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This study evaluated the impact of a parenting intervention on children's cognitive and socioemotional development in a group of caregivers and their 21-to-28-month-old children in a low-income South African township. A randomized controlled trial compared an experimental group (n = 70) receiving training in dialogic book-sharing (8 weekly group sessions) with a wait-list control group (n = 70). They were assessed before the intervention, immediately following it, and at a six month follow-up. The intervention had positive effects on child language and attention, but not behavior problems, prosocial behavior, or theory of mind. Intervention caregivers were less verbally and psychologically harsh, showed more sensitivity and reciprocity and more complex cognitive talk. This program benefitted parenting and child development and holds promise for low-income contexts.

Access to healthcare in developing countries remains a challenge. As a result, task-shifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs-information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government-run CHW program in South Africa's rural Eastern Cape Province. Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy. CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful.

ObjectiveExamine resiliency among a South African population cohort of children of mothers living with HIV (MLH) and mothers without HIV (MWOH) in low-income townships over the first 5 years of life.DesignA cluster randomized controlled intervention trial evaluating child resiliency and the effects of home visiting in township neighborhoods from pregnancy through 5 years postbirth.MethodsThe population of pregnant women in 24 matched neighborhoods were recruited and randomized by neighborhood to a standard care condition (n = 594) or a paraprofessional home visiting intervention condition (n = 644). Mothers and children were assessed at 2 weeks, 6, 18, 36, and 60 months postbirth (92-84% follow-up; 10.2% mortality). Resilient children were identified based on consistently meeting global standards for growth, cognitive functioning, and behavior. Maternal HIV status (n = 354 MLH; n = 723 mothers without HIV MWOH), intervention condition, maternal risks, caretaking, sociodemographic characteristics, and neighborhood were examined as predictors of child resiliency over time using analysis of variance, chi-square analyses, and Fisher's exact tests, where appropriate.ResultsNone of HIV-seropositive children (n = 17) were resilient; 19% of 345 HIV-exposed but uninfected children of MLH were resilient, a rate very similar to the 16% among MWOH. Resiliency was significantly associated with lower income, food security, not having a live-in partner, and the absence of maternal risk (i.e., not being depressed, using alcohol, or being a victim of intimate partner violence). Being randomized to a home visiting intervention, maternal breastfeeding for at least 3 months and attending a preschool crèche were also unrelated to resiliency. Although matched pairs of neighborhoods had similar rates of resilient children, resiliency varied significantly by neighborhood with rates ranging from 9.5 to 27%.ConclusionWe set a new standard to define resiliency, as consistently recommended by theoreticians. Although seropositive children are not resilient, uninfected children of MLH are as resilient as their peers of MWOH. Typical protective factors (e.g., home visiting, breastfeeding, preschool) were unrelated to resiliency over the first 5 years of life.Trial registrationClinicalTrials.gov registration #NCT00996528.

Introduction: The World Health Organization has called for more than 4 million community health workers (CHWs) globally; yet there are gaps in the evidence of CHWs' impact where studies have not had consistent results. South Africa is currently investing in CHW programs. However, there are significant concerns about the implementation and effectiveness of the program. Methods: We interviewed mid-level supervisors involved in eight rural clinics in a deeply rural South African municipality to identify the strengths and weaknesses of the CHW programs currently being implemented. Half of these clinics were part of a program providing enhanced supervision to CHWs, and the remainder were operating as usual. We hypothesized that stakeholders would provide valuable insights on how to improve the implementation of CHW programs. Fourteen interviews with supervisors from three levels of clinic and non-governmental organizations were conducted. Interviews were transcribed and translated from isiXhosa to English, and thematically analysed using ATLAS.ti. Results: Two overarching themes emerged: challenges at the national CHW program level (loss of political support, inadequacy of supervision and access to resources, human resource considerations); and experiences of the enhanced-supervision model provided (engagement and buy-in, link between CHW program and healthcare facilities, improvements through the intervention). Our findings suggest that CHWs operate largely unsupported, with limited access to training, equipment and supervision. The enhanced-supervision intervention appeared to mitigate some of these shortfalls. To make CHW programs efficient, we need to recruit CHWs based on social and administrative competence (rather than network referrals), provide improved higher quality training, provide more resources, especially equipment and transport, and ensure that CHWs receive supportive supervision that goes beyond simply administrative supervision. Furthermore, our findings suggest that the intervention in this study has somewhat mitigated these challenges through a package of supportive supervision and additional resources, highlighting the importance of stakeholder engagement and buy-in. It is clear that the governmental CHW program has many challenges -- a number of which were temporarily mitigated by the intervention tested in this research's parent study. A list of recommendations for practice was developed from this work. First, contracts and reimbursements are important for CHW motivation, and are seen as essential prerequisites for CHW program success. Second, CHWs and other stakeholders must be involved in the design and implementation of the CHW program. Third, good-quality training and refresher trainings for CHWs is critical. Fourth, access to equipment such as scales is needed. Fifth, transport is critical in rural areas to access patients in remote areas. Lastly, supportive supervision was described as of upmost importance. Conclusion: CHWs have the potential to provide invaluable support in communities, and in rural communities in particular -- but they need to operate in a functional supportive system. More resources need to be allocated to training, equipment and supportive supervision. [ABSTRACT FROM AUTHOR]

