Rural Southern Africa Research Articles

Life After Plastic-Wrapped Bodies: COVID, the State and the Crisis of Social Reproduction in Rural South Africa

ABSTRACT: This article explores the impact and implications of the South African state’s adoption of a tough militarized, bio-medical, and essentially neo-colonial approach to the management of the COVID pandemic in the rural former Bantustans (“native reserves”) of the country. It argues that, while the “war on COVID” produced new national legislation for all citizens, those living “with custom” in former homelands were said to possess cultural attributes that amplified the risk of infection and death. The paper focuses on how the state constructed measures for these spaces and managed social interaction and burials in the migrant heartlands. The paper suggests that families “living with custom” in the former homelands were treated differently from other citizens, existing in what Giorgio Agamben (2004) might call a “state of (greater) exception.” Villagers used the metaphor of the gate closing on them (ukuvala isango) to describe their experience and exclusion during lockdown as customary practices were banned, local health facilities closed for deep cleaning, and bodies sealed in plastic at state hospitals and mortuaries. The latter measures disturbed rural families much more than police violence or the closure of government clinics because it presented a serious threat to social reproduction. The paper provides evidence of how families fought to restore conviviality by exhuming the bodies wrapped in plastic to allow them to communicate with kin and ancestors. It also shows how, after lockdown, vaccination was often treated as a family matter not an individual choice, and how families moved quickly to fix the spiritual insecurities wrought by COVID. The paper concludes with a harrowing account of the new epidemic of hunger and malnutrition that is stalking these landscapes as conviviality is not enough to secure survival. The paper highlights the limits of narrow bio-medical and individual rights-based approaches in dealing with health, livelihoods, and well-being in communities devastated by COVID in rural southern Africa.

An Assessment of Parental Involvement in the Supplementary Feeding Programme in Early Childhood Development in Rural Southern Africa

This conceptual discourse interrogates the contributions and challenges faced by parents in supporting the supplementary feeding programme at the Early Childhood Development (ECD) level in rural Southern Africa. This conceptual paper is a literature review study that relies on secondary data to draw the findings. The research hinges on Maslow’s hierarchy of needs and Epstein’s theory of overlapping spheres of influence. The study notes that parents play an important role in supporting the programme through activities such as the construction of cooking sheds, providing relish, fetching firewood, cleaning, and serving meals. Factors such as lack of knowledge, financial constraints, lack of cooperation, poor communication, and time constraints hinder their ability to make a sustained and effective contribution to the programme. The study recommends that parents be educated about the benefits of the supplementary feeding programme, empowered with various projects to improve their economic status, and encouraged to contribute to the programme. Another recommendation is that the school should build strong relationships with the corporate world, government, and non-governmental organisations so that they can work with parents to participate fully in the programme.

Nosocomial Respiratory Infections in a Rural Zambian Hospital.

The burden of nosocomial respiratory infections in rural southern Africa is poorly understood. We established a surveillance program at a rural Zambian hospital to detect influenza-like illness (ILI) and respiratory infections among hospitalized patients and a cohort of healthcare workers (HCWs). Nasopharyngeal specimens from symptomatic patients and HCWs underwent broadly multiplexed molecular testing to detect viruses and atypical bacteria. During 1 year of surveillance, 15 patients (1.7% of admissions) developed ILI more than 48 hours after admission. Among 44 HCWs, 19 (43%) experienced at least one ILI episode, with a total of 31 ILI episodes detected. Respiratory viruses were detected in 45% of patient and 55% of HCW specimens. The cumulative incidence of influenza infection among HCWs over 1 year was 9%. Overall, respiratory viruses were commonly found among patients and HCWs in a rural Zambian hospital with limited infection control infrastructure.

