Protocol of a cost-effectiveness analysis of a combined intervention for depression and parenting compared with enhanced standard of care for perinatally depressed, HIV-positive women and their infants in rural South Africa.

INTRODUCTION: Poverty, HIV and perinatal depression represent a triple threat to public health in sub-Saharan Africa because of their combined negative effects on parenting and child development. In the resource-constrained context of low-income and middle-income countries, a lay-counsellor-delivered intervention that combines a psychological and parenting intervention could offer the potential to mitigate the consequences of perinatal depression while also optimising scarce resources for healthcare.Measuring the cost-effectiveness of such a novel intervention will help decision-makers to better understand the relative costs and effects associated with replicating the intervention, thereby supporting evidence-based decision-making. This protocol sets out the methodological framework for analysing the cost-effectiveness of a cluster randomised controlled trial (RCT) that compares a combined intervention to enhanced standard of care when treating depressed, HIV-positive pregnant women and their infants in rural South Africa. METHODS AND ANALYSIS: This cost-effectiveness analysis (CEA) protocol complies with the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. A societal perspective will be chosen.The proposed methods will determine the cost and efficiency of implementing the intervention as per the randomised control trial protocol, as well as the cost of replicating the intervention in a non-research setting. The costs will be calculated using an appropriately adjusted version of the Standardised Early Childhood Development Costing Tool.Primary health outcomes will be used in combination with costs to determine the cost per improvement in maternal perinatal depression at 12 months postnatal and the cost per improvement in child cognitive development at 24 months of age. To facilitate priority setting, the incremental cost-effectiveness ratios for improvements in child cognitive development will be ranked against six other child cognitive-development interventions according to Verguet et al's methodology (2022).A combination of activity-based and ingredient-based costing approaches will be used to identify, measure and value activities and inputs for all alternatives. Outcomes data will be sourced from the RCT team. ETHICS AND DISSEMINATION: The University of Oxford is the sponsor of the CEA. Ethics approval has been obtained from the Human Sciences Research Council (HSRC, #REC 5/23/08/17), South Africa and the Oxford Tropical Research Ethics Committee (OxTREC #31-17), UK.Consent for publication is not applicable since no participant data are used in this protocol.We plan to disseminate the CEA results to key policymakers and researchers in the form of a policy brief, meetings and academic papers. TRIAL REGISTRATION DETAILS: ISRCTN registry #11 284 870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Identifying pregnant and postpartum women's priorities for enhancing nutrition support through social needs programmes in a resource-constrained urban community in South Africa.

BACKGROUND: Malnutrition remains a pressing public health concern for mothers and children in South Africa. Despite the government's multisectoral response, unaddressed social needs prevent some mothers getting full benefit from interventions, spanning financial planning, income stability, housing, access to government services, social support, and provision of affordable, nutritious foods. Engaging with mothers and prioritising their concerns is important if we wish to overcome obstacles to women benefiting from government nutrition interventions. This study aimed to identify the programmes that women perceived as a priority in addressing the social needs of mothers of young infants and pregnant women to enhance nutrition in a resource-constrained urban township in South Africa. METHODS: A cross-sectional study employed a quantitative preference elicitation survey, administered to 210 mothers and pregnant women from five primary healthcare facilities in Soweto. The survey tool was developed with the community to identify unmet social needs and potential solutions, which were synthesised with findings from the literature. The survey described 15 programmes, grouped into three delivery levels: clinics, community, and government. Participants were required to rank programme options in two stages. First, they selected their top two programmes within each delivery level. Subsequently, they allocated stickers to indicate the strength of their preference among the top programmes across the levels. Rankings were analysed using descriptive statistics. RESULTS: The highest priority was given to five programmes. Two delivered at the community level: Women's economic empowerment groups and Job search assistance, two at the clinic level: Social needs assessment and referral, and Prescription-based food, and one at the government level: Free quality childcare. The lowest-ranked programmes were two clinic-based programmes, specifically Maternal nutrition groups and Couple antenatal education. CONCLUSION: Women expressed strong views about which programmes should be prioritised to support mothers and pregnant women in addressing their social needs and improving nutrition. Key areas included providing support with job searching and entrepreneurship, accessing childcare and the healthy foods recommended at clinics, as well as finding information on available community and government services. Leveraging multisectoral collaboration, aligned policy objectives, efficient public financing, and strengthened implementation capacity will be pivotal in delivering these programmes.

