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Exposure to a multitude of risks, including food insecurity, poverty, and – perhaps most prominently – HIV can be damaging for early childhood survival, healthy growth and development. Yet, guidance regarding the implementation factors that contribute to early child development-focussed programme success is lacking in low- and middle-income countries broadly, and sub-Saharan Africa in particular. Having access to guidelines for practice and implementation could assist in improving the implementation of programmes to improve early childhood development. We conducted a narrative review of the literature with the goal of identifying how implementation features of these early interventions may influence the effectiveness of such work in the complex contexts which characterise this region. Our final review included 197 for final analysis. There were two primary cross-cutting findings. Firstly, the benefit for parents was less clear than they were for children, and secondly, while the benefits for children were clear, those most at risk benefited the most. Home visiting was found to be the predominant service delivery platform, and positive outcomes for children were reported when home visiting programmes were implemented by trained non-professionals, whereas positive parent outcomes were reported more frequently when delivered by professionals. In early childhood care and education programmes, positive outcomes for children and parents were reported when they were implemented by both trained non-professionals and professionals. Trained non-professionals facilitating parent groups produced similar benefits to groups run by professionals. Take-home lessons for successful programmes were that high levels of attendance, regular sessions of at least an hour duration, with the programme continuing for more than 6 months and closer to a year are key for effectiveness. [ABSTRACT FROM AUTHOR]

Scientific and policy advances are putting early childhooddevelopment (ECD) at the center of efforts to improve humandevelopment. This study was undertaken to understand whatknowledge and attitudinal barriers exist that 25 hinder the full-scaleroll-out of services for the youngest children and their families.We used anthropological methods honed by the FrameworksInstitute to plumb beliefs about early childhood development amongmembers of the public and implementation and policy stakeholders,and compare those with the findings from ECD research. Whilemembers of the public and stakeholders agree on the importance ofECD, as demonstrated in other country settings, a major barrier todirecting services to the youngest children is a perceptual tendencyto 'age up'. That is, to consider learning and other important skillsas being acquired in the pre-school rather than infancy period.Communication strategies that incorporate debate are neededto give full effect to the ECD and related policies, especiallyaround the topics of prioritizing the youngest 40 children, physicalpunishment, child rights, and the pervasiveness Q5 of threats toECD arising from poverty and disadvantage. [ABSTRACT FROM AUTHOR]

Adolescents living in low- and-middle incomeand middle-income countries are at a particular risk of poor mental health. Caregiver mental health plays a crucial role in a child's emotional and behavioural development and may directly impact a child's risk for future development of mental health problems. Data collected as part of a two-decade longitudinal multiphase research project were used. Participants, originally women in their third trimester of pregnancy (n = 449), were recruited from a peri-urban impoverished community outside of Cape Town, South Africa, and assessed at several time-points over subsequent years. Data collected during the three phases of the research were used to assess the effects of early and current caregiver depression on adolescent internalising and externalising behaviour. Analyses of Covariance models were used to explore the effect of caregiver depression on adolescent internalising and externalising behaviour, while controlling for multiple covariates. We analysed data for 313 adolescent participants and their primary caregivers. Caregiver depression patterns had a significant main effect on externalising behaviour, F(3,305) = 4.10 (p = 0.007), but not on internalising behaviour, F(3,305) = 2.71 (p = 0.09). Post-hoc analysis showed that those adolescents exposed to early and current caregiver depression scored on average 3.83 points (95% CI [0.99; 6.66]) higher in externalising behaviour than those exposed to no caregiver depression. Also, adolescents who experienced a change in caregiver, compared to those whose biological mother were still their primary caregiver, reported significantly higher levels of externalising behaviour F(1,305) = 5.10, p = 0.03. The study findings provide crucial insight into critical periods of risk, as well as opportunities for prevention. Preventive interventions should ideally target caregivers and adolescents to prevent or reduce behavioural problems and disrupt intergenerational cycles of mental disorders or behavioural problems. [ABSTRACT FROM AUTHOR]

The purpose of this research was to determine whether or not routine home visiting (by the Philani Maternal Child Health and Nutrition Project) influences the prevalence of stunted, wasted and underweight children in Cape Town peri-urban settlements. The study was a cross-sectional cohort in which weight and height measurements were collected for all children from 24 matched neighbourhoods; three years earlier 12 of these neighbourhoods were randomized to receive the home visiting intervention and 12 did not. The research took place at all households located within the 24 neighbourhoods in Khayelitsha and Mfuleni peri-urban settlements. Participants included 8715 children aged 0–6 years old (4694 intervention; 4021 control). A total of 41.3% of children were stunted, 3.1% were underweight and 1.4% were wasted. Children in the intervention group were significantly less likely to be underweight or severely underweight for age than children in the control group. While the rates of stunting were also significantly lower in intervention areas, the effect was not clinically significant, and no significant differences were found between the study arms on the prevalence of wasting. The Philani model is effective in the prevention and rehabilitation of underweight children. Philani could strengthen their intervention by focussing specifically on screening for child stunting in addition to underweight children. The results also suggests that efforts to address the long-term adverse effects of undernutrition require structural and economic transformation, in addition to socio-medical interventions. [ABSTRACT FROM AUTHOR]

