Search

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]

Objectives In Nigeria adherence to exclusive breastfeeding (EBF) practices is currently suboptimal and a better understanding of the factors affecting adherence to EBF is needed. We sought to identify and delineate the barriers to and facilitators of adherence to EBF amongst HIV-infected and uninfected women in Nigeria. Methods We explored the barriers and facilitators to EBF amongst 37 (25 HIV-infected and 12 HIV-uninfected) pregnant women attending an antenatal clinic in Jos, Nigeria. In-depth interviews were conducted with each of the pregnant women in their third trimester of pregnancy and again 1 month after giving birth. Results The themes that emerged were mothers' feeding intentions, significant role players in the decision to breastfeed, perceived barriers (e.g. physiological issues, stigma, employment) and perceived facilitators (e.g. pleasure and enjoyment derived from breastfeeding, natural milk from God, disclosure and family support) associated with EBF. Conclusions Most women preferred EBF and offered it to their infants. However, more efforts are needed to improve support structures at home and at work to accommodate women who choose to do EBF. [ABSTRACT FROM AUTHOR]

Almost all pregnant women (98 %) in 24 Cape Town neighborhoods were randomized by neighborhood to (1) the standard care (SC) condition (n = 12 neighborhoods; n = 594 pregnant women) or (2) the Philani Intervention Program (PIP) in which home visits by Community Health Workers (CHW) were conducted (n = 12 neighborhoods; n = 644 pregnant women). At 36 months post-birth (84.6 % follow-up), PIP mothers were significantly less depressed compared to the SC mothers. Children in PIP were significantly less likely to be stunted (24.3 vs 18.1 %, p = 0.013), to have better vocabularies, and were less likely to be hospitalized than children in the SC condition. These data suggest home visits may need to continue for several years post-birth. Sustainable, scalable perinatal intervention models are needed in LMIC. [ABSTRACT FROM AUTHOR]

Background: Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity.Methods and Findings: We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity.Conclusions: In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored. [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]

Randomized controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultrashort screening instruments programmed into mobile phones. Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies ( N = 1,144 and N = 361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subject research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of four short and ultrashort versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥ 13. The prevalence of probable depression (475/1144 [42 %] and 165/361 [46 %]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach's α ranged from 0.55 to 0.58). All four subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91 to 0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression. The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression. [ABSTRACT FROM AUTHOR]

Risk of antenatal depression has been shown to be elevated in Southern Africa and can impact maternal and child outcomes, especially in the context of the Human Immunodeficiency Virus (HIV). Brief screening methods may optimize access to care during pregnancy, particularly where resources are scarce. This research evaluated shorter versions of the Edinburgh Postnatal Depression Scale (EPDS) to detect antenatal depression. This cross-sectional study at a large primary health care (PHC) facility recruited a consecutive series of 109 antenatal attendees in rural South Africa. Women were in the second half of pregnancy and completed the EPDS and Structured Clinical Interview for Depression (SCID). The recommended EPDS cutoff (≥13) was used to determine probable depression. Four versions, including the 10-item scale, seven-item depression, and novel three- and five-item versions developed through regression analysis, were evaluated using receiver operating characteristic (ROC) analysis. High numbers of women 51/109 (47 %) were depressed, most depression was chronic, and nearly half of the women were HIV positive 49/109 (45 %). The novel three-item version had improved positive predictive value (PPV) over the 10-item version and equivalent specificity to the seven-item depression subscale; the novel five-item provided the best overall performance in terms of ROC and Cronbach's reliability statistics and had improved specificity. The brevity, sensitivity, and reliability of the short and ultrashort versions could facilitate widespread community screening. The usefulness of the novel three- and five-item versions are underscored by the fact that sensitivity is important at first screening, while specificity becomes more important at higher levels of care. Replication in larger samples is required. [ABSTRACT FROM AUTHOR]

