Phyllis Mushati

The Biomedical Research and Training Institute, Salisbury, Harare, Zimbabwe

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Publications (30)145.3 Total impact

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    ABSTRACT: Background Unconditional and conditional cash transfer programmes (UCT and CCT) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS (OVC). We address the gap in current understanding about the extent to which household-based cash transfers differentially impact individual children’s outcomes, according to risk or protective factors such as orphan status and household assets. Methods Data were obtained from a cluster-randomised controlled trial in eastern Zimbabwe, with random assignment to three study arms – UCT, CCT or control. The sample included 5,331 children ages 6-17 from 1,697 households. Generalized linear mixed models were specified to predict OVC health vulnerability (child chronic illness and disability) and social protection (birth registration and 90% school attendance). Models included child-level risk factors (age, orphan status); household risk factors (adults with chronic illnesses and disabilities, greater household size); and household protective factors (including asset-holding). Interactions were systematically tested. Results Orphan status was associated with decreased likelihood for birth registration, and paternal orphans and children for whom both parents’ survival status was unknown were less likely to attend school. In the UCT arm, paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans. Effects of study arms on outcomes were not moderated by any other risk or protective factors. High household asset-holding was associated with decreased likelihood of child’s chronic illness and increased birth registration and school attendance, but household assets did not moderate the effects of cash transfers on risk or protective factors. Conclusion Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based settings. UCT and CCT each produced direct effects on children’s social protection which are not moderated by other child- and household-level risk factors, but orphans are less likely to attend school or obtain birth registration. The effects of UCT and CCT are not moderated by asset-holding, but greater household assets predict greater social protection outcomes. Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children. These efforts might include caregiver education, and additional incentives based on efforts made specifically for orphaned children.
    BMC Public Health 05/2015; 15(1). DOI:10.1186/s12889-015-1857-4 · 2.32 Impact Factor
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    ABSTRACT: Evidence suggests that a regular and reliable transfer of cash to households with orphaned and vulnerable children has a strong and positive effect on child outcomes. However, conditional cash transfers are considered by some as particularly intrusive and the question on whether or not to apply conditions to cash transfers is an issue of controversy. Contributing to policy debates on the appropriateness of conditions, this article sets out to investigate the overall buy-in of conditions by different stakeholders and to identify pathways that contribute to an acceptability of conditions. The article draws on data from a cluster-randomized trial of a community-led cash transfer programme in Manicaland, eastern Zimbabwe. An endpoint survey distributed to 5167 households assessed community members' acceptance of conditions and 35 in-depth interviews and 3 focus groups with a total of 58 adults and 4 youth examined local perceptions of conditions. The study found a significant and widespread acceptance of conditions primarily because they were seen as fair and a proxy for good parenting or guardianship. In a socio-economic context where child grants are not considered a citizen entitlement, community members and cash transfer recipients valued the conditions associated with these grants. The community members interpreted the fulfilment of the conditions as a proxy for achievement and merit, enabling them to participate rather than sit back as passive recipients of aid. Although conditions have a paternalistic undertone and engender the sceptics' view of conditions being pernicious and even abominable, it is important to recognize that community members, when given the opportunity to participate in programme design and implementation, can take advantage of conditions and appropriate them in a way that helps them manage change and overcome the social divisiveness or conflict that otherwise may arise when some people are identified to benefit and others not.