Does perceived caregiver HIV stigma and depression increase adolescent neuro-behavioral difficulties? A mediation analysis in the Asenze Cohort.

People living with HIV (PLWH) often experience HIV related stigma that is, in turn, associated with several negative health outcomes including depression, harmful drinking, and intimate partner violence. Despite knowledge of these proximal impacts of HIV stigma on PLWH, less is known about the impact that Caregivers living with HIV's perception of stigma has on the health and behavior of adolescents in their care. Utilizing data from adolescents and their primary caregivers from the population-based Asenze cohort study in KwaZulu-Natal, South Africa, we conducted a path analysis to determine if caregiver depression [operationalized as mental health functioning] is a mediator of the hypothesized association between caregiver HIV stigma and adolescent neurodevelopmental behavior including internalizing and externalizing behaviors. Results suggest good model fit and a statistically significant relationship between caregiver HIV stigma and caregiver mental health functioning. However, neither the direct nor indirect (including potential mediator caregiver mental health functioning) effect of HIV stigma on adolescent behavioral difficulties was statistically significant. This paper builds on previous research demonstrating the relationship between HIV stigma and depression, highlighting the need for continued study of underlying mechanisms that impact the stigma and health of PLWH and others important to them such as their children.

Addressing unmet social needs for improved maternal and child nutrition: Qualitative insights from community-based organisations in urban South Africa.

Maternal and child malnutrition persists globally, despite existing healthcare and social protection systems. Socio-economic disadvantages contribute to high malnutrition rates, particularly in poor urban communities where many disadvantaged mothers cannot fully benefit from services. To address these disparities, a novel social needs framework has been proposed, emphasising the importance of addressing individuals' unmet needs to enhance the benefits of nutrition services. This study investigates the perceived impact of community-based organisations (CBOs) in addressing the social needs of mothers in a resource-constrained urban township in South Africa. Interviews were conducted with 18 employees from 10 CBOs working on maternal and child health, food security and social support in Soweto. Thematic analysis revealed 23 services and four pathways through which CBOs believed to address unmet social needs of beneficiaries. Services were small-scale, including food aid, learning support, and social protection assistance, available to a few in dire need. CBO services partially addressed social needs of mothers due to scale, coverage, and sustainability limitations. The South African government should reaffirm its commitment to financially supporting the non-profit sector and integrating it into government sectors to provide tailored services and resources to address diverse social needs and mitigate nutrition inequalities among mothers and children.

Whole of government approaches to accelerate adolescent success: efficiency and financing considerations.

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.

Qualitative exploration of the constraints on mothers' and pregnant women's ability to turn available services into nutrition benefits in a low-resource urban setting, South Africa.

