Dispensing with marriage: Marital and partnership trends in rural KwaZulu-Natal, South Africa 2000-2006

This paper describes marriage and partnership patterns and trends in rural KwaZulu-Natal, South Africa from 2000-2006. The study is based on longitudinal, population-based data collected by the Africa Centre demographic surveillance system. We consider whether the high rates of non-marriage among Africans in South Africa reported in the 1980s were reversed following the political transformation underway by the 1990s. Our findings show that marriage has continued to decline with a small increase in cohabitation among unmarried couples, particularly in more urbanised areas. Comparing surveillance and census data, we highlight problems with the use of the ‘living together’ marital status category in a highly mobile population.cohabitation, demographic surveillance system, marriage, partnerships, South Africa, trends

A longitudinal population-based analysis of relationship status and mortality in KwaZulu-Natal, South Africa 2001–2011

BackgroundMortality risk is lower in married than in unmarried men and women. However, little is known about the association between mortality and relationship status in South Africa where marriage rates are low, migration is common, many couples are not co-resident and HIV prevalence is high.MethodUsing demographic surveillance data collected from 2001 to 2011, relationship status was categorised as conjugal (partners belong to the same household), non-conjugal (partners do not belong to the same household) or not partnered. Rates of relationship formation and dissolution were calculated by age and sex. Controlling for antiretroviral treatment (ART) introduction in 2005 as well as education, sex-specific and age-specific Cox proportional hazards models were used to investigate the association between relationship status and (1) all-cause mortality and (2) non-AIDS mortality.ResultsBefore 2005, individuals in conjugal relationships had a lower hazard of all-cause mortality in all age groups than not partnered men and women. Non-conjugal relationships lowered the risk of dying compared with not partnered men and women in fewer age groups. After ART introduction, the protective association of conjugal relationships was weaker but remained generally significant for men and women but not in non-conjugal relationships. In the later period, the association is reversed in young men (20–29?years) with mortality higher in conjugal and non-conjugal relationships compared with men not partnered. The analysis of non-AIDS deaths provided similar results.ConclusionsThe higher degree of social connections within a shared household environment that characterises conjugal relationships affords men and women greater protection against mortality

“It is better to die”: experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)

The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a “test and treat” approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves

An approach to measuring dispersed families with a particular focus on children 'left behind' by migrant parents: findings from rural South Africa

There is growing policy and academic interest in the conditions, experiences, and well-being of migrant families stretched across origin and destination households. In South Africa, the dispersal of children and migrant parents across multiple households is a commonplace childhood experience. However, in common with the broader international context, quantitative analyses of the social and residential connections between children and migrant parents in South Africa have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper describes a new data collection effort in the origin and destination households of migrants from rural KwaZulu-Natal and explains the methodology for using this data to examine multiple household contexts for children and parents. In order to illustrate the contribution that this form of data collection effort could make to family migration studies, the paper also presents results on the living arrangements of children ‘left behind’ by migrant parents; a potentially vulnerable group whose arrangements are challenging to examine with existing data sources. The empirical results show the majority (75%) of left behind children have previously migrated and a significant proportion of migrants' children (25%) were not living in their parent's origin or destination household. The findings highlight the need for careful measurement of the circumstances of left behind children and demonstrate the contribution of linked data for providing insights into the residential arrangements of migrants' children

The impact of adult mortality on household dissolution and migration in rural South Africa.

OBJECTIVE: To investigate the effect of adult death on household dissolution and migration. DESIGN: Demographic surveillance of the population in a rural area of northern KwaZulu Natal, South Africa. METHODS: Data on households resident in the surveillance area on 1 January 2000 were used to examine the effect of adult mortality and household risk factors on household dissolution and mobility between January 2000 and October 2002. Cox regression models were used to assess the risk of household dissolution and migration, controlling for multiple risk factors including causes of death, household composition and household assets. RESULTS: By October 2002, 238 households (2%) had dissolved and 874 (8%) migrated out of the area; 21% (2179) of all households had at least one adult death (18 years and older). Households where one or more adult members died during the follow-up period were four times more likely to dissolve, after controlling for household and community level risk factors [4.3; 95% confidence interval, (CI), 3.3-5.7]. The risk of dissolution was significantly higher in households with multiple deaths (2.3; 95% CI, 1.3-4.3). There were no significant differential risks associated with cause of death, age or sex of the deceased. Adult mortality in the household was not associated with migration. CONCLUSIONS: Poorer households, as measured by asset ownership, and households trying to cope with adult deaths are vulnerable to dissolution. The dramatic increase in adult mortality attributable to AIDS will increase the number of households that do not survive as a functional and cohesive social group

The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural KwaZulu-Natal, South Africa

The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART).Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression.380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children.Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed

Understanding family migration in rural South Africa: exploring children's inclusion in the destination households of migrant parents

Despite the removal of restrictions on movement and increasing female participation in migration, only a minority of migrant parents in South Africa include their children in their destination household. Quantitative analyses of the circumstances in which children accompany a migrant parent have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper uses data about members of rural households in a demographic surveillance population in KwaZulu-Natal and a linked sample survey of adult migrants to examine factors associated with children's inclusion in the destination household of migrant parents, analyse the timing and sequence of children's moves to parental destination households, and describe the composition of parental origin and destination households. The findings confirm that in contemporary South Africa, only a small percentage (14%) of migrants' children who are members of the parental origin household are also members of the parental destination household. Membership of the parental destination household is associated with parental characteristics and the child's age, but not measures of socio-economic status, and children most commonly migrate several years after their migrant parent. Children included in the destination household of migrant fathers frequently live in small households, which also include their mother, whereas children included in the destination household of migrant mothers live in larger households. This study contributes to understanding the contexts of children's inclusion in parental destination households in South Africa and demonstrates the potential of data collected in migrants' origin and destination households

Community perceptions of the socio-economic structural context influencing HIV and TB risk, prevention and treatment in a high prevalence area in the era of antiretroviral therapy.

Following calls for targeted HIV prevention interventions in so-called "hotspots", we explored subjective perceptions of community members in places considered to be high HIV and tuberculosis (TB) transmission areas and those with low prevalence. Although more people now have access to antiretroviral therapy (ART), some areas are still experiencing high HIV transmission rates, presenting a barrier to the elimination of HIV. A rapid qualitative assessment approach was used to access a sample of 230 people who contributed narratives of their experiences and perceptions of transmission, treatment and prevention of HIV and TB in their communities. Theoretical propositions case study strategy was used to inform and guide the thematic analysis of the data with Research Department of Epidemiology & Public Health, University College London, London, UK. Our results support the concept of linking perceived control to health through the identification of structural factors that increase communities' sense of agency. People in these communities did not feel they had the efficacy to effect change in their milieu. The few socio-economic opportunities promote social mobility in search of better prospects which may have a negative impact on community cohesion and prevention strategies. Communities were more concerned with improving their immediate social and economic situations and prioritised this above the prevention messages. Therefore approaches that focus on changing the structural and environmental barriers to prevention may increase people's perceived control. Multifaceted strategies that address the identified constructs of perceived control may influence the social change necessary to make structural interventions successful