Decentralising NCD management in rural southern Africa: evaluation of a pilot implementation study

BackgroundThe prevalence of non-communicable diseases, and associated morbidity and mortality, is increasing rapidly in low and middle-income countries where health systems often have limited access and lower quality of care. The intervention was to decentralise uncomplicated non-communicable disease (NCD) care from a hospital to nurse practitioners in health centres in a poor rural district in Eswatini, southern Africa. The objective of this study was to assess the feasibility and impact of decentralised care for NCDs within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings.MethodsIn collaboration with the Eswatini Ministry of Health, we developed and implemented a package of interventions to support nurse-led delivery of care, including: clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. Ten community clinics in the Lubombo Region of Eswatini were randomly selected to be trained to deliver NCD care for a period of 18 months. Observational data on follow-up rates, blood pressure (BP), glucose etc. were recorded and evaluated. We compared blood pressure and blood glucose measurements between the first and fourth visits and fitted a linear mixed effects model.ResultsOne thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean BP among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic (p = 0.01), and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l (p = 0.2). Key components of NCD care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines.ConclusionsThe findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.

Current and Potential Future Seasonal Trends of Indoor Dwelling Temperature and Likely Health Risks in Rural Southern Africa.

Climate change has resulted in rising temperature trends which have been associated with changes in temperature extremes globally. Attendees of Conference of the Parties (COP) 21 agreed to strive to limit the rise in global average temperatures to below 2 °C compared to industrial conditions, the target being 1.5 °C. However, current research suggests that the African region will be subjected to more intense heat extremes over a shorter time period, with projections predicting increases of 4–6 °C for the period 2071–2100, in annual average maximum temperatures for southern Africa. Increased temperatures may exacerbate existing chronic ill health conditions such as cardiovascular disease, respiratory disease, cerebrovascular disease, and diabetes-related conditions. Exposure to extreme temperatures has also been associated with mortality. This study aimed to consider the relationship between temperatures in indoor and outdoor environments in a rural residential setting in a current climate and warmer predicted future climate. Temperature and humidity measurements were collected hourly in 406 homes in summer and spring and at two-hour intervals in 98 homes in winter. Ambient temperature, humidity and windspeed were obtained from the nearest weather station. Regression models were used to identify predictors of indoor apparent temperature (AT) and to estimate future indoor AT using projected ambient temperatures. Ambient temperatures will increase by a mean of 4.6 °C for the period 2088–2099. Warming in winter was projected to be greater than warming in summer and spring. The number of days during which indoor AT will be categorized as potentially harmful will increase in the future. Understanding current and future heat-related health effects is key in developing an effective surveillance system. The observations of this study can be used to inform the development and implementation of policies and practices around heat and health especially in rural areas of South Africa.

Factors impeding the use of banking services in rural Southern African states

The paper presents factors why people are reluctant to bank money in rural Southern African countries. Six countries namely Botswana, Namibia, Mozambique, Tanzania, Zambia and Zimbabwe were used in the study. A focus group of 10 people from each of the stated Southern African countries was composed and used to obtain perceptions, views, reactions, attitudes, experiences among others on why people are reluctant to bank their money. People are unwilling to bank their money in rural Southern Africa and the reasons behind this seem to be many. If no correctional measures are put in place, rural Southern Africa will continue to be unbanked for the next five decades.

AIDS-affected young people’s access to livelihood assets: Exploring ‘new variant famine’ in rural southern Africa

The ‘new variant famine’ hypothesis suggests AIDS is contributing to food insecurity in southern Africa. Proposed causal mechanisms include a loss of livelihood assets and skills, brought about through AIDS′ impacts on children’s access to inherited property and intergenerationally-transferred knowledge. This paper employs a sustainable livelihoods framework to examine how AIDS is impacting on young people’s access to assets and skills in two southern African countries: Malawi and Lesotho. Drawing on qualitative research with rural youth, the paper shows that AIDS affects some young people’s access to some livelihood assets, but does not do so in a systematic or predictable way, nor are its impacts invariably negative. The broader cultural and institutional context is of key importance. The paper also demonstrates the need for the sustainable livelihoods framework to take greater account of the temporalities of livelihoods, and in particular the significance of lifecourse and generation.

Clinical and socio-demographic predictors for virologic failure in rural Southern Africa: preliminary findings from CART-1.

