Childhood adversity during the post-apartheid transition and COVID-19 stress independently predict adult PTSD risk in urban South Africa: A biocultural analysis of the stress sensitization hypothesis.

OBJECTIVES: The COVID-19 pandemic in South Africa introduced new societal adversities and mental health threats in a country where one in three individuals are expected to develop a psychiatric condition sometime in their life. Scientists have suggested that psychosocial stress and trauma during childhood may increase one's vulnerability to the mental health consequences of future stressors-a process known as stress sensitization. This prospective analysis assessed whether childhood adversity experienced among South African children across the first 18 years of life, coinciding with the post-apartheid transition, exacerbates the mental health impacts of psychosocial stress experienced during the 2019 coronavirus (COVID-19) pandemic (ca. 2020-2021). MATERIALS AND METHODS: Data came from 88 adults who participated in a follow-up study of a longitudinal birth cohort study in Soweto, South Africa. Childhood adversity and COVID-19 psychosocial stress were assessed as primary predictors of adult PTSD risk, and an interaction term between childhood adversity and COVID-19 stress was calculated to evaluate the potential effect of stress sensitization. RESULTS: Fifty-six percent of adults exhibited moderate-to-severe PTSD symptoms. Greater childhood adversity and higher COVID-19 psychosocial stress independently predicted worse post-traumatic stress disorder symptoms in adults. Adults who reported greater childhood adversity exhibited non-significantly worse PTSD symptoms from COVID-19 psychosocial stress. DISCUSSION: These results highlight the deleterious mental health effects of both childhood trauma and COVID-19 psychosocial stress in our sample and emphasize the need for greater and more accessible mental health support as the pandemic progresses in South Africa.

The prevalence of probable depression and probable anxiety, and associations with adverse childhood experiences and socio-demographics: A national survey in South Africa.

Objective and methods: Mental health problems among adults are a growing public health concern, and middle-income countries such as South Africa are disproportionally affected. Using a large scale nationally representative weighted survey, we assessed the prevalence of probable depression, probable anxiety, and adverse childhood experiences (ACEs), and explored associations between probable depression, probable anxiety, ACEs, socio-economic status, and demographic characteristics. Results: Nationally, 25.7, 17.8, and 23.6% of respondents, respectively, reported scores of ≥10 on the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), indicating probable depression or probable anxiety, and an ACE score of ≥4 (high exposure). Overall probable depression prevalence across South Africa varied from 14.7 to 38.8%. Both probable depression and probable anxiety were more frequently reported among adults who were: retired and older (>65 years of age), and widowed, divorced, or separated; living in metropolitan areas; and only had primary school education. In a multivariable adjusted logistic regression, the likelihood of reporting probable depression or probable anxiety was also found to increase with each standard deviation increase in the ACE score (p < 0.001), independent of other socio-demographic determinants. Conclusion: The prevalence of probable depression among respondents in South Africa varies significantly across the nine provinces. Furthermore, higher ACE score and several socio-demographic determinants were associated with a higher likelihood of probable depression and probable anxiety. Adult mental health services are urgently needed to identify groups of the population vulnerable to mental health problems for better targeting of interventions. Given the range of probable depression prevalence across the country, provincial level plans and resources should also reflect the burden of mental health problems in that province.

Assessing the prevalence of young children living in households prepared for COVID-19 in 56 low- and middle-income countries.

BACKGROUND: The COVID-19 pandemic and governments' attempts to contain it are negatively affecting young children's health and development in ways we are only beginning to understand and measure. Responses to the pandemic are driven largely by confining children and families to their homes. This study aims to assess the levels of and associated socioeconomic disparities in household preparedness for protecting young children under the age of five from being exposed to communicable diseases, such as COVID-19, in low- and middle-income countries (LMICs). METHODS: Using data from nationally representative household surveys in 56 LMICs since 2016, we estimated the percentages of young children under the age of five living in households prepared for communicable diseases (e.g., COVID-19) and associated residential and wealth disparities at the country- and aggregate-level. Preparedness was defined on the basis of space for quarantine, adequacy of toilet facilities and hand hygiene, mass media exposure at least once a week, and phone ownership. Disparities within countries were measured as the absolute gap in two domains-household wealth and residential area - and compared across regions and country income groups. RESULTS: The final data set included 766,313 children under age five. On average, 19.4% of young children in the 56 countries lived in households prepared for COVID-19, ranging from 0.6% in Ethiopia in 2016 to 70.9% in Tunisia in 2018. In close to 90% of countries (50), fewer than 50% of young children lived in prepared households. Young children in rural areas or in the poorest households were less likely to live in prepared households than their counterparts. CONCLUSIONS: A large portion of young children under the age of five in LMICs were living in households that did not meet all preparedness guidelines for preventing COVID-19 and caring for patients at home. This study highlights the need to ensure all families in LMICs have the means to prevent the spread of the pandemic or other communicable illnesses to young children during pandemics.