There is strong evidence that both adults and children infected with and affected by HIV have high levels of mental health burden. Yet there have been few studies investigating carer mental health outcomes in the context of HIV in Malawi and South Africa. The objective of this study was to assess the mental health of carers of children affected by HIV as a part of the Child Community Care study, which aims to generate evidence on the effectiveness of community-based organisation (CBO) services to improve child outcomes. In a cross-sectional study, we interviewed 952 carers of children (aged 4–13 years) attending 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Psychological morbidity was measured using the Shona Symptom Questionnaire and suicidal ideation was measured using an item from the Patient Health Questionnaire. Carers were asked about care-seeking for emotional problems. Overall, 28% of carers scored above the clinical cut-off for current psychological morbidity and 12.2% reported suicidal ideation. We used logistic regression models to test factors associated with poor outcomes. Household unemployment, living with a sick family member and perceived lack of support from the community were associated with both psychological morbidity and suicidal ideation in carers. Reported child food insecurity was also associated with psychological morbidity. In addition, carers living in South Africa were more likely to present with psychological morbidity and suicidal ideation than carers in Malawi. Rates of help-seeking for mental health problems were low. Carers of children affected by HIV are at risk for mental health problems as a result of HIV, socio-economic, care-giving and community factors. We call for increased recognition of the potential role of CBOs in providing mental health care and support for families as a means to improve equity in mental health care. Specifically, we highlight the need for increased training and supervision of staff at CBOs for children affected by HIV, and the inclusion of CBOs in broader efforts to improve population mental health outcomes. [ABSTRACT FROM PUBLISHER]

ObjectiveThis study aimed to systematically review the psychometric properties of instruments used to screen for major depressive disorder or assess depression symptom severity among African youth. MethodsSystematic search terms were applied to seven bibliographic databases: African Journals Online, the African Journal Archive, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, and the World Health Organization (WHO) African Index Medicus. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on data collected from youth (any author definition) in an African member state of the United Nations. We extracted data on study population characteristics, sampling strategy, sample size, the instrument assessed, and the type of reliability and/or validity evidence provided. ResultsOf 1 027 records, we included 23 studies of 10 499 youth in 10 African countries. Most studies reported excellent scale reliability, but there was much less evidence of equivalence or criterion-related validity. No measures were validated in more than two countries. ConclusionsThere is a paucity of evidence on the reliability or validity of depression assessment among African youth. The field is constrained by a lack of established criterion standards, but studies incorporating mixed methods offer promising strategies for guiding the process of cross-cultural development and validation. [ABSTRACT FROM PUBLISHER]

HIV disclosure is emphasised as an important component of efforts to prevent HIV transmission, including those to prevent transmission from mother to child. Studies which approach disclosure as a dichotomous variable that is either present or absent have generated a significant body of research describing disclosure patterns, antecedents, barriers and consequences. This study joins a growing body of research which explores disclosure as a complex, selective and gradual process occurring within the context of relationships. Using a qualitative, longitudinal ethnographic approach, the study explores HIV-positive women's subjective experience of disclosure and how they make meaning and understand disclosure processes during pregnancy and early motherhood. An interpretative phenomenological analysis of field notes from participant observation and in-depth interview transcripts suggests that women may experience disclosure as a more fluid construct than previously assumed. In contrast to the traditional dichotomous and linear approach to understanding disclosure, the meaning ascribed to disclosure "events" and behaviours was changeable and even reversible over time. These shifts occurred alongside changes in women's internal, interpersonal and material worlds and served important psychological and social functions. The findings have important implications for HIV counsellors working to encourage disclosure in the context of prevention interventions. [ABSTRACT FROM AUTHOR]

Background: Since the announcement of the results of the international research project to unravel the human genome in the early 1990s there has been a burgeoning of research into the genetic basis of psychopathology and development. South African behavioural researchers, however, have reasons to be cautious about the benefits of genetic research in the light of the historical link between eugenic interests and practices which were attractive to ideologies such as Nazism and apartheid. Methods: In this article we discuss the burgeoning interface internationally between behavioural and genetic research. We describe a number of areas of recent research that are particularly relevant to child and adolescent mental health in South Africa (antisocial behaviour, disorganised attachment and depression) that are beginning to illuminate the interactions between the behavioural and genetic domains. Discussion: We argue that we need to engage more actively with what the sciences of the brain and behaviour have to offer, and in so doing make a case for the urgent inclusion of genetic research in mental health research in South Africa. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents. [ABSTRACT FROM AUTHOR]

The nature and consequences of services innovation remains a woefully under-researched topic. The paper calls into question two statements that are frequently repeated in the political-economic discourse on services. The first concerns the suggestion that Germany is a 'services laggard' that needs to restructure its domestic economy if it is to remain internationally competitive. By contrast, the UK is frequently held up as an example of a successfully restructured 'services economy'. The paper draws an important distinction between the quantity of services in a domestic economy and the degree of connectivity between services and other economic activities. The latter, it is argued, is far more important in determining the size of spill-overs from services innovation enjoyed within a domestic economy and, hence, to international competitiveness. Particular attention is paid to the role and impact of knowledge-intensive service sectors in this regard. In addition to the UK and Germany, data is drawn from the Netherlands and Japan. Using these four comparative cases we explore the distinction between a high representation of services in the domestic economy, and the innovation spill-overs facilitated by a high degree of connectivity between services and other economic sectors within a domestic economy. [ABSTRACT FROM AUTHOR]

Focuses on the results of an analysis at Centre for Research on Innovation and Competition (CRIC) of the data from the 1996 and 1997 Survey of Innovation Trends of firms conducted by the Confederation of British Industry (CBI). Brief outline of the CBI survey; Analysis of the CBI data; Discussion of the issues presented by the survey.