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: It has been proposed that children and young people living in low‐ and middle‐income countries (LMICs) are not only exposed more frequently to trauma but also have a higher likelihood of encountering traumas of greater severity than those living in high‐income countries (HICs). This may lead to higher rates of post‐traumatic stress symptoms (PTSS). However, developmental pathways to risk or resilience after trauma exposure in LMICs are underresearched. Methods: We examined early parenting and attachment as potentially important formative factors for later stress reactivity in a longitudinal cohort of South African children (N = 449). Parenting and attachment were assessed at child age 18 months, and interpersonal trauma exposure, PTSS and parenting stress were measured at 13 years (N = 333; core sample with data on all measures: N = 213). Following a vulnerability‐stress approach, separate regression models were run to investigate whether parent–child attachment at 18 months, parental sensitivity and intrusiveness during play at 12 months, and current parenting stress at 13 years, interacted with adolescents' extent of interpersonal trauma exposure to predict their PTSS levels at 13 years. Results: We found no predictive effects of either early attachment or current parenting stress in relation to child PTSS. There was some evidence for predictive influences of parental early intrusiveness and sensitivity on adolescent outcomes, though associations were unexpectedly positive for the latter. No interaction effects supporting a vulnerability‐stress model were found. Conclusions: Overall, we found limited evidence that elements of the early parent–child environment predict child risk/resilience to trauma in LMIC children. Future studies should include more frequent assessments of relevant constructs to capture changes over time and consider further what comprises adaptive parenting in high‐risk contexts. [ABSTRACT FROM AUTHOR]

Aims: To examine child outcomes over time among mothers with perinatally depressed mood in rural South Africa (SA).Methods: A representative sample of consecutive births (470/493) in the OR Tambo District of the Eastern Cape of South Africa (SA) were recruited and were reassessed at five points over the course of the next two years: 85% were reassessed at 3 months, 92% at 6 months, 88% at 9 months, 91% at 12 months, and 88% at 2 years post-birth. Over time, the children of mothers with perinatally depressed mood (16%) were compared to children of mothers without depressed mood using multiple linear and logistic regressions.Results: Mothers with perinatal depressed mood are significantly less likely to live with the child's father or their in-laws (23% vs 35%), have household incomes above 2000 ZAR (154 USD) (31% vs 51%), and significantly more likely to have experienced IPV prior (19% vs 9%) and during (32% vs 20%) pregnancy compared to mothers without depressed mood. There are no differences in age, education, primipara, HIV status (29% seropositive), or alcohol use. Growth and developmental delays and motor and speech milestones through 24 months post-birth are similar for mothers with and without perinatal depressed mood.Conclusions: Despite increased economic and partner difficulties associated with perinatal depressed mood, infant outcomes are similar in mothers with and without depressed mood in rural South Africa. [ABSTRACT FROM AUTHOR]

In this article the authors discuss mobile health initiatives which use mobile phones and other technologies to improve the health outcomes of patients. They are supportive of the initiatives but are also supportive of implementing several recommendations, including developing an evidence base, developing standards similar to those used in electronic health initiatives and taking a participatory approach, which could reduce waste and make mobile health more cost effective.

Objective To establish global research priorities for interpersonal violence prevention using a systematic approach. Methods Research priorities were identified in a three-round process involving two surveys. In round 1, 95 global experts in violence prevention proposed research questions to be ranked in round 2. Questions were collated and organized according to the four-step public health approach to violence prevention. In round 2, 280 international experts ranked the importance of research in the four steps, and the various substeps, of the public health approach. In round 3, 131 international experts ranked the importance of detailed research questions on the public health step awarded the highest priority in round 2. Findings In round 2, "developing, implementing and evaluating interventions" was the step of the public health approach awarded the highest priority for four of the six types of violence considered (i.e. child maltreatment, intimate partner violence, armed violence and sexual violence) but not for youth violence or elder abuse. In contrast, "scaling up interventions and evaluating their cost-effectiveness" was ranked lowest for all types of violence. In round 3, research into "developing, implementing and evaluating interventions" that addressed parenting or laws to regulate the use of firearms was awarded the highest priority. The key limitations of the study were response and attrition rates among survey respondents. However, these rates were in line with similar priority-setting exercises. Conclusion These findings suggest it is premature to scale up violence prevention interventions. Developing and evaluating smaller-scale interventions should be the funding priority. [ABSTRACT FROM AUTHOR]