Access to healthcare in developing countries remains a challenge. As a result, task‐shifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs—information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government‐run CHW program in South Africa's rural Eastern Cape Province. Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy. CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful. [ABSTRACT FROM AUTHOR]

Social protection interventions (inclusive of cash grant receipt and care provision) have been found to be effective in response to some of the negative implications of the HIV epidemic on children and families. This study explores the impact of cash grant receipt and care provision (operationalised as good parenting) on child nutritional outcomes. In this cross-sectional study, 854 children and younger adolescents (5–15 years) and caregivers affected by HIV, attending community-based organisations in South Africa and Malawi, were interviewed. Interviews comprised inventories on socio-demographic information, family data, cash grant receipt and child nutrition. Parenting was measured using a composite scale. Logistic regression and marginal effects analyses were used to explore the associations between differing levels of social protection (none; either cash or good parenting; cash and good parenting) and child nutritional outcomes. One hundred and sixty children (20.3%) received neither cash nor good parenting; 501 (63.5%) received either cash or good parenting and 128 (16.2%) received both cash and good parenting. In comparison to no intervention, receipt of either cash or good parenting was significantly associated with child non-stunting, the child having sufficient food, and the child not looking thin. Three (3/7) nutritional outcomes showed increased improvement amongst children receiving both cash and good parenting care including child-reported non-hunger, child non-stunting and parental report of sufficient food. Marginal effects analyses further identified an additive effect of cash and good parenting on child nutritional outcomes. This study indicates that receipt of combined cash and good parenting, when compared to cash grant receipt alone, has positive effects on nutrition-related child outcomes. [ABSTRACT FROM AUTHOR]

Children in Southern Africa are exposed to high rates of structural and family adversities. This study tests whether services from Community Based Organisations (CBOs) in South Africa can promote children's resilience against depression exposed to such adversities. Two linked longitudinal studies were conducted, comprising n = 1848 children aged 9 to 13 years. One group received CBO services, whilst the other (quasi-control) did not. Analyses used interaction terms in regression models to test for potential moderation effects of CBO attendance, and marginal effects models to interpret significant interactions. Two interaction effects were shown, demonstrating moderation effects of CBO attendance on common structural disadvantages. First, children exposed to community violence showed increased depression (contrast = 0.62 [95%CI 0.43, 0.82], p <.001), but this association was removed by CBO access (contrast = 0.07 [95%CI −0.28, 0.43], p =.682). Second, children living in informal housing showed increased depression (contrast = 0.63 [95%CI 0.42, 0.85], p <.001), however, this association was removed by CBO access (contrast = 0.01 [95%CI −0.55, 0.56], p =.977). CBO attendance is associated with fewer depressive symptoms, and can buffer against important structural adversities of poor housing and violence that are common in high HIV-prevalence areas. However, CBO attendance was not able to remove the increased psychosocial distress associated with some family-level vulnerabilities such as orphanhood and abuse. These findings highlight the centrality of CBO-provided psychosocial support for children in Southern Africa, and suggest areas for bolstering provision. [ABSTRACT FROM AUTHOR]

The impact of the research process on the researcher is an emerging topic of interest. Data collection in most low- and middle-income countries (LMICs) is often the responsibility of community members who are identified and trained specifically for data collection. When research involves data on mental health and social well-being, data collectors may have specific competency needs and the task of data gathering may impact data collectors. This study aims to explore the experiences and needs of data collectors within South Africa using qualitative methods to examine the impact of data collection on data collectors. Nineteen data collectors, involved in face-to-face data collection, completed semi-structured interviews exploring their insights, attitudes and experiences. Thematic analysis revealed barriers and challenges associated with research, complexities regarding boundaries within the participant-data collector relationship and the benefits of being involved with research for the individual and the community. Numerous challenges and opportunities are outlined. Findings expose the beneficial and often overlooked contribution of data collectors and warrants key considerations in the planning and implementation of future research to ensure adequate support and standardization of practice. [ABSTRACT FROM AUTHOR]