Understanding the needs of your child is complicated. Understanding the varied needs of a population of children with whom you have no direct contact is the near impossible challenge policy makers, government planners and donors face when making policy or selecting interventions to fund and implement. They cannot unpack children's individual needs and so must predict what is most important for a given population and which services to prioritise. This can be simplified by assuming that the needs of other people's children are hierarchical: basic needs, such as food and shelter, must be met before considering higher-order needs. This conceptualisation justifies a focus on basic needs and decision makers can ignore higher-order needs and the complex interventions they may require, because both are assumed to be of secondary importance. Assuming a hierarchy of needs is a mistake. By drawing on examples from the literature, we outline how children, our own and other people's, have non-hierarchical needs and thus caring for them is a balancing act, best done by those close to them. This conceptualisation highlights the importance of supporting families to support children. For a subset of families who are struggling, additional family strengthening interventions may be needed. In the relatively rare cases that such interventions are insufficient as family function is severely compromised, more intensive interventions may be necessary, but must be undertaken with great care and skill. Social services are critical because they have the potential to facilitate the intensive interventions when they are required, and while they are not required by all, for some of the most vulnerable children they are essential. The quality standards of such a service will be key in meeting the needs of other people's children. [ABSTRACT FROM AUTHOR]

Background:Globally, and in low and middle income countries (LMIC) specifically, there is a critical shortage of workers. The use of volunteers to support such care delivery systems has been examined, there is scant literature on the impact of volunteers on child outcome in high human immunodeficiency virus (HIV)-affected communities. Objectives:To examine the differential impact of paid versus volunteer workforce in Community Based Organisations (CBOs) providing care to children and families affected by the HIV epidemic in South Africa and Malawi on child outcomes over time. Methods:This study compared child outcomes for 989 consecutive children attending CBOs (0.7% refusal) at baseline and 854 at follow-up (86.3% response rate). Results:Children attending CBOs with paid staff had higher self-esteem, fewer emotional/behavioural problems and less perceived stigma. Likewise, children attending CBOs with paid staff had fewer educational risks, and 20 heightened cognitive performance, and the digit-span memory test. After controlling for outcome at baseline, gender, age, HIV status, and disability, attending a CBO with paid staff remained a significant independent predictor of higher self-esteem scores, less perceived stigma, as well as fewer educational risks and better performance on the drawing test. We found no associations between CBO attendance – paid or volunteer – and children’s depressive and trauma symptoms. Conclusions:Our findings show that in order to most optimally impact on child outcome 30 community-based workers (CBWs) should ideally be paid with trained staff. Specialised input for more severe child difficulties is needed. [ABSTRACT FROM PUBLISHER]

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men. [ABSTRACT FROM AUTHOR]

An image of a child receiving training in sensitive book-sharing skills as part of a randomized controlled trial to evaluate an integrated Early Childhood Care and Development intervention in the Mokhotlong district of Lesotho, is presented.

There is strong evidence that both adults and children infected with and affected by HIV have high levels of mental health burden. Yet there have been few studies investigating carer mental health outcomes in the context of HIV in Malawi and South Africa. The objective of this study was to assess the mental health of carers of children affected by HIV as a part of the Child Community Care study, which aims to generate evidence on the effectiveness of community-based organisation (CBO) services to improve child outcomes. In a cross-sectional study, we interviewed 952 carers of children (aged 4–13 years) attending 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Psychological morbidity was measured using the Shona Symptom Questionnaire and suicidal ideation was measured using an item from the Patient Health Questionnaire. Carers were asked about care-seeking for emotional problems. Overall, 28% of carers scored above the clinical cut-off for current psychological morbidity and 12.2% reported suicidal ideation. We used logistic regression models to test factors associated with poor outcomes. Household unemployment, living with a sick family member and perceived lack of support from the community were associated with both psychological morbidity and suicidal ideation in carers. Reported child food insecurity was also associated with psychological morbidity. In addition, carers living in South Africa were more likely to present with psychological morbidity and suicidal ideation than carers in Malawi. Rates of help-seeking for mental health problems were low. Carers of children affected by HIV are at risk for mental health problems as a result of HIV, socio-economic, care-giving and community factors. We call for increased recognition of the potential role of CBOs in providing mental health care and support for families as a means to improve equity in mental health care. Specifically, we highlight the need for increased training and supervision of staff at CBOs for children affected by HIV, and the inclusion of CBOs in broader efforts to improve population mental health outcomes. [ABSTRACT FROM AUTHOR]