Childhood factors associated with suicidal ideation among South African youth: A 28-year longitudinal study of the Birth to Twenty Plus cohort.

BACKGROUND: Although early life factors are associated with increased suicide risk in youth, there is a dearth of research on these associations for individuals growing up in disadvantaged socioeconomic contexts, particularly in low- and middle-income countries (LMICs). We documented the association between individual, familial, and environmental factors in childhood with suicidal ideation among South African youth. METHODS AND FINDINGS: We used data from 2,020 participants in the Birth to Twenty Plus (Bt20+) study, a South African cohort following children born in Soweto, Johannesburg from birth (1990) to age 28 years (2018). Suicidal ideation was self-reported at ages 14, 17, 22, and 28 years, and the primary outcome of interest was suicidal ideation reported at any age. We assessed individual, familial, and socioeconomic characteristics at childbirth and during infancy, adverse childhood experiences (ACEs) between ages 5 and 13 years, and externalizing and internalizing problems between 5 and 10 years. We estimated odds ratios (ORs) of suicidal ideation for individuals exposed to selected childhood factors using logistic regression. Lifetime suicidal ideation was reported by 469 (23.2%) participants, with a 1.7:1 female/male ratio. Suicidal ideation rates peaked at age 17 and decreased thereafter. Socioeconomic adversity, low birth weight, higher birth order (i.e., increase in the order of birth in the family: first, second, third, fourth, or later born child), ACEs, and childhood externalizing problems were associated with suicidal ideation, differently patterned among males and females. Socioeconomic adversity (OR 1.13, CI 1.01 to 1.27, P = 0.031) was significantly associated with suicidal ideation among males only, while birth weight (OR 1.20, CI 1.02 to 1.41, P = 0.03), ACEs (OR 1.11, CI 1.01 to 1.21, P = 0.030), and higher birth order (OR 1.15, CI 1.07 to 1.243, P < 0.001) were significantly associated with suicidal ideation among females only. Externalizing problems in childhood were significantly associated with suicidal ideation among both males (OR 1.23, 1.08 to 1.40, P = 0.002) and females (OR 1.16, CI 1.03 to 1.30, P = 0.011). Main limitations of the study are the high attrition rate (62% of the original sample was included in this analysis) and the heterogeneity in the measurements of suicidal ideation. CONCLUSIONS: In this study from South Africa, we observed that early life social and environmental adversities as well as childhood externalizing problems are associated with increased risk of suicidal ideation during adolescence and early adulthood.

The Long-Term Health and Human Capital Consequences of Adverse Childhood Experiences in the Birth to Thirty Cohort: Single, Cumulative, and Clustered Adversity.

Human capital-that is the cumulative abilities, education, social skills, and mental and physical health one possesses-is increasingly recognized as key to the reduction of inequality in societies. Adverse childhood experiences have been linked to a range of human capital indicators, with the majority of research in high-income, western settings. This study aims to examine the link between adverse childhood experiences and adult human capital in a South African birth cohort and to test whether associations differ by measurement of adversity. Secondary analysis of data from the Birth to Thirty study was undertaken. Exposure data on adversity was collected prospectively throughout childhood and retrospectively at age 22. Human capital outcomes were collected at age 28. Adversity was measured as single adverse experiences, cumulative adversity, and clustered adversity. All three measurements of adversity were linked to poor human capital outcomes, with risk for poor human capital increasing with the accumulation of adversity. Adversity was clustered by quantity (low versus high) and type (household dysfunction versus abuse). Adversity in childhood was linked to a broad range of negative outcomes in young adulthood regardless of how it was measured. Nevertheless, issues of measurement are important to understand the risk mechanisms that underlie the association between adversity and poor human capital.