IntroductionIn 2013, the World Health Organization (WHO) recommended scaling up of routine viral load (VL) monitoring for patients on antiretroviral therapy (ART) in resource-limited settings [1]. During the transition phase from no VL-testing at all to routine VL-monitoring, targeted VL for groups at particular risk of virologic failure (VF) may be an option [2]. We present socio-demographic and clinical risk factors for VF in a cohort in rural Lesotho with no access to VL prior to the study.Materials and MethodsData derive from a cross-sectional study providing multi-disease screening as well as VL testing to adult patients (≥16 years old) on first-line ART ≥6 months [3]. VF was defined as VL≥1000 copies/mL. Assessed potential predictors of VF were: (1) socio-demographic (sex, age, wealth-quintile, education, employment status, disclosure of HIV status to environment, travel-time to facility); (2) treatment history (history of treatment interruption >2 days, previous drug substitution within first-line ART, time on ART, ART-base and -backbone); (3) adherence (pill count) and (4) clinical (clinical or immunological failure as defined by WHO guidelines [1], presence of papular pruritic eruption (PPE)). All variables with association to VF in univariate analysis were included in a multivariate logistic regression reporting adjusted Odds ratios (aOR).ResultsData from 1,488 patients were analyzed. Overall VF-prevalence was 6.9% (95% CI 5.7–8.3). In univariate analysis, the following were associated with VF: age <30, lower wealth-quintile, no primary education, history of treatment interruption, nevirapine-base, zidovudine-backbone, history of drug substitution, travel-time to clinic ≥2 hours, disclosure of HIV status to <5 persons, clinical failure, presence of PPE and immunological failure. In multivariate analysis, 6 out of the above 12 variables were independent predictors: age <30 years (aOR: 2.4; 95% CI 1.1–5.3, p=0.029), history of treatment interruption (2.5; 1.3–4.7, p=0.005), PPE (6.9; 2.5–18.9, p<0.001), immunological failure (11.5; 5.7–23.2, p<0.001), history of drug substitution (1.9; 1.0–3.7, p=0.043), disclosure of HIV status to <5 persons (1.8; 1.1–3.1, p=0.03).ConclusionIn this cohort in rural Lesotho, several socio-demographic and clinical predictors were associated with VF. Particularly age <30 years, history of treatment interruption, PPE and immunological failure were strongly associated with VF. These patients may be prioritized for targeted VL-testing.

Development of a locally sustainable functional food based on mutandabota, a traditional food in southern Africa

A probiotic dairy product was developed on the basis of a traditional dish called mutandabota to enable resource-poor populations in southern Africa to benefit from a functional food. Mutandabota is widely consumed in rural southern Africa, making it an ideal food matrix to carry probiotics. First, a process to produce probiotic mutandabota was designed. Raw cow milk was boiled and subsequently cooled to ambient temperature (25°C). Next, dry pulp from the fruit of the baobab tree (Adansonia digitata L.) was added to the milk at a concentration of 4% (wt/vol). This mixture was inoculated with the probiotic Lactobacillus rhamnosus yoba and left to ferment for 24h, while the growth of the bacterial culture was monitored. Final ingredients were then added to produce probiotic mutandabota that had 14% (wt/vol) baobab fruit pulp and 7% (wt/vol) sugar in cow milk. The pH of probiotic mutandabota was pH 3.5, which ensures that the product is microbiologically safe. The viable plate count of L. rhamnosus yoba increased from 5.8±0.3 log cfu/mL at the point of inoculation to 8.8±0.4 log cfu/mL at the moment of consumption, thereby meeting the criterion to have a viable count of the probiotic bacterium in excess of 6 log cfu/mL of a product. Baobab fruit pulp at 4% promoted growth of L. rhamnosus yoba with a maximal specific growth rate (μmax) of 0.6±0.2/h at 30°C. The developed technology, though specific for this particular product, has potential to be applied for the delivery of probiotics through a variety of indigenous foods in different regions of the world. Upon consumption, probiotic mutandabota is expected to improve the population's intestinal health, which is especially relevant for vulnerable target groups such as children and elderly people.