OBJECTIVES: Despite free primary healthcare services and social protection system for mothers and children, significant nutrition inequalities occur across the globe, including in South Africa. This study aimed to explore what determines mothers' ability to access and turn available services into nutrition benefits. DESIGN: An exploratory qualitative study was conducted including semistructured interviews with employees from community-based organisations and focus groups with pregnant women and mothers. Discussions focused on existing services perceived as important to nutrition, differences in mothers' ability to benefit from these services, and the underlying unmet needs contributing to these disparities. Data were analysed thematically using a novel social needs framework developed for this study where social needs are defined as the requisites that can magnify (if unmet) or reduce (if met) variation in the degree to which individuals can benefit from existing services. SETTING: A resource-constrained urban township, Soweto in Johannesburg. PARTICIPANTS: Thirty mothers of infants (<1 year old) and 21 pregnant women attending 5 primary healthcare facilities participated in 7 focus groups, and 18 interviews were conducted with employees from 10 community-based organisations. RESULTS: Mothers identified social needs related to financial planning, personal income stability, appropriate and affordable housing, access to government services, social support and affordable healthier foods. The degree to which these needs were met determined mothers' capabilities to benefit from eight services. These were clinic-based services including nutrition advice and social work support, social grants, food aid, community savings groups, poverty alleviation projects, skills training workshops, formal employment opportunities and crèches/school feeding schemes. CONCLUSION: Findings demonstrate that while current social protection mechanisms and free health services are necessary, they are not sufficient to address nutrition inequalities. Women's social needs must also be met to ensure that services are accessed and used to improve the nutrition of all mothers and their children.

Measuring the cost-effectiveness of a home-visiting intervention to promote early child development among rural families linked to the Rwandan social protection system.

Early childhood development (ECD) programmes are heralded as a way to improve children's health and educational outcomes. However, few studies in developing countries calculate the effectiveness of quality early childhood interventions. This study estimates the cost and cost-effectiveness of the Sugira Muryango (SM) trial, a home-visiting intervention to improve ECD outcomes through positive parent-child relationships. Cost-effectiveness analysis of ECD interventions is challenging given their potential to have multiple benefits. We propose a cost-effectiveness method using a single outcome, in this case the improvement in cognitive development per home-visit session, as an indication of efficiency comparable across similar interventions. The trial intervention cost US$456 per family. This cost will likely fall below US$200 if the intervention is scaled through government systems. The cost-effectiveness analysis suggests that while SM generated a relatively small impact on markers of early development, it did so efficiently. The observed improvements in cognitive development per home-visit are similar to other home-visiting interventions of longer duration. SM by focusing on the family had benefits beyond ECD, including reductions in violence against children and intermate partner violence, further analysis is needed to include these returns in the economic evaluation.

The impact of caregiver mental health on child prosocial behavior: A longitudinal analysis of children and caregivers in KwaZulu-Natal, South Africa.

BACKGROUND: Prosocial behavior has positive social, cognitive, and physical health effects on the individual exhibiting the behavior as well as on society as a whole, and is integral to overall mental and physical wellbeing. The development of prosocial behavior is rooted in early childhood and learned through observation. As such, those spending time with children, especially their caregiver, play a critical role in their prosocial development. The current study investigates the impact of caregiver mental health on the prosocial development of young children over time. METHODS: This paper presents a secondary analysis of child prosocial development in the Asenze Study, a longitudinal, population-based cohort study based in KwaZulu-Natal, South Africa. Children were followed-up over time from an average age of five to seven years along with their caregivers. Linear GEE regression analysis was used to assess whether a change in presence of a mental health disorder in a caregiver during this 2-year interval (using the Client Diagnostic Questionnaire) impacted the development of their child's prosocial behavior (using the Strengths and Difficulties Questionnaire). RESULTS: After adjusting for early child-care, child HIV status, SDQ child prosocial subscale, SDQ total difficulties score, and household order score (CHAOS), children whose caregivers acquired a mental health disorder had a significantly smaller increase in prosocial behavioral development compared to children whose caregivers never had a mental health disorder. CONCLUSIONS: Identifying contextually relevant modifiable factors such as this will help stimulate the development of interventions to promote prosocial development in childhood.

Assessing the cost-effectiveness of economic strengthening and parenting support for preventing violence against adolescents in Mpumalanga Province, South Africa: An economic modelling study using non-randomised data.