Community‐based home visiting programs using community health workers (CHWs) have become popular modes of delivering health care services, especially in settings where health workers are overburdened and resources are limited. Yet, little is known about the processes that shape effective implementation in low‐resource settings, and whether these processes adhere to home visitors' training. This study used the newly‐developed Home Visit Communication Skills Inventory (HCSI) to explore the delivery of a CHW program in rural South Africa. Routine home visits from CHWs to their maternal care clients were audio‐recorded with consent, and later transcribed and translated into English. The HCSI, devised and piloted using existing frameworks and program‐specific training components, consisted of 21 items covering domains related to active listening, active delivery, and active connecting, and was used to score English transcripts of the home visits. The HCSI was used to generate general frequencies and aggregate scores for each CHW. Eighty‐four home visits by 14 CHWs showed a diverse application of communication skills. Active listening and active delivery were common, with fewer instances of active connecting observed. Practices disaggregated by CHW showcased varying strengths by an individual. In reviewing visit characteristics, longer average visit duration was significantly correlated with the presence of multiple types of active connecting skills. While technical skills were widely observed, fewer CHWs engaged in more complex "connecting" skills. The HCSI is a feasible, low‐cost, and practical way to describe home visit fidelity among CHWs. Audio‐based checklists can be used to describe fidelity to a model in the absence of additional supervisory resources. [ABSTRACT FROM AUTHOR]

Background: Social protection interventions, including cash grants and care provision have been shown to effectively reduce some negative impacts of the HIV epidemic on adolescents and families. Less is known about the role of social protection on younger HIV affected populations. This study explored the impact of cash grants on children's cognitive development. Additionally, we examined whether combined cash and care (operationalised as good parenting) was associated with improved cognitive outcomes.Methods: The sample included 854 children, aged 5 - 15, participating in community-based organisation (CBO) programmes for children affected by HIV in South Africa and Malawi. Data on child cognitive functioning were gathered by a combination of caregiver report and observer administered tests. Primary caregivers also reported on the economic situation of the family, cash receipt into the home, child and household HIV status. Parenting was measured on a 10 item scale with good parenting defined as a score of 8 or above.Results: About half of families received cash (55%, n = 473), only 6% (n = 51) reported good parenting above the cut-off point but no cash, 18% (n = 151) received combined cash support and reported good parenting, and 21% (n = 179) had neither. Findings show that cash receipt was associated with enhanced child cognitive outcomes in a number of domains including verbal working memory, general cognitive functioning, and learning. Furthermore, cash plus good parenting provided an additive effect. Child HIV status had a moderating effect on the association between cash or/plus good parenting and cognitive outcomes. The association between cash and good parenting and child cognitive outcomes remained significant among both HIV positive and negative children, but overall the HIV negative group benefited more.Conclusions: This study shows the importance of cash transfers and good parenting on cognitive development of young children living in HIV affected environments. Our data clearly indicate that combined provision (cash plus good parenting) have added value. [ABSTRACT FROM AUTHOR]

Background: Children in low and middle-income countries (LMICs) are at risk for problems in their cognitive, social and behavioural development. Factors such as a lack of cognitive stimulation, harsh parenting practices, and severe and persistent aggression in early childhood are central to the genesis of these problems. Interventions that target the intersection between early childhood development, parenting, and early violence prevention are required in order to meaningfully address these problems.Methods: We are conducting a randomised controlled trial to evaluate a parenting intervention for caregivers of children aged between 23 and 27 months, designed to promote child cognitive and socioemotional development in Khayelitsha, a low-income peri-urban township in South Africa. Families are randomly allocated to a book-sharing intervention group or to a wait-list control group. In the intervention, we train caregivers in supportive book-sharing with young children. Training is carried out in small groups over a period of 8 weeks. Data are collected at baseline, post intervention and at 6 months post intervention. In addition to targeting child cognitive development, the intervention aims to improve child socioemotional functioning.Discussion: The Benefits of Early Book Sharing (BEBS) trial aims to evaluate the impact of an early parenting intervention on several key risk factors for the development of violence, including aspects of parenting and child cognition, prosocial behaviour, aggression, and socioemotional functioning. The study is being carried out in a LMIC where violence constitutes a major social and health burden. Since the intervention is brief and, with modest levels of training, readily deliverable in LMIC contexts, a demonstration that it is of benefit to both child cognitive and socioemotional development would be of significance.Trial Registration: The BEBS trial is registered on the International Standard Randomised Controlled Trial Number database, registration number ISRCTN71109104 . Registered on 9 February 2016. This is version 1 of the protocol for the BEBS trial. [ABSTRACT FROM AUTHOR]