Throughout the rapid and intense changes that adolescents experience, their parents retain important influence over how they interact with the complex factors that shape their development. How parents care for their adolescent children has a deep and lasting impact on their well-being and development. Yet, parents often require support to meet their own and their adolescent children's needs, which can be achieved through parenting support programmes. Parenting support programmes are delivered to parents of younger children across different contexts and populations, but the benefit of these programmes for parents of adolescents is not well-recognised or prioritised. Given the clear need for these interventions during adolescence and the substantial evidence for effectiveness in this age group, it is time to move the field forward. Increased resources to support parents of adolescents would maximise adolescents' developmental potential and promote their well-being. We highlight four pressing areas for action: including parents of adolescents in parenting initiatives; involving parents in adolescent programming; strengthening efforts to address poverty and inequality, violence, and gender inequality; and engaging in strategic research to intensify the impact of programming. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has substantially affected the lives of young people living in sub-Saharan Africa (SSA), leading to poorer short-term mental health outcomes. However, longitudinal data investigating changes in mental health from pre-COVID levels and their predictors are lacking. Our longitudinal sample comprised N = 233 young people (mean age: 17.8 years at baseline, 55.6% female) living in a deprived neighbourhood near Cape Town, South Africa. Symptoms of depression (PHQ-9), anxiety (GAD-7) and alcohol use (AUDIT) were assessed during two waves of data collection, pre-pandemic (2018/19) and via phone interviews in June to October 2020, during South Africa's first COVID wave and subsequent case decline. Latent change score models were used to investigate predictors of changes in mental health. Controlling for baseline levels, we found increases in depression and anxiety but not alcohol use symptoms during the COVID-19 pandemic. Higher baseline symptoms were associated with smaller increases on all measures. Socio-economic deprivation (lack of household income, food insecurity) before and during COVID were associated with higher anxiety and depression symptom increases. Having had more positive experiences during COVID was associated with lower post-COVID onset anxiety and depression increases, and marginally with less alcohol use, while negative experiences (household arguments, worries) were linked to stronger symptom increases. Overall, in a sample of young people from an adverse environment in South Africa, we found increased mental health difficulties during the COVID-19 pandemic, though higher baseline symptoms did not necessarily predict stronger increases. Several factors pre- and post-COVID onset were identified that could be relevant for determining risk and resilience. In the long term, it will be key to address these structural drivers of well-being and to ensure mental health needs of young people are being met to support SSA countries in building back successfully from COVID-19 and preparing for future shock events. [ABSTRACT FROM AUTHOR]

Adolescents exposed to high levels of adversity are vulnerable to developing mental health challenges, with long-lasting adverse consequences. Promoting the psychological well-being of adolescents and protecting them from adverse experiences is crucial for their quality of life. There is a need for evidence on which combinations of protective factors can improve the wellbeing of adolescents to inform future programming efforts. We used data from a longitudinal study that took place in Khayelitsha, South Africa, a semi-urban impoverished community in Cape Town. Data were collected from adolescents when they were 12–14 years of age (n = 333) and again at follow-up when they were aged 16–19 years (n = 314). A path analysis was used to estimate associations between access to service, food security, safe environment, family support, and social support and five outcomes related to adolescent mental health and risky behaviours. The fitted model was used to calculate adjusted mean differences comparing different combinations of risk factors. Two protective factors (food security and safe environment) were positively associated with three outcomes relating to mental health and the absence of risky behaviours. Further investigation revealed that the presence of high food security and safer environments was associated with higher adjusted mean scores: +16.2% (p <.0001) in no substance use; +16.5% (p <.0001) in no internalising behaviour, +19.5% (p <.0001) in self-esteem; +12.2% (p <.0001) in positive peer relationships; and +11.4% (p <.0001) in no suicidal ideation. Interventions targeting adolescents, that aim to improve food security together with improving the safety of their environment, are likely to impact their well-being. [ABSTRACT FROM AUTHOR]

The article discusses the development of medical staff guidelines for the care of extremely early gestation pregnancies and premature infants. Topics covered include the goal of promoting a paradigm based on sound principles and practice, the purpose of the perinatal ethics consultation and the concern raised over the omission of any mention of an antenatal/periviability counseling dialogue.

In the spirit of critical reflection, we examine how the field of global health might surmount current challenges and prioritize its ethical mandate, namely to achieve, for all people, equity in health. We use the parlance of mastering deadly sins and striving for greater virtues in an effort to review what is needed to transform global health action. Global health falls prey to four main temptations: coveting silo gains, lusting for technological solutions, leaving broad promises largely unfulfilled, and boasting of narrow successes. This necessitates a change of heart: to keep faith with the promise it made, global health requires a realignment of core values and a sharper focus on the primacy of relationships with the communities it serves. Based on the literature to date, we highlight six steps to re-orienting global health action. Articulating a coherent global health agenda will come from principled action, enacted through courage and prudence in decision-making to foster people-centered systems of care over the entire lifespan. [ABSTRACT FROM AUTHOR]