    Health Policy and Planning 10/2014; 29(7):809-817. DOI:10.1093/heapol/czt060 · 3.00 Impact Factor
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    ABSTRACT: In an HIV/AIDS epidemic driven primarily by heterosexual transmission, it is important to have an understanding of the human sexual behaviour patterns that influence transmission. We analysed the distribution and predictors of within-partnership sexual behaviour and condom use in rural Zimbabwe and generated parameters for use in future modelling analyses. A population-based cohort was recruited from a household census in 12 communities. A baseline survey was carried out in 1998-2000 with follow-up surveys after 3 and 5 years. Statistical distributions were fitted to reported within-partnership numbers of total, unprotected and protected sex acts in the past two weeks. Multilevel linear and logistic regression models were constructed to assess predictors of the frequency of unprotected sex and consistent condom use. A normal distribution of ln(sex acts+1) provided the best fit for total and unprotected sex acts for men and women. A negative binomial distribution applied to the untransformed data provided the best fit for protected sex acts. Condom use within partnerships was predominantly bimodal with at least 88% reporting zero or 100% use. Both men and women reported fewer unprotected sex acts with non-regular compared to regular partners (men: 0.26 fewer every two weeks (95% confidence interval 0.18-0.34); women: 0.16 (0.07-0.23)). Never and previously married individuals reported fewer unprotected sex acts than currently married individuals (never married men: 0.64 (0.60-0.67); previously married men: 0.59 (0.50-0.67); never married women: 0.51 (0.45-0.57); previously married women: 0.42 (0.37-0.47)). These variables were also associated with more consistent condom use. We generated parameters that will be useful for defining transmission models of HIV and other STIs, which rely on a valid representation of the underlying sexual network that determines spread of an infection. This will enable a better understanding of the spread of HIV and other STDs in this rural sub-Saharan population.
    PLoS ONE 02/2014; 9(2):e88378. DOI:10.1371/journal.pone.0088378 · 3.53 Impact Factor
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    ABSTRACT: We used baseline data, collected in July–September 2009, from a randomized controlled trial of a cash transfer program for vulnerable children in eastern Zimbabwe to investigate the effectiveness, coverage, and efficiency of census- and community-based targeting methods for reaching vulnerable children. Focus group discussions and in-depth interviews with beneficiaries and other stakeholders were used to explore community perspectives on targeting. Community members reported that their participation improved ownership and reduced conflict and jealousy. However, all the methods failed to target a large proportion of vulnerable children and there was poor agreement between the community- and census-based methods.
    World Development 02/2014; 54(100). DOI:10.1016/j.worlddev.2013.09.002 · 1.73 Impact Factor
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    ABSTRACT: Background Cash transfer programmes are increasingly recognised as promising and scalable interventions that can promote the health and development of children. However, concerns have been raised about the potential for cash transfers to contribute to social division, jealousy and conflict at a community level. Against this background, and in our interest to promote community participation in cash transfer programmes, we examine local perceptions of a community-led cash transfer programme in Eastern Zimbabwe. Methods We collected and analysed data from 35 individual interviews and three focus group discussions, involving 24 key informants (community committee members and programme implementers), 24 cash transfer beneficiaries, of which four were youth, and 14 non-beneficiaries. Transcripts were subjected to thematic analysis and coding to generate concepts. Results Study participants described the programme as participatory, fair and transparent – reducing the likelihood of jealousy. The programme was perceived to have had a substantial impact on children’s health and education, primarily through aiding parents and guardians to better cater for their children’s needs. Moreover, participants alluded to the potential of the programme to facilitate more transformational change, for example by enabling families to invest money in assets and income generating activities and by promoting a community-wide sense of responsibility for the support of orphaned and vulnerable children. Conclusion Community participation, combined with the perceived impact of the cash transfer programme, led community members to speak enthusiastically about the programme. We conclude that community-led cash transfer programmes have the potential to open up for possibilities of participation and community agency that enable social acceptability and limit social divisiveness.