There is evidence that children who are HIV positive (HIV +) are at risk for poor developmental outcomes. The aims of this study were to use developmental screening tools to measure outcomes of children affected by HIV/AIDS attending community-based organisations (CBO) and to determine what types of CBO provision these children were receiving. In a cross-sectional study, we interviewed 979 children and their carers (4 to 13 years) at 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Developmental outcomes were assessed using the Ten Questions childhood disability screening tool and the Strengths and Difficulties Questionnaire. Health-related quality of life was measured using the Paediatric Quality of Life Scale. Overall, 13.8% ( n = 135) were HIV +. HIV + children were more likely to have developmental difficulties and lower health and educational quality of life, controlling for a range of factors. Developmental difficulties and poorer quality of life were predicted by being HIV +, living in South Africa, not attending school regularly, poor housing conditions and living with a sick family member. HIV + children tended to have been enrolled in CBO programmes for a longer period compared to other children but reported lower rates of contact. A greater proportion of HIV + children received medical services, psychosocial interventions and emotional support, compared to HIV − children. However, fewer HIV + children were enrolled in play groups, early childhood intervention programmes and educational programmes. Screening for developmental problems using short tools is possible in community settings in order to identify children with developmental difficulties and plan services for children infected with and affected by HIV. This study highlights the important role of CBOs to intervene to improve child development outcomes. The delivery of evidence-based services that target child development outcomes will enable HIV-infected children to meet their developmental potential and promote their participation in their communities. [ABSTRACT FROM AUTHOR]

Women in low- and middle-income countries and in contexts characterized by inequality face various interpersonal and structural barriers when accessing formal maternal and child health (MCH) services. These barriers persist even in contexts where programs to increase access to services, such as community health worker (CHW) interventions, have been implemented. However, while barriers to accessing care have been extensively documented, less is known about the diverse ways that women respond to, and navigate, these situations. This study explores strategies pregnant women and new mothers use to navigate and respond to health care barriers in a rural district in the Eastern Cape, South Africa. Twenty-six pregnant or recently delivered clients of the Enable Mentor Mother program were interviewed about their experiences of accessing formal MCH services. Interviews were conducted between February-March 2018 by an experienced isiXhosa-speaking research assistant, translated and transcribed into English, with transcripts coded and organized by themes using ATLAS.ti software. Facing resource shortages, inconsistent communication, and long travel times to clinics, participants employed diverse, innovative strategies to navigate interpersonal and structural barriers to care. While some participants chose to respond to barriers more passively—citing endurance and acceptance as practices of health system engagement—those participants who focused more on active responses tended to leverage their education, existing relationships, and available community resources to overcome barriers. Nevertheless, most participants described feelings of frustration and dejection. While CHW interventions may alleviate some of the burdens facing fragile health care systems in these contexts, these programs still rely on an underlying infrastructure of care that primary health care clinics and hospitals should be providing. Future programming should work in tandem with formal health systems and should support staff to improve quality of care provided to pregnant women, new mothers, and their infants to prioritize their health at a time of vulnerability. • Passive and assertive approaches were common responses to health access barriers. • Pregnant women and new mothers leveraged internal and community support resources. • Women felt less motivated to access care following repeated systemic failings. • Community health programs have limited impact when facing larger-level challenges. [ABSTRACT FROM AUTHOR]

Research suggests that parenting behaviours are negatively affected by parental trauma. However, thus far, the evidence base has provided limited insight into why this occurs. Further, the available evidence has focused largely on high income contexts (HICs), and we know much less about the experiences of parents in low- and middle-income countries (LMICs) who are frequently coping with multiple adversities. The current qualitative study aimed to gain a more in-depth understanding from the parent's perspective about whether and how their trauma impacted themselves and their parenting behaviours. We conducted interviews with 30 trauma-exposed, Xhosa speaking parents (28 mothers) from Khayelitsha, a township outside Cape Town in South Africa, 66% of whom reported experiencing moderate to severe posttraumatic stress symptoms. Five key themes were identified: consequences for parents as individuals (in terms of mental and physical health); the centrality of community and cultural context to parental experiences; consequences in terms of parenting capacity; trauma related effects on the child and how these may influence parental coping; and mechanisms of coping and achieving recovery. Findings highlight the difficult nature of parenting following trauma due to impacts on multiple areas of life, and suggest potential avenues for the development of parenting interventions in order to support parents and families more effectively following trauma. • Trauma exposure and posttraumatic distress present many challenges to LMIC parents. • Posttrauma anger, threat perceptions, poor coping may particularly affect parenting. • Physical consequences (e.g., loss of income) are also crucial for LMIC parents. • Perceived negative impacts for their children can compound parental distress. • Despite these challenges, parental bonds with their children may be retained. [ABSTRACT FROM AUTHOR]