Reactive attachment disorder (RAD) is a psychiatric disorder developing in early or middle childhood as a consequence of significant failures in the caregiving environment. RAD results in children failing to relate socially, either by exhibiting markedly inhibited behaviour or by indiscriminate social behaviour and is associated with significant socio-behavioural problems in the longer term. This study examined RAD in South Africa, a setting with high environmental risks. We recruited a sub-sample of 40 10-year-old children from a cohort enrolled during pregnancy for whom early attachment status was known. Children were purposefully selected to represent the four attachment categories using the data available on the strange situation procedure (SSP) at 18 months. The Manchester Child Attachment Story Task (MCAST) assessed current attachment and RAD was diagnosed using a standardised assessment package. A high proportion of the children (5/40% or 12.5%) fulfilled diagnostic criteria for RAD; all were boys and were displaying the disinhibited type. SSP classification at 18 months was not significantly associated with RAD symptoms at age of 10 years, while current MCAST classifications were. This suggests that children in this sample are at much higher risk of RAD than in high-income populations, and despite a fairly typical attachment distribution in this population at 18 months, RAD was evidenced in later childhood and associated with current attachment disorganisation. The strengths of this research include its longitudinal nature and use of diagnostic assessments. Given increasing evidence that RAD is relatively stable over time and introduces longer term socio-behavioural risks; the high rate of RAD in this sample (12.5%) highlights potential developmental threats to children in low- and middle-income countries (LMICs). Our results should be interpreted with caution given sample size and risk of selection bias. Further research is needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC). [ABSTRACT FROM AUTHOR]

User satisfaction with outpatient mental health services is an important factor in ensuring continued engagement with mental health services for people with mental health conditions. Yet, in many low and middle-income countries, including Malawi, there is a dearth of information about user's experiences of outpatient mental health care services, and little is known about which factors might affect user satisfaction. The aim of the present work was to evaluate user satisfaction with outpatient mental health services in southern Malawi and to explore whether social demographic variables, mental health status, and treatment characteristics explain variance in user satisfaction. This cross-sectional study was conducted in Malawi at one urban (Blantyre) and one rural (Thyolo) outpatient psychiatric clinics. Two-hundred and sixteen randomly sampled service users were enrolled into the study and completed the Charlestone Psychiatric Outpatient Satisfaction Scale (CPOSS). The unadjusted and adjusted associations between user satisfaction as the dependent variable, and participant socio-demographic characteristics as independent variables, were examined. Eighty percent of all participants were satisfied with the outpatient mental health services, although participants presenting to the rural clinic were less likely to be satisfied than participants presenting at the urban clinic, according to the adjusted odds ratio (AOR; AOR = 0.31; 95% confidence interval (CI): 0.13–0.76; p < 0.05). Any admission due to a mental health condition significantly explained variance in user satisfaction at the rural (Thyolo) study site; as those who had been admitted previously were less satisfied than those who had never been admitted (AOR = 0.11; 95% CI: 0.02–0.54; p < 0.05). As may be expected, these findings demonstrate that service user satisfaction is linked to service quality and past service experiences. Further research is required in order to nuance these findings in the context of Malawi's efforts to strengthen service quality. Nonetheless, rural facilities may require additional support to deliver satisfactory care. [ABSTRACT FROM AUTHOR]

Background: Rates of adolescent HIV and unintended pregnancy in southern Africa are amongst the highest in the world. Gender-transformative interventions that address underlying gender inequalities and engage both males and females have been emphasised by the World Health Organisation, amongst others, to target prevention. However, few such gender-transformative interventions have been rigorously developed or evaluated. Objective: To expedite potential impact and reduce development costs, we conducted a needs assessment to inform the co-design, in consultation with local stakeholders, of adapted versions of an existing gender-transformative Relationships and Sexuality Education intervention for use in South Africa and Lesotho. Methods: Adaptation of the intervention was guided by a modified version of Intervention Mapping (IM). This process involved consultation with separate adolescent, community and expert advisory groups and a collaboratively conducted needs assessment, which drew on focus groups with adolescents (8 groups, n = 55) and adults (4 groups, n = 22) in South Africa and Lesotho, and was informed by our systematic review of the literature on the determinants of condom use among adolescents in the region. Results: The findings clarified how the intervention should be adapted, which individual- and environmental-level determinants of condom use to target, and actions for facilitating successful adoption, evaluation and implementation in the new settings. Conclusions: The IM approach allows for a systematic appraisal of whether components and processes of an existing intervention are appropriate for a new target population before costly evaluation studies are conducted. The findings will be of interest to those wishing to rigourously develop and evaluate gender-transformative interventions engaging men to improve health for all. [ABSTRACT FROM AUTHOR]

Background: Research shows that caregiver mental health problems have direct, significant effects on child behaviour. While these risks are amplified in low-resource settings, limited evidence exists from these places, especially sub-Saharan Africa. Objective: We measured associations between caregiver mental health and child behaviour in a rural Kenyan sample, hypothesizing that higher rates of caregiver mental health would be associated with increased child behavioural problems. We also sought to provide an overview of caregiver mental health symptoms in our sample. Method: Cross-sectional data were collected from caregivers of children ages 4–5 years old enrolled in a community-based early child development programme in western Kenya. 465 caregivers were recruited and assessed at baseline, and answered questions about child behaviour, mental health symptoms (depression, anxiety, stress), and help-seeking. A multivariate linear regression model was used to assess significance of each mental health factor. Results: Caregiver anxiety (p = 0.01) and parenting stress (p < 0.001) were significantly associated with child behavioural problems. 245 caregivers (52.9%) had high levels of symptoms of depression, anxiety, or both; furthermore, 101 caregivers (21.7%) scored above the cut-off for both of these scales. A high proportion of our sample (60.6%) reported seeking some formal or informal psychosocial support services; however, less than one-third of these caregivers were symptomatic (30.9%). Conclusion: Anxiety and stress were associated with poorer child behavioural outcomes. Our sample reflected a higher prevalence of caregiving adults with mental health symptomology than previous estimates from Kenya, with few high-symptom caregivers seeking support. We discuss further implications for programming and health services delivery. [ABSTRACT FROM AUTHOR]