    BMC Public Health 04/2013; 13(1):342. DOI:10.1186/1471-2458-13-342 · 2.32 Impact Factor
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    ABSTRACT: BACKGROUND: Cash-transfer programmes can improve the wellbeing of vulnerable children, but few studies have rigorously assessed their effectiveness in sub-Saharan Africa. We investigated the effects of unconditional cash transfers (UCTs) and conditional cash transfers (CCTs) on birth registration, vaccination uptake, and school attendance in children in Zimbabwe. METHODS: We did a matched, cluster-randomised controlled trial in ten sites in Manicaland, Zimbabwe. We divided each study site into three clusters. After a baseline survey between July, and September, 2009, clusters in each site were randomly assigned to UCT, CCT, or control, by drawing of lots from a hat. Eligible households contained children younger than 18 years and satisfied at least one other criteria: head of household was younger than 18 years; household cared for at least one orphan younger than 18 years, a disabled person, or an individual who was chronically ill; or household was in poorest wealth quintile. Between January, 2010, and January, 2011, households in UCT clusters collected payments every 2 months. Households in CCT clusters could receive the same amount but were monitored for compliance with several conditions related to child wellbeing. Eligible households in all clusters, including control clusters, had access to parenting skills classes and received maize seed and fertiliser in December, 2009, and August, 2010. Households and individuals delivering the intervention were not masked, but data analysts were. The primary endpoints were proportion of children younger than 5 years with a birth certificate, proportion younger than 5 years with up-to-date vaccinations, and proportion aged 6-12 years attending school at least 80% of the time. This trial is registered with ClinicalTrials.gov, number NCT00966849. FINDINGS: 1199 eligible households were allocated to the control group, 1525 to the UCT group, and 1319 to the CCT group. Compared with control clusters, the proportion of children aged 0-4 years with birth certificates had increased by 1·5% (95% CI -7·1 to 10·1) in the UCT group and by 16·4% (7·8-25·0) in the CCT group by the end of the intervention period. The proportions of children aged 0-4 years with complete vaccination records was 3·1% (-3·8 to 9·9) greater in the UCT group and 1·8% (-5·0 to 8·7) greater in the CCT group than in the control group. The proportions of children aged 6-12 years who attended school at least 80% of the time was 7·2% (0·8-13·7) higher in the UCT group and 7·6% (1·2-14·1) in the CCT group than in the control group. INTERPRETATION: Our results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa, but further evidence is needed for the comparative effectiveness of UCT and CCT programmes in this region. FUNDING: Wellcome Trust, the World Bank through the Partnership for Child Development, and the Programme of Support for the Zimbabwe National Action Plan for Orphans and Vulnerable Children.
    The Lancet 02/2013; 381(9874). DOI:10.1016/S0140-6736(12)62168-0 · 45.22 Impact Factor
  • Journal of the International AIDS Society 10/2012; · 4.21 Impact Factor
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    ABSTRACT: Census data, collected in July 2009, from 27,672 children were used to compare the effectiveness, coverage and efficacy of three household-based methods for targeting cash transfers to vulnerable children in eastern Zimbabwe: targeting the poorest households using a wealth index; targeting HIV-affected households using socio-demographic information (households caring for orphans, chronically-ill or disabled members; child-headed households); and targeting labour-constrained households using dependency ratios. All three methods failed to identify large numbers of children with poor social and educational outcomes. The wealth index approach was the most efficient at reaching children with poor outcomes whilst socio-demographic targeting reached more vulnerable children but was less efficient.
    Social Science [?] Medicine 10/2012; 75(12). DOI:10.1016/j.socscimed.2012.09.031 · 2.56 Impact Factor
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    ABSTRACT: To compare socio-demographic patterns in access to antiretroviral therapy (ART) across four community HIV cohort studies in Africa. Data on voluntary counselling and testing and ART use among HIV-infected persons were analysed from Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and Manicaland (Zimbabwe), where free ART provision started between 2004 and 2007. ART coverage was compared across sites by calculating the proportion on ART among those estimated to need treatment, by age, sex and educational attainment. Logistic regression was used to identify socio-demographic characteristics associated with undergoing eligibility screening at an ART clinic within 2 years of being diagnosed with HIV, for three sites with information on diagnosis and screening dates. Among adults known to be HIV-infected from serological surveys, the proportion who knew their HIV status was 93% in Karonga, 37% in Kisesa, 46% in Masaka and 25% in Manicaland. Estimated ART coverage was highest in Masaka (68%) and lowest in Kisesa (2%). The proportion of HIV-diagnosed persons who were screened for ART eligibility within 2 years of diagnosis ranged from 14% in Kisesa to 84% in Masaka, with the probability of screening uptake increasing with age at diagnosis in all sites. Higher HIV testing rates among HIV-infected persons in the community do not necessarily correspond with higher uptake of ART, nor more equitable treatment coverage among those in need of treatment. In all sites, young adults tend to be disadvantaged in terms of accessing and initiating ART, even after accounting for their less urgent need.