There is limited evidence around the cost-effectiveness of interventions to reduce violence against children in low- and middle-income countries. We used a decision-analytic model to evaluate the cost-effectiveness of three intervention scenarios for reducing adolescent emotional, physical, and sexual abuse in Mpumalanga Province, South Africa. The intervention scenarios were: 1) Community grant outreach to link households to South Africa's Child Support Grant (CSG) if they are eligible, but not receiving it; 2) Group-based parenting support; and 3) Group-based parenting support 'plus' linkage to the CSG. We estimated average cost-effectiveness ratios (ACERs) for intervention scenarios over a ten-year time horizon, and compared them to a South Africa-specific willingness-to-pay (WTP) threshold (USD3390). Health effects were expressed in disability-adjusted life years (DALYs) averted. Our model considered four combinations of routine service versus trial-based costing, and population-average versus high prevalence of violence. Under routine service costing, ACERs for grant outreach and parenting support were below the WTP threshold when considering a population-average prevalence of violence USD2850 (Lower: USD1840-Upper: USD10,500) and USD2620 (USD1520-USD9800) per DALY averted, respectively; and a high prevalence of violence USD1320 (USD908-USD5180) and USD1340 (USD758-USD4910) per DALY averted, respectively. The incremental cost-effectiveness of parenting support plus grant linkage relative to parenting support alone was USD462 (USD346-USD1610) and USD225 (USD150-USD811) per DALY averted at a population-average and high prevalence of violence, respectively. Under trial-based costing, only the ACER for grant outreach was below the WTP threshold when considering a high prevalence of violence USD2580 (USD1640-USD9370) per DALY averted. Confidence intervals for all ACERs crossed the WTP threshold. In conclusion, grant outreach and parenting support are likely to be cost-effective intervention scenarios for reducing violence against adolescents if they apply routine service costing and reach high risk groups. Combining parenting support with grant linkage is likely to be more cost-effective than parenting support alone.

The impact of family support and organization on adolescents during school closure under Covid-19 lockdown regulations in an area of South Africa.

The Covid-19 pandemic and resultant disruptions to schooling presented significant challenges for many families. Well organised families have been shown to have a protective effect on adolescent wellbeing in periods of shock. At the onset of the Covid-19 pandemic, Asenze, a population-based cohort study, was conducting a third wave of data collection in peri-urban South Africa, examining risk and protective factors during adolescence. By March 2020, n = 272 adolescents and their caregivers (n = 241) in the cohort had been assessed when in-person data collection was halted by lockdown measures countrywide. During this cessation we undertook a brief telephonic qualitative sub-study to explore whether families enrolled in the cohort were able to cohabit cohesively and undertake distance learning during lockdown. A purposeful sample of 20 families (caregivers n = 20, adolescents n = 24) recently assessed in the Wave 3 of the main study, participated in semi-structured interviews. Quantitative data from Waves 1-3 of the main study was used to measure family function, adolescent cognitive function, and profile adolescent and caregivers. The quantitative and qualitative data were integrated to illustrate the dynamics of the participants' lives before and during lockdown. We found that families classified as well-organized before lockdown, were more likely to report co-operation during lockdown. Adolescents who were self-motivated, had access to smartphones or the internet, and were supported by both family and educators, were well-placed to continue their education without much disruption. However, few schools instituted distance learning. Of the adolescents who were not assisted- some studied on their own or with peers, but others did no schoolwork, hindered by a lack of digital connectivity, and poor service delivery. The experience of adolescence and caregivers in the Asenze Cohort during lockdown highlight the importance of family functioning for adolescent wellbeing in crisis, as well as the need for access to health, mental health, and social services, communication upgrades, and enhancements to the education system during peaceful times, to make a difference to young lives in times of crisis.

A conceptual framework and exploratory model for health and social intervention acceptability among African adolescents and youth.