Evidence from high-income countries (HICs) has documented a higher rate of post-traumatic stress disorder (PTSD) in females than males. However, data are limited on sex differences in PTSD from low- and middle-income countries (LMICs), despite particularly high levels of trauma experienced by LMIC youth. In a sample of adolescents from an impoverished South African community, we examined sex differences in PTSD, as well as co-occurring depression, adolescent age, and the type and extent of trauma exposure as potential contributors to female vulnerability. Participants were recruited from high schools in the Khayelitsha area of Cape Town. Self-reported trauma exposure, PTSD and depressive symptoms were measured in 797 adolescents (62% female) aged 13–17 years. Poisson regressions were used to examine Risk Ratios (RR) based on probable PTSD diagnoses, and linear regressions were applied to assess posttraumatic stress symptom (PTSS) severity. 92% of adolescents reported trauma exposure, of whom 28% had probable PTSD. Prevalence of PTSD was higher for females than for males, even when controlling for total trauma exposure (RR = 1.71, p <.001) and co-occurring depressive symptoms (RR = 1.45, p =.005). By contrast, sex differences in depression were eliminated after controlling for co-occurring PTSS. There was little evidence of age effects on the emergence of sex differences. At lower thresholds of interpersonal trauma, females showed higher levels of PTSS compared to males, but no sex differences were found at high levels of exposure. Higher PTSD rates are observed in adolescent females in a high adversity-LMIC sample suggesting sex differences are robust across international contexts. Sex differences in PTSD are unlikely to be explained by co-occurring depression and in this context sex differences in depression may be secondary to trauma and PTSD. However, exposure to significant interpersonal trauma appears to overrule any specific female vulnerability. Sex differences in post-traumatic stress disorder are observed in adolescence from a high-adversity LMIC. Greater female risk occurs even when adjusting for trauma exposure and depressive symptoms. Females also show greater vulnerability to lower thresholds of interpersonal trauma. [ABSTRACT FROM AUTHOR]

A mathematical model, populated primarily with data from South Africa, was developed to model the numbers of children affected by maternal HIV, and the number who will experience long-term negative developmental consequences. A micro-simulation model generated two scenarios. The first simulated a cohort of women whose HIV status mimicked that of a target population, and mother–child dyads by way of age- and disease-specific fertility rates. Factors defining risk were used to characterize the simulated environment. The second scenario simulated mother-child dyads without maternal HIV. In the first scenario an estimated 26% of children are orphaned, compared to 10% in the absence of HIV. And a further 19% of children whose mother is alive when they turn 18 are affected by maternal HIV. School drop-out among all children increased by 4 percentage points because of maternal HIV, similarly population level estimates of abuse and negative mental health outcomes are elevated. Relative to HIV unaffected children, HIV affected have elevated risk of poor outcomes, however not all will suffer long-term negative consequences. Interventions to protect children should target the proportion of children at risk, while interventions to mitigate harm should target the smaller proportion of children who experience long-term negative outcomes.. [ABSTRACT FROM AUTHOR]

In the era of widespread antiretroviral therapy (ART), consequences of being HIV-exposed is unclear for children, especially in rural communities. A population sample of consecutive births (470/493) in the Eastern Cape of South Africa (SA) were recruited and reassessed at five points over the first 24 months. Maternal and child outcomes between mothers living with and without HIV were assessed using multiple linear and logistic regressions. At birth, 28% of the sample was mothers living with HIV and five additional mothers seroconverted. All mothers living with HIV reported taking ART. The rate of depressed mood and IPV was similar across serostatus. However, mothers living with HIV significantly decreased their alcohol use after learning about their pregnancy and were more likely to exclusively breastfeed when compared to mothers without HIV. Despite maternal HIV status, children had similar growth across the first 24 months of life. Future work is needed to assess if these developmental trajectories will persist. [ABSTRACT FROM AUTHOR]

Little is known about how young children in low- and middle-income countries (LMICs) experience violence in their homes, and how different types of household violence may affect child development. This study reports on levels of exposure to household violence and associations with child behavioural outcomes in preschool-aged children in western Kenya. A sample of 465 caregivers, whose children (n = 497) attended early learning centres supported by an international NGO, were enrolled in the study. Caregivers reported on exposure to intimate partner violence (IPV), household discipline practices, attitudes about gender roles, and child behavioural outcomes. Multivariable analysis showed significant predictive effects of IPV (regression coefficient = 1.35, SE = 0.54, p = 0.01) and harsh psychological child discipline (regression coefficient = 0.74, SE = 0.22, p = 0.001), but not physical discipline (regression coefficient = 0.42, SE = 0.24, p = 0.08), on worse child behavioural problems. These findings indicate that child exposure to violence in different forms is highly prevalent, and associated with poorer outcomes in young children. Community-based programmes focused on parenting and early child development are well-positioned to address household violence in LMIC settings, but must be supported to provide a broader understanding of violence and its immediate and long-term consequences. [ABSTRACT FROM AUTHOR]