    Tropical Medicine & International Health 08/2012; 17(8):e38-48. DOI:10.1111/j.1365-3156.2011.02925.x · 2.30 Impact Factor
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    ABSTRACT: Abstract The high prevalence of human immunodeficiency virus/acquired immune deficiency syndrome in sub-Saharan Africa has resulted in a dramatic increase in orphans and vulnerable children (OVC) over the past decade. These children typically rely on extended family networks for support, but the magnitude of the crisis has resulted in traditional familial networks becoming overwhelmed and more economically and socially vulnerable. Previous research consistently demonstrates the positive influence of household asset ownership on children's well-being. Using data from impoverished households caring for OVC in rural Manicaland Province, Zimbabwe, this study explores the influence of household asset ownership on OVC health vulnerability (HV) and social vulnerability (SV). Findings indicate that asset ownership is associated with significantly lower SV, in terms of school attendance and birth registration. Yet, assets do not emerge as a direct influence of OVC HV as measured by disease and chronic illness, although having a chronically ill adult in the household increases HV. These findings suggest that asset ownership, specifically a combination of fixed and movable assets, may offset the influence of other risk factors for children's SV.
    AIDS Care 05/2012; DOI:10.1080/09540121.2012.687812 · 1.60 Impact Factor
  • Sexually Transmitted Infections 07/2011; 87(Suppl 1):A37-A38. DOI:10.1136/sextrans-2011-050109.36 · 3.08 Impact Factor
  • Sexually Transmitted Infections 07/2011; 87:A197-A197. DOI:10.1136/sextrans-2011-050108.228 · 3.08 Impact Factor
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    ABSTRACT: Social capital—especially through its “network” dimension (high levels of participation in local community groups)—is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998–2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities—often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.
    Population and Development Review 06/2011; 37(2):333 - 359. DOI:10.1111/j.1728-4457.2011.00413.x · 2.22 Impact Factor
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    ABSTRACT: To add to the evidence on the impact of national HIV prevention programs in reducing HIV risk in sub-Saharan African countries. Statistical analysis of prospective data on exposure to HIV prevention programs, relatives with AIDS and unemployment, and sexual behavior change and HIV incidence, in a population cohort of 4047 adults, collected over a period (1998-2003) when HIV prevalence and risk-behavior declined in eastern Zimbabwe. Exposure to HIV prevention programs and relatives with AIDS-but not unemployment-increased from 1998 to 2003. Men and women exposed to media campaigns and HIV/AIDS meetings had greater knowledge and self-efficacy, attributes that were concomitantly protective against HIV infection. Women attending community HIV/AIDS meetings before recruitment were more likely than other women to adopt lower-risk behavior (96.4% vs. 90.8%; adjusted odds ratio, 3.09; 95% confidence interval [CI], 1.27-7.49) and had lower HIV incidence (0.9% vs. 1.8%; adjusted incidence rate ratio, 0.63; 95% CI, 0.32-1.24) during the intersurvey period. Prior exposure to relatives with AIDS was not associated with differences in behavior change. More newly unemployed men as compared with employed men adopted lower-risk behavior (84.2% vs. 76.0%; adjusted odds ratio, 2.13; 95% CI, 0.98-4.59). Community-based HIV/AIDS meetings reduced risk-behavior amongst women who attended them, contributing to HIV decline in eastern Zimbabwe.