Development and testing of models of tuberculosis contact tracing in rural southern Africa.

A regional hospital in rural Swaziland. To evaluate a hospital-based contact screening programme and test approaches to improve its effectiveness. An evaluation and quality improvement study of tuberculosis (TB) contact tracing services. Hospital-based TB contact tracing led to screening of 157 (24%) of 658 contacts; of these, 4 (2.5%) were diagnosed with TB. Of 68 contacts eligible for human immunodeficiency virus (HIV) testing and counselling, 45 (66%) were tested and 7/45 (16%) were identified as HIV-positive. Twelve (50%) of 24 screened contacts aged <5 years were provided isoniazid prophylaxis. Three enhanced models of TB contact tracing were piloted to screen contacts in the community. Although some enhanced models screened large numbers of contacts, no contacts were diagnosed with TB. Contact tracing of household members conducted in TB clinics within hospital settings is effective in high-burden, low-income settings, and can be provided using current resources. Enhanced household contact tracing models that followed up contacts in the community were not found to be effective. Additional resources would be required to provide household TB contact tracing in the community.

Childhood Psychological Problems in School Settings in Rural Southern Africa

BackgroundMany children can be exposed to multiple adversities in low and middle-income countries (LMICs) placing them at potential risk of psychological problems. However, there is a paucity of research using large representative cohorts examining the psychological adjustment of children in school settings in these countries. Children’s psychological adjustment has been shown to affect educational progress which is critical for their future. This study, based in a rural, socio-economically disadvantaged area of South Africa, aimed to examine the prevalence of children’s psychological problems as well as possible risk and protective factors.MethodsRates of psychological problems in 10–12 year olds were examined using teacher- and child-report questionnaires. Data on children from 10 rural primary schools, selected by stratified random sampling, were linked to individual and household data from the Agincourt health and socio-demographic surveillance system collected from households over 15 years.ResultsA total of 1,025 children were assessed. Teachers identified high levels of behavioural and emotional problems (41%). Children reported lower, but substantial rates of anxiety/depression (14%), and significant post-traumatic stress symptoms (24%); almost a quarter felt unsafe in school. Risk factors included being a second-generation former refugee and being from a large household. Protective factors highlight the importance of maternal factors, such as being more educated and in a stable partnership.ConclusionThe high levels of psychological problems identified by teachers are a serious public health concern, as they are likely to impact negatively on children’s education, particularly given the large class sizes and limited resources in rural LMIC settings. Despite the high levels of risk, a proportion of children were managing well and research to understand resilience could inform interventions.

The spatial construction of young people's livelihoods in rural southern Africa

ABSTRACTYoung people in southern Africa, in common with young people around the world, are social agents, constructing their own lives, albeit within significant structural constraints. Unlike young people in some regions, for most the need to generate a livelihood is a key consideration. Livelihood construction is a profoundly spatial activity, yet while there have been a number of studies of the spatial construction of young people's livelihoods in African cities, the spatiality of rural livelihoods has received less attention. Rural environments pose particular challenges for livelihood construction, and require particular spatial strategies. Four are discussed here: accessing education and training; migration for work; developing extensive social networks; and producing for markets. There are, however, aspects of the spatial structuring of rural southern African societies that seriously constrain the pursuit of productive livelihoods by young people. Two are considered: migration (for reasons unconnected with young people's livelihoods) and marriage practices.