Background: Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective: To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method: We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results: Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion: Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions. [ABSTRACT FROM AUTHOR]

Background: Lay health workers (LHWs) are critical in linking communities and primary healthcare (PHC) facilities. Effective communication between facilities and LHWs is key to this role. We implemented a mobile health (mHealth) system to improve communication and continuity of care for chronically ill clients. The system focused on requests from facility staff to LHWs to follow up clients and LHW referrals of people who needed care at a facility. We implemented the system in two rural and semi-rural sub-districts in South Africa. Objective: To assess the feasibility of the mHealth system in improving continuity of care for clients in PHC in South Africa. Method: We implemented the intervention in 15 PHC facilities. The clerks issued recalls to LHWs using a tablet computer. LHWs used smartphones to receive these requests, communicate with clerks and refer people to a facility. We undertook a mixed-methods evaluation to assess the feasibility of the mHealth system. We analysed recall and referral data using descriptive statistics. We used thematic content analysis to analyse qualitative data from semi-structured interviews with facility staff and a researcher fieldwork journal. Results: Across the sub-districts, 2,204 clients were recalled and 628 (28%) of these recalls were successful. LHWs made 1,085 referrals of which 485 (45%) were successful. The main client group referred and recalled were children under 5 years. Qualitative data showed the impacts of facility conditions and interpersonal relationships on the mHealth system. Conclusion: Using mHealth for recalls and referrals is probably feasible and can improve communication between LHWs and facility staff. However, the low success rates highlight the need to assess facility capacity beforehand and to integrate mHealth with existing health information systems. mHealth may improve communication between LHWs and facility staff, but its success depends on the health system capacity to incorporate these interventions. [ABSTRACT FROM AUTHOR]

Human studies consistently report a 60%–80% maternal left cradling preference. The dominant explanation points to an engagement of the emotionally more-attuned right brain. In contrast, we found equal incidences of left (31.3%), right (34.3%) and no-preference (34.3%) cradling in an impoverished South African population living under adverse conditions characterized by extreme dangers. We found striking differences on the Parenting Stress Index (PSI) between mothers with no cradling laterality preference and mothers with either a left or right preference. In several mammals a homologous left preference becomes stronger when acute threats prevail, rendering the rightwards shift we observed under dangerous conditions seemingly paradoxical. We propose this paradox can be resolved in terms of life-history strategy theory which predicts reduced parental investment in chronically dangerous environments. We interpret our high PSI score findings in no-preference cradlers as indicative of poorer, or at least ambivalent, maternal coping which many studies show is typically associated with reduced emotional sensitivity and responsiveness. We suggest that the latter may be a psychological mechanism mediating a partial withdrawal of parental investment in response to an enduringly adverse environment. To the best of our knowledge, this is the first study investigating cradling laterality preferences in an adverse socioeconomic environment. [ABSTRACT FROM AUTHOR]

Background: Posttraumatic stress disorder (PTSD) is a serious and debilitating disorder that can develop following exposure to a traumatic event. Where parents develop PTSD, it may have an impact on their parenting role. Objective: The objective was to review the existing evidence base on parental PTSD, examining whether parental PTSD has an impact on key parenting domains. Method: A comprehensive web-based search identified 27 quantitative studies that examined parental PTSD in relation to parenting domains. Results: Several parenting domains were investigated including: parenting satisfaction, parenting stress, the parent–child relationship, and specific parenting practices. Sample sizes ranged from 19 to 3931 parents. A range of parental traumas were investigated, including traumatic birth experiences, military trauma, and intimate partner violence. Findings indicated associations between parental PTSD and several domains of parenting, but there were inconsistencies across studies. Conclusions: Findings suggested that parental PTSD is associated with impaired functioning across a number of parenting domains, including increased levels of parenting stress, lower parenting satisfaction, less optimal parent–child relationships, and more frequent use of negative parenting practices, such as overt hostility and controlling behaviours. However, methodological limitations across the literature as a whole limited the potential to infer causal impacts of PTSD on parenting. Further study is also needed to advance our current understanding around the impact of different trauma types on parenting domains. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the authors discuss various articles published within the issue on such topics as the co-morbid epidemics of HIV and non-communicable diseases, HIV prevention, and prophylaxis for HIV prevention (PrEP).