Background: Consistent with evidence from high-income countries (HICs), we previously showed that, in an informal peri-urban settlement in a low-middle income country, training parents in book sharing with their infants benefitted infant language and attention (Vally, Murray, Tomlinson, & Cooper, 2015). Here, we investigated whether these benefits were explained by improvements in carer-infant interactions in both book-sharing and non-book-sharing contexts. We also explored whether infant socioemotional development benefitted from book sharing. Methods: We conducted a randomized controlled trial in Khayelitsha, South Africa. Carers of 14-16-month-old infants were randomized to 8 weeks' training in book sharing (n = 49) or a wait-list control group (n = 42). In addition to the cognitive measures reported previously, independent assessments were made at base line and follow-up of carer-infant interactions during book sharing and toy play. Assessments were also made, at follow-up only, of infant prosocial behaviour in a ‘help task', and of infant imitation of doll characters' nonsocial actions and an interpersonal interaction. Eighty-two carer-infant pairs (90%) were assessed at follow-up. (Trial registration ISRCTN39953901). Results: Carers who received the training showed significant improvements in book-sharing interactions (sensitivity, elaborations, reciprocity), and, to a smaller extent, in toy-play interactions (sensitivity). Infants in the intervention group showed a significantly higher rate of prosocial behaviour, and tended to show more frequent imitation of the interpersonal interaction. Improvements in carer behaviour during book sharing, but not during toy play, mediated intervention effects on all infant cognitive outcomes, and tended to mediate intervention effects on infant interpersonal imitation. Conclusions: Training in book sharing, a simple, inexpensive intervention that has been shown to benefit infant cognitive development in a low-middle income country, also shows promise for improving infant socioemotional outcomes in this context. Benefits are mediated by improvements in carer-infant interactions, particularly in book-sharing contexts. [ABSTRACT FROM AUTHOR]

Intimate partner violence (IPV) is a common traumatic stressor for women worldwide, especially for women living in low-and-middle-income countries. One of the most common correlates of IPV victimization is alcohol use, but the dynamics of IPV and drinking among women are not well understood. Although some research suggests that women drink in the aftermath of IPV to cope with distress related to the violence they experienced, other studies imply that higher levels of alcohol use among one or both partners in a relationship make violence more likely. In this study, we examine this question in a secondary analysis of a longitudinal study of a population cohort of pregnant women in South Africa (N = 1238) using a Bayesian approach to latent growth curve structural equation modeling. Results indicate that on average, IPV decreases and alcohol use increases over time and that these trajectories are associated with each other. Further, results suggest that although IPV drives drinking (rather than the other way around), higher average levels of alcohol use are associated with a slower decrease in IPV. Findings have implications for future research on the association between IPV and alcohol use, as well as for clinical intervention for women who experienced IPV. [ABSTRACT FROM AUTHOR]

Measures that produce valid and reliable antenatal depressive symptom scores in low-resource country contexts are important for efforts to illuminate risk factors, outcomes, and effective interventions in these contexts. Establishing the psychometric comparability of scores across countries also facilitates analyses of similarities and differences across contexts. To date, however, few studies have evaluated the psychometric properties and comparability of the most widely used antenatal depressive symptom measures across diverse cultural, political, and social contexts. To address this gap, we used data from the Evidence for Better Lives Study-Foundational Research (EBLS-FR) project to examine the internal consistency reliability, nomological network validity, and cross-country measurement invariance of the nine-item version of the Patient Health Questionnaire (PHQ-9) in antenatal samples across eight low-resource contexts. We found that the PHQ-9 scores had good internal consistency across all eight countries. Correlations between PHQ-9 scores and constructs conceptually associated with depression were generally consistent, with a few exceptions. In measurement invariance analyses, only partial metric invariance held and only across four of the countries. Our results suggest that the PHQ-9 yields internally consistent scores when administered in culturally diverse antenatal populations; however, the meaning of the scores may vary. Thus, interpretation of PHQ-9 scores should consider local meanings of symptoms of depression to ensure that context-specific conceptualizations and manifestations of antenatal depressive symptoms are adequately reflected. (PsycInfo Database Record (c) 2022 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