Secondary analysis of retrospective and prospective reports of adverse childhood experiences and mental health in young adulthood: Filtered through recent stressors.

BACKGROUND: Evidence has identified the detrimental effects that adverse childhood experiences (ACEs) have on outcomes across the life course. We assess associations between prospective and retrospective ACEs and mental health in young adulthood and the influence of recent stressors. METHODS: Secondary analysis of a sample of 1592 young adults from the Birth to Twenty Plus cohort, from 1990 to 2013, were assessed throughout their first 18 years for prospective ACEs. Retrospective ACEs and an assessment of mental health were collected at the 22-23-year data point. FINDINGS: Prospective physical and sexual abuse are associated with an increased risk of depression (OR 1·7 [95% CI 1·37-1·93, p = 0·034], and OR 1·8 [95% CI 1·27-2·07, p = 0·018], respectively). Retrospective emotional abuse/neglect is associated with increased anxiety (OR 1·8 [95% CI 1·32-2·36, p = 0·000]), depression (OR 1·6 [95% CI 1·08-2·25, p = 0·018]) and overall psychological distress (OR 1·6 [95% CI 1·18-2·17, p = 0·002]). Prospectively reporting four or more ACEs is associated with a twofold increase in risk for overall psychological distress (OR 2·2 [95% CI 1·58-3.12, p = 0·008]). Retrospectively reporting four or more ACEs is associated with increased likelihood of somatization (p = 0·004), anxiety (p = 0·002), depression (p = 0·021), and overall psychological distress (p = 0·005). INTERPRETATION: Both individual and combined retrospective and prospective ACEs are related to mental health in young adulthood. Recent stressors reinforce this relationship; the likelihood of those who report more ACEs experiencing psychological distress increases when adjusting for recent stressors. FUNDING: Wellcome Trust (UK), South African Medical Research Council, Human Sciences Research Council, University of the Witwatersrand and supported by the DSI-NRF Centre of Excellence in Human Development.

Measuring and forecasting progress in education: what about early childhood?

A recent Nature article modelled within-country inequalities in primary, secondary, and tertiary education and forecast progress towards Sustainable Development Goal (SDG) targets related to education (SDG 4). However, their paper entirely overlooks inequalities in achieving Target 4.2, which aims to achieve universal access to quality early childhood development, care and preschool education by 2030. This is an important omission because of the substantial brain, cognitive and socioemotional developments that occur in early life and because of increasing evidence of early-life learning's large impacts on subsequent education and lifetime wellbeing. We provide an overview of this evidence and use new analyses to illustrate medium- and long-term implications of early learning, first by presenting associations between pre-primary programme participation and adolescent mathematics and science test scores in 73 countries and secondly, by estimating the costs of inaction (not making pre-primary programmes universal) in terms of forgone lifetime earnings in 134 countries. We find considerable losses, comparable to or greater than current governmental expenditures on all education (as percentages of GDP), particularly in low- and lower-middle-income countries. In addition to improving primary, secondary and tertiary schooling, we conclude that to attain SDG 4 and reduce inequalities in a post-COVID era, it is essential to prioritize quality early childhood care and education, including adopting policies that support families to promote early learning and their children's education.

Adolescent Mental Health Problems and Adult Human Capital: Findings From the South African Birth to Twenty Plus Cohort at 28 Years of Age.

PURPOSE: We investigated associations between adolescent internalizing and externalizing problems and adult human capital in a non-Western setting. Little is known about adolescent mental health problems and adult outcomes in low- and middle-income countries, many of which are characterized by high levels of adversities. METHODS: Data came from the Birth to Twenty Plus cohort, started in Soweto, Johannesburg, South Africa, in 1990. We estimated associations of internalizing and externalizing problems at the age of 14 years with self-reported educational, employment, welfare receipt, psychosocial (psychological distress, criminality, substance use), interpersonal (social isolation, intimate partner violence, partnership status), and HIV outcomes at the age of 28 years. RESULTS: Adolescents with high internalizing problems were less likely to have completed secondary school or be formally employed and more likely to report psychological distress. Those with high levels of externalizing problems were more likely to report adulthood criminal activity and substance use. We found significant associations between internalizing and externalizing problems and intimate partner violence. There was no association between adolescent mental health problems and welfare receipt, HIV, social isolation, or partnership status. Men were more likely to report incomplete secondary education, no formal employment, criminality and substance use, social isolation, and no serious relationship, whereas women were more likely to experience psychological distress and be in receipt of welfare. CONCLUSIONS: Adolescent mental health problems are associated with long-term negative adult functioning under varying socioeconomic conditions. Interventions to recognize and address youth mental health problems in low- and middle-income countries are needed to avert serious adverse adult and societal consequences.