Intervention acceptability has become an increasingly key consideration in the development, evaluation and implementation of health and social interventions. However, to date this area of investigation has been constrained by the absence of a consistent definition of acceptability, comprehensive conceptual frameworks disaggregating its components, and few reliable assessment measures. This paper aims to contribute to this gap, by proposing a conceptual framework and exploratory model for acceptability with a specific priority population for health and developmental interventions: adolescents and youth in Africa. We document our multi-staged approach to model development, comprising both inductive and deductive components, and both systematic and interpretative review methods. This included thematic analyses of respective acceptability definitions and findings, from 55 studies assessing acceptability of 60 interventions conducted with young people aged 10-24 in (mainly Southern and Eastern) Africa over a decade; a consideration of these findings in relation to Sekhon et al.'s Theoretical Framework of Acceptability (TFA); a cross-disciplinary review of acceptability definitions and models; a review of key health behavioural change models; and expert consultation with interdisciplinary researchers. Our proposed framework incorporates nine component constructs: affective attitude, intervention understanding, perceived positive effects, relevance, perceived social acceptability, burden, ethicality, perceived negative effects and self-efficacy. We discuss the rationale for the inclusion and definition of each component, highlighting key behavioural models that adopt similar constructs. We then extend this framework to develop an exploratory model for acceptability with young people, that links the framework components to each other and to intervention engagement. Acceptability is represented as an emergent property of a complex, adaptive system of interacting components, which can influence user engagement directly and indirectly, and in turn be influenced by user engagement. We discuss opportunities for applying and further refining or developing these models, and their value as a point of reference for the development of acceptability assessment tools.

Investing in human development and building state resilience in fragile contexts: A case study of early nutrition investments in Burkina Faso.

Maternal and early malnutrition have negative health and developmental impacts over the life-course. Consequently, early nutrition support can provide significant benefits into later life, provided the later life contexts allow. This study examines the limits of siloed investments in nutrition and illustrates how ignoring life-course contextual constraints limits human development benefits and exacerbates inequality, particularly in fragile contexts. This case study focuses on Burkina Faso, a country with high rates of early malnutrition and a fragile state. We modelled the impact of scaling up 10 nutrition interventions to 80% coverage for a single year cohort on stunting, nationally and sub-nationally, using the Lives Saved Tool (LiST), and the consequent impact on earnings, without and with a complementary cash-transfer in later life. The impact on earnings was modelled utilising the well-established pathway between early nutrition, years of completed schooling and, consequent adult earnings. Productivity returns were estimated as the present value of increased income over individuals' working lives, then compared to estimates of the present value of providing the cost of nutrition interventions and cash-transfers. The cost benefit ratio at the national level for scaled nutrition alone is 1:1. Sub-nationally the worst-off region yields the lowest ratio < 0.2 for every dollar spent. The combination of nutrition and cash-transfers national cost benefit is 1:12, still with regional variation but with great improvement in the poorest region. This study shows that early nutrition support alone may not be enough to address inequality and may add to state fragility. Taking a life-course perspective when priority-setting in contexts with multiple constraints on development can help to identify interventions that maximizing returns, without worsening inequality.

Triple Benefit: Impact of an Integrated Early Childhood Development and PMTCT Intervention on ART Outcomes Among Mothers Living with HIV and Infants in Malawi-An Endline Evaluation.

We conducted a programmatic, observational cohort study with mother-infant pairs (MIPs) enrolled in prevention-of-mother-to-child-transmission (PMTCT) programs in Malawi to assess the feasibility and potential HIV-related benefits of integrating Early Childhood Development (ECD) services into PMTCT programs. Six health facilities were included in the intervention. We offered ECD counseling from the WHO/UNICEF Care for Child Development package in PMTCT waiting spaces while MIPs waited for PMTCT and broader treatment consultations. Primary outcomes were mothers' retention in HIV care at 12 months and infant HIV testing at 6 weeks and 12 months after birth. Routine facility-level data from six comparison health facilities were collected as an adhoc standard of care comparison and used to calculate the cost of delivering the intervention. A total of 607 MIPs were enrolled in the integrated ECD-PMTCT intervention between June 2018 and December 2019. The average age of MIPs was 30 years and 7 weeks respectively. We found that 86% of mothers attended ≥ 5 of the 8 ECD sessions over the course of 12 months; 88% of intervention mothers were retained in PMTCT versus 59% of mothers in comparison health facilities, and 96% of intervention infants were tested for HIV by six weeks compared to 66% of infants in comparison health facilities. Costing data demonstrated the financial feasibility of integrating ECD and PMTCT programs in government health facilities in Malawi. Integrating ECD into PMTCT programs was feasible, acceptable, resulted in better programmatic outcomes for both mothers and infants. Further investigation is required to determine optimal delivery design for scale-up.

