, and/or allocated resources to address existing youth development concerns of the community. The approach would have been strengthened if it had included a mechanism to solicit and then respond to the concerns of young women, for example gender‐related norms and how young women experience their sexuality, and if this listening was supported by versatility to adapt to the social context. In a context of high HIV vulnerability across all adolescents and youth, an over‐emphasis on targeting specific groups, whether geographically or by risk profile, may have hampered acceptability and reach of the intervention. Absence of meaningful engagement of AGYW in the development, delivery and leadership of the intervention was a lost opportunity to achieve sustainable development goals among young people and shift gender‐norms.ConclusionsCentrally directed and target‐focused scale‐up of defined packages of HIV prevention across sectors was largely successful in reaching AGYW in this rural South African setting rapidly. However, to achieve sustainable and successful long‐term youth development and transformation of gender‐norms there is a need for greater adaptability, economic empowerment and meaningful engagement of AGYW in the development and delivery of interventions. Achieving this will require sustained commitment from government and funders.

The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study

IntroductionAdministering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting.Materials and methodsParticipants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test–retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs).Results147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78–0.89) and EQ-5D VAS (0.73; 95% CI 0.64–0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62–0.82) and EQ-VAS (0.72; CI 0.62–0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels.ConclusionsText messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.

Parent-carers of children with physical disabilities in a rural South African setting: Their cultural and social resourcing

This study explored lived parent-carer experiences of children with physical disabilities in a rural South African setting. Participants were eight parent-carers (female = 8; age range = 40 to 50 years). The parent-carers completed semi-structured face-to-face interviews on the lived experience of caring for their children with physical disabilities. Findings from the thematic analysis suggest perceiving culturally conflicted advice from traditional healers and church leaders. The parent- carers also reported with diminished material and social support resources and transportation difficulties of getting their children to needed services.