    Sexually transmitted diseases 06/2011; 38(6):475-82. DOI:10.1097/OLQ.0b013e3182080877 · 2.75 Impact Factor
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    ABSTRACT: Social capital—especially through its “network” dimension (high levels of participation in local community groups)—is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998–2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities—often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.
    Population and Development Review 01/2011; 37(2):333-59. · 2.22 Impact Factor
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    ABSTRACT: There is increasing consensus on the importance of strengthening global health research to meet health and development goals. Three key global health research aims are to ensure that research (i) addresses priority health needs, (ii) contributes to policy development, and (iii) adds value to investments in developing countries through South-South collaboration and capacity-strengthening in the South. The ALPHA network ( Analysing Longitudinal Population-based HIV/AIDS data on Africa) is an illustrative example of how these global health research aims can be translated into action. The network facilitates additional collaborative HIV epidemiological research among six independent research projects in Africa studying population-based cohorts. Under the first of the earlier mentioned aims, the network addresses key epidemiology research issues in HIV/AIDS which are crucial to making progress and monitoring progress in the response against HIV/AIDS. Under the second aim, the network's scientific programme of research has contributed to strengthening the evidence base on HIV epidemiology in Africa and has informed policy development in areas such as targeted HIV prevention, social support, monitoring epidemic response and epidemic forecasting. Under the third aim, investment in the network has added value to the research investment in the individual projects through capacity development among African researchers as well as through the collaborative research outputs of the individual projects. Lessons from the network are relevant to collaborations facing similar challenges in other areas of global health research. These include the importance of establishing transparent and efficient governance for research collaborations, developing advance consensus on data sharing, ensuring effective communication for networking and demonstrating the added value of research investment in South-South collaborations.
    Tropical Medicine & International Health 02/2010; 15(3):321 - 328. DOI:10.1111/j.1365-3156.2009.02456.x · 2.30 Impact Factor
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    ABSTRACT: To compare reported numbers of sexual partners in Eastern and Southern Africa. Sexual partnership data from four longitudinal population-based surveys (1998-2007) in Zimbabwe, Uganda and South Africa were aggregated and overall proportions reporting more than one lifetime sexual partner calculated. A lexis-style table was used to illustrate the average lifetime sexual partners by site, sex, age group and birth cohort. The male-to-female ratio of mean number of partnerships in the last 12 months was calculated by site and survey. For each single year of age, the proportion sexually active in the past year, the mean number of partners in the past year and the proportion with more than one partner in the past year were calculated. Over 90% of men and women between 25 and 45 years of age reported being sexually active during the past 12 months, with most reporting at least one sexual partner. Overall, men reported higher numbers of lifetime sexual partners and partners in the last year than women. The male-to-female ratio of mean partnerships in the last year ranged from 1.41 to 1.86. In southern African cohorts, individuals in later birth cohorts reported fewer sexual partners and a lower proportion reported multiple partnerships compared with earlier birth cohorts, whereas these behavioural changes were not observed in the Ugandan cohorts. Across the four sites, reports of sexual partnerships followed a similar pattern for each sex. The longitudinal results show that reductions in the number of partnerships were more evident in southern Africa than in Uganda.
    Sexually transmitted infections 05/2009; 85 Suppl 1(Suppl_1):i72-80. DOI:10.1136/sti.2008.033985 · 3.08 Impact Factor
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    ABSTRACT: To identify reporting biases and to determine the influence of inconsistent reporting on observed trends in the timing of age at first sex and age at marriage. Longitudinal data from three rounds of a population-based cohort in eastern Zimbabwe were analysed. Reports of age at first sex and age at marriage from 6837 individuals attending multiple rounds were classified according to consistency. Survival analysis was used to identify trends in the timing of first sex and marriage. In this population, women initiate sex and enter marriage at younger ages than men but spend much less time between first sex and marriage. Among those surveyed between 1998 and 2005, median ages at first sex and first marriage were 18.5 years and 21.4 years for men and 18.2 years and 18.5 years, respectively, for women aged 15-54 years. High levels of reports of both age at first sex and age at marriage among those attending multiple surveys were found to be unreliable. Excluding reports identified as unreliable from these analyses did not alter the observed trends in either age at first sex or age at marriage. Tracing birth cohorts as they aged revealed reporting biases, particularly among the youngest cohorts. Comparisons by birth cohorts, which span a period of >40 years, indicate that median age at first sex has remained constant over time for women but has declined gradually for men. Although many reports of age at first sex and age at marriage were found to be unreliable, inclusion of such reports did not result in artificial generation or suppression of trends.