Background: There is a growing body of literature outlining the promise of mobile information and communication technologies to improve healthcare in resource-constrained contexts. Methods: We reviewed the literature related to mobile information and communication technologies which aim to improve healthcare in resource-constrained contexts, in order to glean general observations regarding the state of mHealth in high-income countries (HIC) and low- and middle-income countries (LMIC). Results: mHealth interventions in LMIC often differ substantively from those in HIC, with the former being simpler, delivered through a single digital component (an SMS as opposed to a mobile phone application, or ‘app’), and, as a result, targeting only one of the many factors which impact on the activation (or deactivation) of the target behaviour. Almost as a rule, LMIC mHealth interventions lack an explicit theory of change. Conclusion: We highlight the necessity, when designing mHealth interventions, of having a theory of change that encompasses multiple salient perspectives pertaining to human behaviour. To address this need, we explore whether the concept of Life History Strategy could provide the mHealth field with a useful theory of change. Life History Strategy Theory may be particularly useful in understanding some of the problems, paradoxes, and limitations of mHealth interventions found in LMIC. Specifically, this theory illuminates questions regarding ‘light-weight’ programmes which solely provide information, reminders, and other virtual ‘nudges’ that may have limited impact on behaviours governed by extrinsic structural factors. [ABSTRACT FROM PUBLISHER]

In addition to its contribution to child mortality, HIV/AIDS has a substantial impact on the psychosocial well-being of children. We conducted a systematic review to identify studies that assess the effectiveness of interventions developed to improve the psychosocial well-being of children affected by HIV/AIDS, published between January 2008 and February 2016. Studies were eligible for the review if they included children under the age of 18 years, who had lost a parent to HIV/AIDS, were living with a parent with HIV/AIDS, or were vulnerable because of other factors and living in communities of high HIV/AIDS prevalence. Studies documented any intervention to improve the psychosocial well-being of children including psychological, psychosocial, medical, and social interventions, with psychological and/or social factors as outcomes. We identified 17 interventions to improve the psychosocial well-being of children affected by HIV/AIDS. Of these, 16 studies took place in 8 different low- and middle-income countries (LMIC), and 6 in Southern and Eastern Africa. Of the total, 15 showed some significant benefits of the intervention, while 2 showed no difference to psychosocial outcomes. The content of interventions, dosage and length of follow-up varied substantially between studies. There were few studies on children under 7 years and several focused mostly on girls. Due to the variability between interventions, it was not possible to make consolidated recommendations for programming based on the results of this review. However, we note that efforts to improve evaluation of interventions to improve the psychosocial well-being of children affected by HIV/AIDS have resulted in a number of new studies which met the inclusion criteria for the review. Most were research projects and not evaluations of existing services. We call for increased partnerships between policymakers, practitioners, and researchers in order to design evaluation studies that can feed into the growing evidence base. [ABSTRACT FROM AUTHOR]

Paraprofessional home visitors trained to improve multiple outcomes (HIV, alcohol, infant health and malnutrition) have been shown to benefit mothers and children over 18 months in a cluster randomised controlled trial. These longitudinal analyses examine the mechanisms which influence child outcomes at 18 months post-birth in Cape Town, South Africa. The results were evaluated using structural equation modelling, specifically examining the mediating effects of prior maternal behaviours and a home visiting intervention post-birth. Twelve matched pairs of neighbourhoods were randomised within pairs to: (1) the control condition, receiving comprehensive health care at community primary health care clinics (n = 12 neighbourhoods;n = 594 pregnant women), or (2) the Philani Intervention Program, which provided home visits by trained, paraprofessional community health workers, here called Mentor Mothers, in addition to clinic care (n = 12 neighbourhoods;n = 644 pregnant women). Recruitment of all pregnant neighbourhood women was high (98%) with 88% reassessed at 6 months and 84% at 18 months. Infants’ growth and diarrhoea episodes were examined at 18 months in response to the intervention condition, breastfeeding, alcohol use, social support and low birth weight, controlling for HIV status and previous history of risk. We found that randomisation to the intervention was associated with a significantly lower number of recent diarrhoea episodes and increased rates and duration of breastfeeding. Across both the intervention and control conditions, mothers who used alcohol during pregnancy and had low birth weight infants were significantly less likely to have infants with normal growth patterns, whereas social support was associated with better growth. HIV infection was significantly associated with poor growth and less breastfeeding. Women with more risk factors had significantly smaller social support networks. The relationships among initial and sustained maternal risk behaviours and the buffering impact of home visits and social support are demonstrated in these analyses. [ABSTRACT FROM PUBLISHER]

This paper applies social network analysis to three case study social movement organizations based in the north of England: a local Labour Party branch, an environmental group, and a conservation group. Using a postal survey of members, we chart the extent of ties between members of these three groups, indicating how each group has its own internal social dynamics and characteristics that are related to the nature of the movement organizations themselves. We explore how the network structures interrelate with the socio-demographic structure of the membership of the three organizations, and we show there are important differences in the way that core members of the three organizations are recruited compared to those who are either peripheral or isolated. Our paper is the first to analyse the networks of whole populations of case study organizations in the UK, and can therefore be read as developing the potential of social network analysis for case study research and for understanding social movements. Analytically we argue it is important to distinguish two different types of ways that networks are important. They can be seen as offering resources for mobilization, or they can be seen as providing a means of integrating particular types of individuals into organizations. It is this latter sense that offers a more fundamental role for network analysis, and we argue that it offers an important way of developing insights from resource mobilization theory by relating them to Bourdieu's provocative arguments regarding the exclusiveness of the political field. [ABSTRACT FROM AUTHOR]