Outcomes of Antiretroviral Treatment Programs in Rural Southern Africa

Data on outcomes of antiretroviral treatment (ART) programs in rural sub-Saharan African are scarce. We describe early losses and long-term outcomes in 6 rural programs in Southern Africa with limited access to viral load monitoring and second-line ART. Patients aged ≥16 years starting ART in 2 programs each in Zimbabwe, Mozambique, and Lesotho were included. We evaluated risk factors for no follow-up after starting ART and mortality and loss to follow-up (LTFU) over 3 years of ART, using logistic regression and competing risk models. Odds ratios and subdistribution hazard ratios, adjusted for gender, age category, CD4 category, and World Health Organization stage at start of ART are reported. Among 7725 patients, 449 (5.8%) did not return after initiation of ART. During 9575 person-years, 698 (9.6%) of those with at least 1 follow-up visit died, and 1319 (18.1%) were LTFU. At 3 years, the cumulative incidence of death and LTFU were 12.5% (11.5%-13.5%) and 25.4% (24.0%-26.9%), respectively, with important differences between countries as follows: in Zimbabwe 75.1% (72.8%-77.3%) were alive and on ART at 3 years compared with 55.4% (52.8%-58.0%) in Lesotho and 51.6% (48.0%-55.2%) in Mozambique. In all settings, young age and male gender predicted LTFU, whereas advanced clinical stage and low baseline CD4 counts predicted death. In African ART programs with limited access to second-line treatment, mortality, and LTFU are high in the first 3 years of ART. Low retention in care is a major threat to the sustainability of ART delivery in Southern Africa, particularly in rural sites.

Youth, AIDS and Rural Livelihoods in Southern Africa

AbstractAIDS, in interaction with other factors, is impacting on the livelihood activities, opportunities and choices of young people in southern Africa. This article explores these linkages firstly by reviewing what is known about the impacts of AIDS on young people, before looking more specifically at how this impinges on their future ability to secure livelihoods. Within the home and family, AIDS often results in youth taking on a heavy burden of responsibilities. This can include caring for sick relatives, helping with chores and taking on paid employment. This burden of care and work can have further impacts on young people's future livelihoods as they find they have reduced access to schooling, potential loss of inheritance and a breakdown in the intergenerational transfer of knowledge, which is especially important for sustained agricultural production. The article ends by suggesting that the sustainable livelihoods approach can be useful for understanding the complexity of the issues surrounding the impacts of AIDS on young people's livelihoods and calls for further research to explore how their access to future sustainable livelihoods in rural southern Africa might be supported.

Health, population and social transitions in rural South Africa

It is now 13 years since the political liberation of South Africa – a rollercoaster period through which citizens of the ‘‘rainbow nation’’ have struggled to live up, individually and as a people, to the ideals articulated by visionaries that include Nobel laureates Nelson Mandela and Desmond Tutu. The country’s near-miraculous peaceful transition from apartheid rule to genuine democracy inspired the world community, providing a springboard for President Thabo Mbeki to launch continent-wide initiatives, pre-eminently the New Partnership for Africa’s Development (NEPAD). In parallel with such inspirational efforts has been the difficult, down-to-earth business of building a competent system of government and establishing a stable macro-economic and social environment responsive to the nation’s citizenry, especially the poor and vulnerable. The apartheid legacy of inadequate education and high unemployment, poverty and extreme inequality, and exaggerated emphasis on that which divides rather than unites people, is proving deeply embedded in the fabric of modern South Africa – more so perhaps than national leadership appreciated. In such circumstances, there is no substitute for informed leadership and astute decision-making that takes the longas well as short-term view. This in turn depends – as Adetokunbo Lucas put it – on generating the necessary ‘‘intelligence’’: information that is valid, responds to strategic priorities and captures change over time. While progress has been made – with the efforts of the Medical Research Council, Statistics South Africa, Human Sciences Research Council and key university-linked groups standing out – we submit that South Africa today faces a real ‘‘crisis of evidence’’. This is reflected in the limited availability of empirically-derived population-based data, weak investments to support their production, and limited public sector capacity to absorb, sift, interpret and respond to findings. The situation has been fuelled by the counter-scientific stance that, until recently, characterised government’s response to HIV/AIDS. This volume – comprising some 20 peer-reviewed articles and accompanying commentaries – is part of an effort to address this gap in information and understanding. Work demonstrates the unusual utility of health and demographic surveillance when characterising the dramatic transitions underway in South Africa today, and the exceptional R&D platform that such infrastructure can provide. The study site is part of a district barely 25 miles west of the southern Mozambique border, this rendering it part of north-eastern South Africa and integral to a cross-border region of rural Southern Africa – thereby amplifying the relevance and applicability of data and findings.