    Sexually transmitted infections 05/2009; 85 Suppl 1(Suppl_1):i34-40. DOI:10.1136/sti.2008.033431 · 3.08 Impact Factor
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    ABSTRACT: AIDS is the main driver of young widowhood in southern Africa. The demographic characteristics of widows, their reported risk behaviours and the prevalence of HIV were examined by analysing a longitudinal population-based cohort of men and women aged 15-54 years in Manicaland, eastern Zimbabwe. The results from statistical analyses were used to construct a mathematical simulation model with the aim of estimating the contribution of widow behaviour to heterosexual HIV transmission. 413 (11.4%) sexually experienced women and 31 (1.2%) sexually experienced men were reported to be widowed at the time of follow-up. The prevalence of HIV was exceptionally high among both widows (61%) and widowers (male widows) (54%). Widows were more likely to have high rates of partner change and engage in a pattern of transactional sex than married women. Widowers took partners who were a median of 10 years younger than themselves. Mathematical model simulations of different scenarios of sexual behaviour of widows suggested that the sexual activity of widow(er)s may underlie 8-17% of new HIV infections over a 20-year period. This combined statistical analysis and model simulation suggest that widowhood plays an important role in the transmission of HIV in this rural Zimbabwean population. High-risk partnerships may be formed when widowed men and women reconnect to the sexual network.
    Sexually transmitted infections 05/2009; 85 Suppl 1(Suppl_1):i41-8. DOI:10.1136/sti.2008.033043 · 3.08 Impact Factor
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    ABSTRACT: Model-based estimates of maternal (but not paternal) orphanhood are higher than those based on data from demographic and health surveys (DHS). We investigate the consistency of reporting of parental survival status in data from Manicaland, Zimbabwe. We compared estimates of paternal and maternal orphan prevalence in three rounds of a prospective household census in Manicaland (1998-2005) with estimates from DHS surveys and UNAIDS model projections. We investigated the consistency of reporting of parental survival status across the three rounds and compared estimates of adult mortality from the orphan data with direct estimates from concurrent follow-up of a general population cohort. Qualitative data were collected on possible reasons for misreporting. Paternal and maternal orphan prevalence is increasing in Zimbabwe. Mothers reported as deceased in round 1 of the Manicaland survey were more likely than fathers to be reported as alive in rounds 2 or 3 (33.3% vs 13.4%). This pattern was most apparent among younger children. The qualitative findings suggest that foster parents sometimes claim adopted children as their natural children. These results are consistent with misreporting of foster parents as natural parents. This appears to be particularly common among foster mothers and could partly explain the discrepancy between mathematical model and DHS estimates of maternal orphanhood.
    Sexually transmitted infections 08/2008; 84 Suppl 1(Suppl_1):i57-i62. DOI:10.1136/sti.2008.029926 · 3.08 Impact Factor

Publication Stats

535 Citations
145.30 Total Impact Points

Institutions

  • 2007–2014
    • The Biomedical Research and Training Institute
      Salisbury, Harare, Zimbabwe
  • 2005–2011
    • Imperial College London
      • Department of Infectious Disease Epidemiology
      Londinium, England, United Kingdom
  • 2004
    • University of Zimbabwe
      Salisbury, Harare Province, Zimbabwe