Background Dialogic book-sharing is an interactive form of shared reading. It has been shown in high income countries ( HICs) to be of significant benefit to child cognitive development. Evidence for such benefit in low and middle income countries ( LMICs) is scarce, although a feasibility study of our own produced encouraging findings. Accordingly, we aimed to establish the impact on child language and attention of providing training in dialogic booksharing to carers of infants in an impoverished South African community. Methods We conducted a randomized controlled trial in Khayelitsha, an informal settlement in South Africa. Mothers of infants aged between 14 and 16 months were recruited and randomized to either 8 weeks of manualized training in dialogic book-sharing or a no-intervention control group. Independent assessments were made of infant language and attention at baseline and following training. The trial was registered ( ISRCTN39953901). Results Ninety one carer-infant dyads were recruited and randomized to the intervention group ( n = 49) or the control group ( n = 42), 82 (90%) of whom were available for follow-up assessments. On a standardized carer report of infant vocabulary, compared to those in the control group, carers who received the intervention reported a significantly greater increase in the number of words understood by their infants as well as a larger increase in the number of words that their infant understood and could vocalize. Intervention group children also showed substantially greater gains on a measure of sustained attention. Conclusions In line with evidence from HICs, a dialogic book-sharing programme delivered to an impoverished South African sample was shown to be of considerable benefit to the development of child language and focussed attention. The training programme, which is simple and inexpensive to deliver, has the potential to benefit child cognitive development in LMIC contexts where such development is commonly compromised. [ABSTRACT FROM AUTHOR]

Background: While the negative impact of peri-natal depression is well-documented in high-income countries, the long-term effects across the life course in low and middle-income countries is less clear. Children's adjustment over the first five years is examined as a function of patterns of maternal depressed mood.Methods: Pregnant women in 24 peri-urban townships (N = 1,238) were randomized to a home-visiting intervention or standard care and reassessed five times, with high retention. There were no intervention effects on children past 18 months. Multilevel regression models examined the impact of depressed mood on child outcomes. Using the Edinburgh Postnatal Depression Scale, four patterns of maternal depressed mood were identified: never (40.6%); antenatal (13.0%); early childhood (26.1%); and recurrent episodes of depressed mood (20.3 %).Findings: Mothers' patterns of depressive symptoms and child outcomes were similar, regardless of intervention. Never depressed mothers were significantly younger, had higher income, less food insecurity, were more likely to have electricity, be living with HIV or have an HIV positive partner, and had fewer problems with alcohol than depressed mothers. Children of mothers who experienced depressed mood weighed less, were more aggressive, and were hospitalized more often than children of never depressed mothers, but were similar in cognitive and social development.Interpretations: Depressed mood, has significant negative impacts on South African children's growth and aggressive behavior. The timing of maternal depressed mood was less important than never having a depressed mood or a recurrent depressed mood.Funding: There were no funding conflicts in executing this trial. [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]

The article discusses the challenges facing mental health research in poor countries and offers suggestions on how it should be governed. These challenges include the lack of an organizational structure, financial limitations, and research capacity constraints. It stresses the importance of institutionalizing the general orientation of mental health research to address the challenges. It notes that expensive research must be balanced with assessment services and resources using cheap methods.