Defining a project life-cycle for implementating a high-tech project in rural southern africa - a case study

Bridging the gap between first world practices and third world needs remains a topic for continuous debate, research and experimentation. Although the practices of project management are deemed to be generally and universally applicable, the success rate of projects in the developing world is questionable.

Dog ecology and demography information to support the planning of rabies control in Machakos District, Kenya

A study of 150 dog-owning households from six randomly selected sublocations was conducted in Machakos District, Kenya. Initially, all households were visited to collect information on dog ecology and demography based on WHO guidelines and to collect serum for rabies antibody detection. A second visit was made 1 year later, to obtain follow-up data on births, deaths, dog movements and other events since the first visit. Dog ownership was common, with a range of 53–81% (mean=63%) of households owning dogs in the six sublocations. Dog density for the five more rural sublocations ranged from 6 to 21 dogs km −2 and for the peri-urban sublocation was 110 dogs km −2. The dog population was estimated to be growing at 9% p.a. (95% C.I. 4–14%). This growth was a function of very high fecundity (1.3 females per female per year) more than compensating for high mortality, particularly among females. Life expectancy from birth was 3.5 years for males and 2.4 years for females. Half the dogs at any one time were less than 1 year of age. All dogs, by design of the study, were owned. Of these, 69% were never restricted and roamed freely to forage for food and mix with other dogs. Only a small proportion of dogs (5%) were fed commercial dog food. Most households reported observing dogs scavenging their garbage, including: their own dogs (81%), their neighbours’ dogs (75%) and unknown dogs (45%). Only 29% of dogs at least 3 months of age were reported to be vaccinated against rabies. The proportion vaccinated varied widely between sublocations (5–68%); 48% of dogs reportedly vaccinated had detectable antibodies, 31% at or above levels considered to indicate seroconversion. The proportion of dogs with detectable antibodies declined according to the time since last vaccination (55% if vaccinated ≤1 year, 47% ≤2 years and 36% >2 years); 20% of dogs reported not to have been vaccinated had detectable rabies antibody. Compared to other dog populations in rural eastern and southern Africa, Machakos District has a high density of dogs. The Machakos dog population is growing, highly dynamic, poorly supervised and inadequately vaccinated against rabies. The main implication for rabies control is that adequate vaccination coverage is unlikely to be achieved, even under optimal delivery, using the current strategy of annual vaccination of dogs older than 3 months.

Beekeeping and Local Self‐Reliance in Rural Southern Africa

Beekeeping has the potential to supplement incomes in rural southern Africa. In light of regional economic constraints, self‐reliance strategies that draw on local knowledge and skills take on a renewed importance. We consider the advantages and disadvantages of beekeeping and examine appropriate forms of development support. A short case study from Zimbabwe illustrates these issues.

Beekeeping and Local Self-Reliance in Rural Southern Africa

Beekeeping and Local Self-Reliance in Rural Southern Africa

Providing Grassroots Social Services to Women and Children in Rural Southern Africa: A Roundtable Discussion

The state of Lesotho, which became independent from Great Britain in 1966, is completely surrounded by South Africa, a geographic encapsulation that is reflected in its economic dependency. Nevertheless, Lesotho is not a South African homeland; it is an internationally recognized, independent country, and as such is eligible for international aid, like other countries in southern Africa such as Botswana and Swaziland. This eligibility, unfortunately, has not served to catalyze the country's economic development, and the government is becoming increasingly indebted to foreign donor agencies. Less than 15 percent of Lesotho's land is arable-all in the lowlands, which are overpopulated, not only with people1 but also with livestock. To produce wool and mohair for international markets, Lesotho's people, the Basotho, herd sheep and goats as well as cattle. Overgrazing, together with irregular rainfall, has contributed to increasing soil erosion. Lesotho has not been self-sufficient in agricultural production since the 1930s.