Understanding accelerators to improve SDG-related outcomes for adolescents-An investigation into the nature and quantum of additive effects of protective factors to guide policy making.

Recent evidence has shown support for the United Nations Development Programme (UNDP) accelerator concept, which highlights the need to identify interventions or programmatic areas that can affect multiple sustainable development goals (SDGs) at once to boost their achievement. These data have also clearly shown enhanced effects when interventions are used in combination, above and beyond the effect of single interventions. However, detailed knowledge is now required on optimum combinations and relative gain in order to derive policy guidance. Which accelerators work for which outcomes, what combinations are optimum, and how many combinations are needed to maximise effect? The current study utilised pooled data from the Young Carers (n = 1402) and Child Community Care (n = 446) studies. Data were collected at baseline (n = 1848) and at a 1 to 1.5- year follow-up (n = 1740) from children and young adolescents aged 9-13 years, living in South Africa. Measures in common between the two databases were used to generate five accelerators (caregiver praise, caregiver monitoring, food security, living in a safe community, and access to community-based organizations) and to investigate their additive effects on 14 SDG-related outcomes. Predicted probabilities and predicted probability differences were calculated for each SDG outcome under the presence of none to five accelerators to determine optimal combinations. Results show that various accelerator combinations are effective, though different combinations are needed for different outcomes. Some accelerators ramified across multiple outcomes. Overall, the presence of up to three accelerators was associated with marked improvements over multiple outcomes. The benefit of targeting access to additional accelerators, with additional costs, needs to be weighed against the relative gains to be achieved with high quality but focused interventions. In conclusion, the current data show the detailed impact of various protective factors and provides implementation guidance for policy makers in targeting and distributing interventions to maximise effect and expenditure. Future work should investigate multiplicative effects and synergistic interactions between accelerators.

Is hope associated with HIV-acquisition risk and intimate partner violence amongst young women and men? A cross-sectional study in urban informal settlements in South Africa.

Hope is a concept that may mediate between the structural constraints people live under and their HIV-acquisition risk behaviours/experiences. Drawing on data collected as the baseline for an intervention trial between September 2015 and September 2016, among young (18-30-year-old), out-of-school women and men in urban informal settlements in Durban, South Africa, we assess whether hope, assessed by the Snyder Hope Scale, is associated with HIV-risk behaviours/experiences. 677 women (35.5%; 33.7%; 30.9%; low, medium, and high hope scores respectively) and 668 men (40.6%; 32.8%; 26.7%; low, medium, and high hope scores respectively) were included. Among women, adjusted analyses showed high levels of hope, compared to low levels, were associated with greater modern contraceptive use (aOR1.57, 1.04-2.37). For men, medium or high levels of hope, compared to low levels, were associated with reduced physical and/or sexual IPV perpetration (med: aOR0.55, 0.38-0.81, high: 0.38, 0.25-0.57), emotional IPV perpetration (med: aOR0.54, 0.36-0.80, high: aOR0.62, 0.41-0.94) and transactional sex (med: 0.57, 0.38-0.84, high: aOR0.57, 0.39-0.86) respectively. For men, hope potentially captured a pathway between an individual's structural context and their HIV-risk behaviour. Yet this was not the case for women. It may be the Snyder Hope Scale does not adequately capture localised meanings of hope.

