Livelihoods, Health and Wellbeing

Theme leaders: Mark Collinson and Wayne Twine Water collection

Problem statement
Poverty remains an unresolved burden for the majority of rural households, with significant negative implications for health and well-being.   While ill-health, food insecurity, and malnutrition are outcomes of poverty on the one hand, they are also constraints on the ability of households to escape poverty on the other.  Poverty also heightens household vulnerability to the impacts of shocks and stresses such as HIV/AIDS and environmental change, to which rural households are increasingly being exposed.  Nevertheless, some households do manage to escape or remain out of poverty, even in the face of shocks and stresses, while others do not.  Aspects of rural livelihoods such as social connections, use of the local natural environment, and engagement in off-farm livelihood strategies such as labour migration, are well studied and have been shown to have positive implications for health and well-being.  Nevertheless, household, community and environmental level factors which promote or constrain household resilience and the ability to ascend out of poverty are complex, interactive, and remain poorly understood.  Deeper understanding of household livelihoods in this context is thus essential for informing policy and programmes aimed at promoting health and social development in transitioning rural societies which are exposed to multiple shocks and stresses .

The Natural Environment and Resilience – SUCSES (Sustainability in Communal Socio-Ecological Systems)
Collaboration with APES (School of Animal, Plant and Environmental Sciences) at Wits, and University of Colorado at Boulder, USA.

Previous work shows that food security is threatened by adult mortality, and that greater reliance on natural resources is often a coping response of households impacted by such crises.  In this longitudinal study, we examine how natural resources are used to offset the impacts of household shocks, the degree to which this buffers households against adversity, and how environmental change might erode the resilience of households.  A cohort of 600 households within the HDSS was established in 2010 to examine livelihood strategies and outcomes. This is linked with environmental surveillance, both climatic and ecological, in the study villages.  In 2014, the fifth annual round of the household livelihoods survey was completed. 

Migration, Livelihoods and Health 
Collaboration with Brown University, University of Colorado at Boulder, USA: Université Catholique de Louvain, Belgium

Analysis of the health and demographic surveillance system data has shown that rural households are dependent on labour migration for socio-economic well-being, especially female migration in poorer households and male migration in better-off households. Labour migration involves a household splitting, with the migrant moving to the work-place for the majority of each year. If they become sick the normal pattern is to return to the rural household and possibly die there. The contribution of AIDS and TB among returned migrants to the overall increase in crude death rate in the 2000 to 2006 period was 84% for males and 49% for females.

A study covering the period 2000 – 2011 revealed a high prevalence of temporary migration amongst males, with females increasingly participating in temporary movement. Such temporary migrants were found to have a higher probability of mortality, and analysis has revealed positive links between temporary migration and both infectious disease (ID) and non-communicable disease (NCD). For example, over the period 2008–11, we found that 66 % of male and 78% of female deaths in younger adults (18-44 years) ages were attributable to IDs, whereas 13% (both male and female) deaths were attributable to NCDs.

Given the historical pattern of labour migration across the region, these findings call urgently for health services that bridge long distances and span different settlement types to maintain continuity of care. To establish the feasibility of contacting and interviewing migrants at their place of work we conducted a pilot study in 2012. We contacted and interviewed 93% of the chosen sample (N=363). The pilot study provided us with some insights into the relationship between migration (temporary or permanent), the distance moved and selected behavioural and health outcomes. For example, amongst long-distance migrants there was a lower rate of using either government or private clinics (possibly due to their better overall health), but when in need of health care, these migrants would more typically access private health clinics.


On the INDEPTH platform, seven HDSS centres were involved in comparative studies which were published a peer-reviewed volume in 2009. Despite the diversity of contexts from which the data originated (rural/urban, African/Asian) and the variation in time threshold used to define migration (varying from one to six months of continuous residence), a relatively regular age structure for migration was found. The largest group are young adults (aged 20-24 years), sometimes accompanied by children under five years. The age patterns indicate that key components of the migration profiles are labour migration of young adults, children migrating with parents, and, to lesser extents, marriage formation, the dissolution of households and households moving to access better services. Three studies of migration and livelihoods (in rural Thailand, South Africa and Bangladesh) have shown that out-migration from origin HDSS communities generally contributed to improved living conditions at the places of origin by way of agricultural production, household assets, and educational progression.  The findings from three studies that focused on migration and morbidity/mortality, highlighted the potentially negative consequences of migration on health in urban Kenya, rural Mozambique and rural Vietnam, which contrasted the beneficial socio-economic impacts of migration seen above. The healthy migrant hypothesis was demonstrated by returning migrant mothers in rural Kenya whose under-five children displayed improved survival rates compared to children of non-migrant, local mothers.

Multi-centre analysis of the dynamics in migration and health (MADIMAH)
Collaboration with INDEPTH Migration, Urbanisation and Health Working Group

In addition to graduate research training the Unit takes a leading role in capacity building initiatives, through the provision of support for researchers and data scientists. The MADIMAH project (Multi-centre Analysis of the Dynamics In Migration and Health) is based on a platform of 10 HDSS sites. Enhanced capacity was required at the HDSS sites to produce the required datasets and conduct analyses, thus capacity development has been central to the project. The MADIMAH project has contributed to an increase in capacity in data management and longitudinal analysis at these HDSS sites. The first phase of the MADIMAH project was completed during the course of 2014. This comprised a study on migration, urbanisation and human capital and used datasets from eight HDSS sites in four countries, namely Nanoro, Nouna and Ouagadougou (Burkina Faso), Nairobi, Kilifi and Kisumu (Kenya), Manhica (Mozambique) and Agincourt (South Africa). The study concludes that human capital does not necessarily leave rural areas to accumulate in the cities, and the educated are not always those who are on the move. Migration systems in sub-Saharan Africa appear to vary depending on the regional contexts, leading to different patterns of human capital redistribution. The second phase of the MADIMAH project is currently underway and involves the study of migration, mortality and epidemiological transition.

Household structure and vulnerability/resilience
Collaboration with Maryland, Missouri, Colorado at Boulder and Brown Universities, USA

The life-cycle of households are changing due to changing migration patterns and increasing mortality of prime age adults. This cluster uses qualitative studies triangulated with surveillance-based analyses to investigate changing household structure and composition. Changing social roles of fathers, mothers and older adults are examined as well as the importance of meaningful links to networks beyond the household. Migration of under-five children is significantly related to household poverty. There is an important household role for women over 60 years shown by the fact that 15% of households had a at least one fostered child and 6% at least one maternal orphan, while 27% of households with an over sixty year old woman included a fostered child and 16% a maternal orphan.


Determinants and consequences of socio-economic dynamics
Collaboration with Brown University, USA

The HDSS meticulously tracks asset ownership in households which is used to examine the dynamics of household poverty, in particular how chronically poor households manage to climb out of poverty. Research findings indicate that factors improving asset scores vary significantly. The poorest households tend to improve socioeconomic status through government grants and female labour migration, and are more resilient to shocks and stresses if they use available natural resources for fuel and dietary supplements. Better-off households improve socioeconomic status through local employment and male labour migration. In an analysis of migration and its role in the well-being of rural households, we have found that temporary migration may be employed as a household strategy to improve the socioeconomic position of the origin household