Background: Home visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities.Methods: A non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth.Results: Home visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3-0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9).Conclusion: The impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context. [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]

Despite empirical support for "Self-control theory" in criminology, there is controversy about how self-control should be operationalized. Working within the framework of "self-control theory," we investigated if violence and criminal behaviors are associated with nine distinct dimensions of cognitive control in a community sample of young men (n = 654) living in peri-urban townships in South Africa. Cognitive control was assessed using the Behavior Rating Inventory of Executive Function. Multivariate statistical analysis was used, to identify associations between violence and criminality, and deaggregated measures of nine distinct components of cognitive control. Fifteen percent of the sample reported recent violence, 27% had been in physical fights with family/friends in the preceding 6 months, 10% reported being arrested, 4% reported forced sexual contact, and 26% reported intimate partner violence (IPV). Controlling for substance use and sociodemographic variables, contact with the criminal justice system and violence were associated with deficits in all domains of cognitive control. Forced sexual contact was associated with behavioral dysregulation. IPV was associated with behavior dysregulation and executive control dysfunction. Future studies might utilize deaggregated measures of self-control to provide further insight into links between particular components of cognitive control and various forms of offending and violence. [ABSTRACT FROM AUTHOR]

Objectives: To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries.Data Sources: Oregon vital statistics records, 2008-2013.Study Design: Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy.Data Collection/extraction Methods: We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011.Principal Findings: The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends.Conclusions: Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes. [ABSTRACT FROM AUTHOR]

In light of South Africa's high prenatal HIV prevalence and infant mortality rate, a cluster randomized controlled trial was conducted to evaluate an intervention called Philani+, which used community health workers (known as Mentor Mothers) to deliver pre- and postnatal home visits in Cape Town, South Africa, to improve maternal and child health. We assessed the costs and benefits of this intervention and made comparisons with other scenarios that depicted increased capacity and provision of nurse-delivered care. The recurrent cost of the twenty-four-month intervention was US$80,001. The major health outcomes analyzed were differences in the proportion of infants who were low birthweight, stunted, and suboptimally breastfed between intervention and control groups. Each case of low birthweight averted cost US$2,397; of stunted growth, US$2,454; and of suboptimal breastfeeding, US$1,618. Employment of community health workers was cost saving compared to that of nurses. Philani+ improved child health at a relatively low cost, considering the health system costs associated with low birthweight and undemutrition. The model could be suitable for replication in low-resource settings to improve child health in other countries. [ABSTRACT FROM AUTHOR]

Background: Concurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting.Methods/design: In the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2 years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW's mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24 months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones.Discussion: The proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs' over time will improve MCH outcomes over the first 2 years of life.Trial Registration: ClinicalTrials.gov registration #NCT02957799 , registered on October 26, 2016. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association of Oregon's hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal-neonatal outcomes.Methods: This was a population-based retrospective cohort study of Oregon births between 2008 and 2013 using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods prepolicy (2008-2010) and postpolicy (2012-2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N=181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (ie, elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death.Results: The rate of elective inductions before 39 weeks of gestation declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<.001); a similar decline was observed for elective early-term cesarean deliveries (from 3.4% to 2.1%; P<.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation prepolicy and postpolicy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<.001; adjusted odds ratio 1.94, 95% confidence interval 1.80-2.09).Conclusions: Oregon's statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes. [ABSTRACT FROM AUTHOR]

Background: In low and middle-income countries (LMIC), common mental disorders affecting pregnant women receive low priority, despite their disabling effect on maternal functioning and negative impact on child health and development. We investigated the prevalence of risk factors for antenatal depression among women living in adversity in a low-resource, urban setting in Cape Town, South Africa.Methods: The MINI Neuropsychiatric Interview (MINI Plus) was used to measure the diagnostic prevalence of depression amongst women attending their first antenatal visit at a primary-level, community-based clinic. Demographic data were collected followed by administration of questionnaires to measure psychosocial risk. Analysis examined the association between diagnosis of depression and psychosocial risk variables, and logistic regression was used to investigate predictors for major depressive episode (MDE).Results: Among 376 women participating, the mean age was 26 years. The MINI-defined prevalence of MDE was 22%, with 50% of depressed women also expressing suicidality. MDE diagnosis was significantly associated with multiple socioeconomic and psychosocial risk factors, including a history of depression or anxiety, food insecurity, experience of threatening life events and perceived support from family.Limitations: The use of self-report measures may have led to recall bias. Retrospective collection of clinical data limited our ability to examine some known risk factors for mental distress.Conclusion: These findings confirm the high prevalence of MDE among pregnant women in LMIC settings. Rates of depression may be increased in settings where women are exposed to multiple risks. These risk factors should be considered when planning maternal mental health interventions. [ABSTRACT FROM AUTHOR]