Association between caregiver and household alcohol use and child behavior problems in KwaZulu Natal, South Africa.

We explored the association between household alcohol use and behavior problems among South-African children, using data from the Asenze study, a population-based cohort of South African children and their caregivers. Household alcohol use and child behavior were assessed when children were 6-8 years old. To examine the association, we performed linear regressions. The sample included 1383 children with complete data under the care of 1251 adults. Children living in a household where self-reported caregiver alcohol use was scored as hazardous (4.6%) had higher levels of problem behavior (ß = 1.94, 95% CI 0.06-3.82). There were no statistically significant associations between reported hazardous alcohol use by another member of the household (14.5%) and child problem behavior. Hazardous household alcohol use was associated with child problem behavior and this effect appeared to be mainly driven by primary caregiver use.

Consolidate, conceptualize, contextualise: key learnings for future intervention acceptability research with young people in Africa.

Acceptability has become a key consideration in the development, evaluation and implementation of health and social interventions. This commentary paper advances key learnings and recommendations for future intervention acceptability research with young people in Africa, aimed at supporting the achievement of developmental goals. It relates findings of the adolescent acceptability work conducted within the Accelerate Hub, since mid 2020, to broader inter-disciplinary literatures and current regional health and social priorities. We argue that, in order to strengthen the quality and applied value of future acceptability work with young people, we need to do three things better. First, we need to consolidate prior findings on acceptability, within and across intervention types, to inform responses to current public health and social challenges and further the conceptual work in this area. Second, we need to better conceptualise acceptability research with young people, by developing stronger conceptual frameworks that define acceptability and its constructs, and predict its relationship with intervention engagement. Third, we need to better contextualise findings by considering acceptability data within a broader social and political context, which in turn can be supported by better conceptualisation. In this paper we describe contributions of our work to each of these three inter-connected objectives, and suggest ways in which they may be taken forward by researchers and practitioners. These include aggregating evidence from past interventions to highlight potential barriers and enablers to current responses in priority areas; involving key actors earlier and more meaningfully in acceptability research; further developing and testing behavioural models for youth acceptability; and working collaboratively across sectors towards programmatic guidance for better contextualisation of acceptability research. Progress in this field will require an inter-disciplinary approach that draws from various literatures such as socio-ecological theory, political economy analysis, health behaviour models and literature on participatory research approaches.

Intergenerational education and violence effects on adolescent education, early employment and adolescent parenting.

Adolescence is a crucial phase in life, when foundations are established for future health . Therefore, supporting adolescents is necessary to meet the sustainable development goals by 2030. Evidence on the intergenerational transmission of poverty, education and violence suggests that to improve adolescents' well-being, the broader context in which they grow up needs to be understood when developing programmes and approaches to improve their lives. Our study explored intergenerational factors and early childhood influences on adolescent education, employment and parenthood, using the fourth wave of the MAISHA longitudinal study. This study took place in 2016-2021 among 986 adult women in Mwanza, Tanzania, including questions answered by the women on their adolescent's (aged 13-18) education, employment and parenthood, as well as their participation in early childhood programmes, education attainment and other socio-economic variables. Among the 577 mothers in our analysis who had adolescents living in their households, 32% reported that their adolescents did not attend secondary school, 11% were employed, 4% were pregnant or parents. For adolescents in secondary school, 15% ever failed a grade and 10% missed school more than 2 weeks in the last term. Grandparents' not having secondary education was significantly associated with adolescents not attending secondary education and being employed. Living in a female-headed household and mother's experience of intimate partner violence was associated with adolescent early employment. Early childhood influences showed no impact on any outcome in the multivariate analysis. Overall, we report a strong intergenerational impact of education on adolescent outcomes, suggesting the adoption of a strong policy focus on the provision of secondary education for both men and women due to its long-lasting effect. Interventions aimed at improving adolescent outcomes need to be long-term and invest in whole family poverty reduction measures.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV.

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.