A Data-Free Digital Platform to Reach Families With Young Children During the COVID-19 Pandemic: Online Survey Study.

BACKGROUND: The COVID-19 pandemic and containment measures have severely affected families around the world. It is frequently assumed that digital technologies can supplement and perhaps even replace services for families. This is challenging in conditions of high device and data costs as well as poor internet provision and access, raising concerns about widening inequalities in availability of support and consequent effects on child and family outcomes. Very few studies have examined these issues, including in low- and middle-income countries. OBJECTIVE: The study objectives were two-fold. The first objective was to gather data on the impact of the COVID-19 pandemic on families of young children using an online survey. The second objective was to assess the feasibility of using a data-free online platform to conduct regular surveys and, potentially, to provide support for parents and families of young children in South Africa. METHODS: We used a data-free mobile messenger platform to conduct a short digital survey of the impact of the COVID-19 pandemic on caring for young children in South Africa. We report on the methodological processes and preliminary findings of the online survey. RESULTS: More than 44,000 individuals accessed the survey link and 16,217 consented to the short survey within 96 hours of its launch. Respondents were predominantly from lower classes and lower-middle classes, representing the majority of the population, with urban residential locations roughly proportionate to national patterns and some underrepresentation of rural households. Mothers comprised 70.2% (11,178/15,912) of respondents and fathers comprised 29.8% (4734/15,912), representing 18,672 children 5 years of age and younger. Response rates per survey item ranged from 74.8% (11,907/15,912) at the start of the survey to 50.3% (8007/15,912) at completion. A total of 82.0% (12,729/15,912) of parents experienced at least one challenge during the pandemic, and 32.4% (2737/8441) did not receive help when needed from listed sources. Aggregate and individual findings in the form of bar graphs were made available to participants to view and download once they had completed the survey. Participants were also able to download contact details for support and referral services at no data cost. CONCLUSIONS: Data-free survey methodology breaks new ground and demonstrates potential not previously considered. Reach is greater than achieved through phone surveys and some social media platforms, men are not usually included in parent surveys, costs are lower than phone surveys, and the technology allows for immediate feedback to respondents. These factors suggest that zero-rated, or no-cost, services could provide a feasible, sustainable, and equitable basis for ongoing interactions with families of young children.

Early childhood development: an imperative for action and measurement at scale.

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children's development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

An analysis of retrospective and repeat prospective reports of adverse childhood experiences from the South African Birth to Twenty Plus cohort.

Most studies rely on cross-sectional retrospective reports from adult samples to collect information about adverse childhood experiences (ACEs) to examine relationships with adult outcomes. The problems associated with these reports have long been debated, with only a few studies determining their reliability and validity and fewer still reaching consensus on the matter. This paper uses repeat prospective and retrospective reports of adverse childhood experiences from two respondent sources in the South African Birth to Twenty Plus (Bt20+) cohort to explore agreement and concordance in the prospective reporting of ACEs by caregivers and respective children as adolescents and then as young adults. The findings demonstrate little overall agreement between prospective and retrospective accounts of childhood experiences, with 80% of kappa values below the moderate agreement cutoff (k = .41). The highest levels of agreement were found between prospective and retrospective reporting on parental and household death (kappas ranging from .519 to .944). Comparisons between prospective caregiver reports and retrospective young adult reports yielded high concordance rates on sexual and physical abuse and exposure to intimate partner violence (91.0%, 87.7% and 80.2%, respectively). The prevalence of reported ACEs varied with the age of the respondent, with adolescents reporting much higher rates of exposure to violence, physical and sexual abuse than are reported retrospectively or by caregivers. This variation may partly reflect actual changes in circumstances with maturation, but may be influenced by developmental stage and issues of memory, cognition and emotional state more than has been considered in previous analyses. More research, across disciplines, is needed to understand these processes and their effect on recall. Long-term prospective studies are critical for this purpose. In conclusion, methodological research that uses a range of information sources to establish the reliability and validity of both retrospective and prospective reports ‒ recognizing that the two approaches may fundamentally answer different questions ‒ should be encouraged.