Maternal depression, including antepartum and postpartum depression, is a neglected public health issue with potentially far-reaching effects on maternal and child health. We aimed to measure the burden of antepartum depression and identify risk factors among women in a peri-urban community in Swaziland. We conducted a cross-sectional study within the context of a community outreach peer support project involving 'Mentor Mothers'. We used of the Edinburgh Postnatal Depression Scale (EPDS) to screen women for depression during the third trimester of pregnancy, using a cut-off score of ≥13 to indicate depression. We also collected demographic and socioeconomic factors, and assessed the association of these factors with EPDS score using logistic regression models. A total of 1038 pregnant women were screened over a period of 9 months. Almost a quarter (22.7 %) had EPDS scores ≥13 and 41.2 % were HIV positive. A fifth, 17.5 % were teenagers and 73.7 % were unemployed. Depression was not associated with HIV status, age or employment status. However, women with multiple socioeconomic stressors were found to be more likely to score highly on the EPDS. Depression was common among pregnant women in the peri-urban areas of Swaziland. Screening for depression using the EPDS is feasible and can be included in the community health worker standard tool box as a way to improve early detection of depression and to highlight the importance of maternal mental health as a core public health concern. [ABSTRACT FROM AUTHOR]

Aim: To determine whether, in an impoverished South African community, an intervention that benefitted infant attachment also benefitted cognitive development.Method: Pregnant females were randomized to intervention (n=220) and no-treatment control groups (n=229). The intervention was home-based parenting support for attachment, delivered until 6 months postpartum. At 18 months, infants were assessed on attachment and cognitive development (Bayley Scales Mental Development Index [MDI]) (n=127 intervention, n=136 control participants). Infant MDI was examined in relation to intervention, socio-economic risk, antenatal depression, and infant sex and attachment.Results: Overall, there was little effect of the intervention on MDI (p=0.094, d=0.20), but there was an interaction between intervention and risk (p=0.03, ηp2=0.02). MDI scores of infants of lower risk intervention group mothers were, on average, 4.84 points higher than those of other infants (p=0.002, d=0.41). Antenatal depression was not significant once intervention and risk were controlled (p=0.08); there was no association between infant MDI and either sex (p=0.41) or attachment (p=0.56).Interpretation: Parenting interventions for infant cognitive development may benefit from inclusion of specific components to support infant cognition beyond those that support attachment, and may be most effective for infants over 6 months. They may need augmentation with other input where adversity is extreme. [ABSTRACT FROM AUTHOR]

Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services. [ABSTRACT FROM AUTHOR]

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.Setting: A township near Durban, South Africa.Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2·29; 95 % CI 1·80, 2·92), increased exclusive formula-feeding (OR=1·70; 95 % CI 1·28, 2·27), increased predominant breast-feeding (OR=1·71; 95 % CI 1·34, 2·19), decreased mixed formula-feeding (OR=0·68; 95 % CI 0·55, 0·83) and decreased mixed breast-feeding (OR=0·54; 95 % CI 0·44, 0·67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0·01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0·03). The effect on exclusive feeding was not different by household wealth or maternal education levels.Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding. [ABSTRACT FROM AUTHOR]

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs. [ABSTRACT FROM AUTHOR]

Background: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa.Methods/design: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17.Discussion: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa.Trial Registration: Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (http://www.pactr.org): PACTR201403000676264, registered on 11/10/2013. [ABSTRACT FROM AUTHOR]