Development and pilot evaluation of a home-based palliative care training and support package for young children in southern Africa.

BACKGROUND: The leading cause of death among young children in southern Africa is complications due to HIV infection and, in South Africa, over a third of all deaths of children younger than five are associated with HIV infection. There is a great and urgent need for children's palliative care in Africa, whether HIV-related or not. It is often not possible for sick children and their carers to attend clinics and hospitals cannot accommodate children for long periods of time. As a result children are often cared for in their own homes where caregivers require support to provide informed and sensitive care to reduce children's suffering. Home-care places a heavy burden on families, communities and home- and community-based care workers. METHODS: This project involved the development and pilot evaluation of a training and support package to guide home and community-based care workers to help caregivers of seriously ill young children at home in southern Africa. A number of research methods were used, including a cross-sectional survey of content experts using the Delphi technique, participatory action research with photo elicitation and qualitative thematic analysis. RESULTS: Because the palliative care needs of these children are complex, the package focuses on delivering 9 key messages essential to improving the quality of care provided for young children. Once the key messages were developed, culturally relevant stories were constructed to enhance the understanding, retention and enactment of the messages. The various research methods used, including literature reviews, the Delphi technique and photo-elicitation ensured that the content included in the package was medically sound and culturally relevant, acceptable, feasible, and comprehensive. The end product is a home-based paediatric palliative care training and support package in English designed to help train community workers who are in a position to support families to care for very sick young children at home as well as to support families in looking after a very sick child. CONCLUSION: A pilot study to assess the training and support package found it to be useful in delivering the key messages to caregivers. The training component was found to be feasible. It is concluded that the package offers a practical means of integrating palliative care with home-based care. Further implementation and evaluation is needed to establish its utility and impact.

Training and capacity development: the foundation of interventions to support young children affected by HIV and AIDS in sub-Saharan Africa.

Many programs to support young children and families affected by HIV and AIDS depend substantially on a model of cascaded training from international nongovernmental organizations, through in-country groups and organizations to services on the ground. In this paper, we describe the training and capacity building - as described in proposals, progress reports, and individualized questionnaires - offered by 10 international organizations funded by the Conrad N. Hilton Foundation to provide supportive services for young children and their families in five southern and eastern African countries. We related the findings to effective features of training described in the literature. Training and capacity development were found to be the most substantial activities in rendering services to children and families, both in terms of effort and human and financial resources. A total of 67 trainings were conducted over a period of 18 months. Almost all trainings combine lecture-based instruction, group work/discussions, and role play, but only half of the trainings report some form of mentoring, supervision or coaching following the training. Drawing on the literature, it is likely that more purposeful planning is required in terms of the selection of trainees, local adaptation and development of materials, participatory training approaches, and techniques to develop and sustain skills as well as knowledge. Demonstration and mentorship in the field together with quality assurance procedures, pre-and post-assessment to evaluate training, processes to transfer learning into subsequent practice, as well as certification, are all fundamental steps to ensure that training plays a supportive role in the behavior changes necessary to support young children affected by HIV and AIDS and their families.

Associations between perceptions of school connectedness and adolescent health risk behaviors in South African high school learners.

BACKGROUND: This study investigated the relationship between school connectedness and health risk behaviors, specifically, substance abuse, violence-related behaviors, sexual risk behaviors, and suicidal ideation among school-going adolescents. School connectedness was understood to encompass a range of aspects pertaining to a learner's sense of belonging to the school. We hypothesized that strong perceptions of school connectedness will more likely be associated with lower levels of risk behaviors among school-going adolescents. METHODS: The study was conducted in 2 neighboring public co-educational schools in Durban, South Africa. Independent measures assessed school connectedness, substance abuse, violence-related behaviors, sexual risk behaviors, and suicidal ideation. RESULTS: Strong negative correlations were found between adolescents' perceptions of school connectedness and the 4 health risk behaviors, particularly suicidal ideation. The relative importance of risk factors was also evidenced in the sample. CONCLUSIONS: Adolescents with lower perceptions of school connectedness were more likely to engage in various risk behaviors, supporting the literature that a lack of school connectedness can act as a risk factor for adolescent involvement in clustering of risk behaviors. Further the relative weighting of individual risk factors, it is argued, was an effect of the sociocultural context of the study.