Four Steps To My Future (4STMF): acceptability, feasibility and exploratory outcomes of a universal school-based mental health and well-being programme, delivered to young adolescents in South Africa.

OBJECTIVE: Mental health disorders affect many children in South Africa, where vulnerability is high, and treatment is limited. We sought to determine the feasibility and acceptability of a universally delivered classroom-based programme for the promotion of mental health in young adolescents. METHOD: We pilot tested an 8 session, cognitive-behavioural therapy-based programme, 4 Steps To My Future (4STMF) in two schools. Participants were grade 5 learners (n = 222; Meanage = 10.62 (Standard deviation = 0.69)). 4STMF was delivered in class time by trained psychology postgraduates. Feasibility (rates of parental opt-out, child assent, assessment completion at baseline and follow-up, programme completion, session attendance and programme fidelity), acceptability (teacher feedback and focus groups with learners), as well as demographic data and data on a battery of a psychological measures were collected at baseline, postintervention and at one-month follow-up. RESULTS: Most eligible learners at both schools agreed to participate (85% - school 1; 91% - school 2) with more than 80% completing postintervention measures. Learner session attendance and programme fidelity were high. Teachers rated facilitators highly on confidence, preparedness, enthusiasm and classroom management and observed children to be enjoying the programme. Focus group data suggest that learners liked the programme, could recall the content and had shared some of the content with their family. An exploratory analysis of outcomes showed significant pre-post differences on self-esteem at school 1 and on emotion regulation at school 1 and school 2, maintained at follow-up. CONCLUSIONS: This pilot study has shown that 4STMF can acceptably and feasibly be delivered, at classroom level, as a universal school-based prevention programme to young adolescent learners in South African primary schools. The programme could fit in with school context, could be delivered by nonspecialists, showed significant improvements on self-esteem and emotion regulation and was liked by the learners.

Factors influencing the transition from paediatric to adult HIV care in the Western Cape, South Africa: perspectives of health care providers.

Transitioning to adult care for HIV-infected adolescents is a critical process in determining long-term health outcomes. Poor transitioning to adult care can lead to several adverse HIV-related outcomes for adolescents living with HIV, including disruption of care, non-adherence to ART and virological failure. In this qualitative study, we explore the barriers to and facilitators of the transition to adult care among HIV-infected youth from the perspectives of health care workers and allied staff. We enrolled 24 health care workers and allied staff from two infectious diseases clinics in the Western Cape of South Africa. Participants took part in a once-off, semi-structured interview that was conducted face-to-face at the respective clinics. Interviews were audio-recorded and transcribed verbatim for thematic analysis using ATLAS.ti. Two superordinate themes and seven subthemes emerged from the data. We found that barriers to the transition process were related to a lack of preparedness and readiness to transition at both an institutional level and at the level of the caregiver and adolescent. At the institutional level, a lack of a transition policy and limited time and resources available for the transition process were salient barriers. At the caregiver-adolescent level, adolescents' desire for normality and caregivers' reluctance to devolve responsibility of care to their children were important barriers to the transition process. Facilitators prepare adolescents and caregivers for transition from an early age. Our findings highlight the importance of considering both adolescent, caregiver and institutional factors when preparing for the transition process. Our findings also show that pressure on the health care system precludes the time required for this process. However, counselling for transition from an early age might be an important way to negate these issues.

South African youth's understanding of feelings, thoughts and behaviours: Implications for the development of CBT-based mental health interventions.

BACKGROUND: Mental health problems are common in youth in low- and middle-income countries (LMICs), including South Africa. Preventative interventions, based on cognitive behaviour therapy (CBT), delivered in schools, have been found to alleviate symptoms of depression and anxiety in high income countries (HICs). However, less is known about whether youth in LMICs are able to engage with the core concepts of CBT. AIMS: To explore how young people in the Western Cape, South Africa, understand key CBT concepts, such as feelings, thoughts and behaviours. METHOD: We interviewed 22 young people (10-15 years of age; mean age 11.6 years; SD = 1.0) recruited from two public primary schools in the Western Cape, South Africa. Interviews were audio-recorded, transcribed verbatim, translated from Afrikaans into English where necessary and analysed thematically using a deductive approach. RESULTS: Young people described feelings as internal, private, and should only be shared with trusted others. They also described how feelings varied, depending on the situation. They found the concept of thoughts more challenging to describe. Youth were able to say what they do when they experience unpleasant feelings, and they linked their behaviours to their feelings and thoughts. CONCLUSIONS: In this cultural context, our qualitative investigation found evidence that young people were able to engage with abstract concepts including feelings and to some degree, thoughts. To ensure that CBT-based interventions are developmentally appropriate and accessible, psychoeducation may help youth distinguish between thoughts, feelings and behaviours, and a focus on identifying and naming feelings may be beneficial.

Universal school-based mental health programmes in low- and middle-income countries: A systematic review and narrative synthesis.

Depression and anxiety pose a significant burden during adolescence, which may have consequences for adulthood and future generations. The mental health needs of children and adolescents in low- and middle-income countries are not adequately addressed due to a lack of availability and access to services, and limited intervention research in these contexts. Universal school-based interventions provide a unique and potentially scalable opportunity to prevent and address mental health concerns amongst children and adolescents in low- and middle-income countries. This systematic review aimed to identify and provide a narrative synthesis of universal school-based programmes delivered to children (aged 6-18 years) in low- and middle-income countries reporting on anxiety and/or depression outcomes. We searched Academic Search Premier, ERIC, PsycINFO, PubMed, Scopus, Web of Science, and ProQuest Dissertations using a pre-specified search strategy. Of the 12,478 articles identified, 12 studies met our inclusion criteria and were included in this review. The included studies report on a variety of interventions differing in approach, format and content. Given the small number of studies and concerns with study quality, we are unable to conclude that universal school-based interventions may reduce symptoms of anxiety and depression in children in low- and middle-income countries.

Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program.

BACKGROUND: Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa. METHODS: We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February-March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients' home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed. RESULTS: We found that clients' home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother's advice. CONCLUSIONS: These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients' voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.

Moving Beyond Text-and-Talk in Qualitative Health Research: Methodological Considerations of Using Multiple Media for Data Collection.

Qualitative researchers are increasingly making use of multiple media to collect data within a single study. Such approaches may have the potential to generate rich insights; however, there are also potential methodological challenges in simultaneously analyzing data from multiple media. Using three case studies from our work with women who had recurrent breast cancer in South Africa, we explore four challenges of using multiple media to collect data: (a) how to understand the repetition of themes (or lack thereof) across multiple media; (b) whether or not data collected from multiple media over a protracted period should be read as longitudinal data reflecting a dynamic process; (c) what impact using multiple media has on the participant-researcher relationship; and (d) how the medium may shape the data obtained. We propose that the value of using multiple methods lies in the opportunity they provide to understand how participants engage with the different media.

The home visit communication skills inventory: Piloting a tool to measure community health worker fidelity to training in rural South Africa.

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.

Correlates of Fatigue Among South African Adolescents Living with HIV and Receiving Antiretroviral Therapy.

Fatigue among adolescents living with HIV is poorly understood. In this study, we examined the relationships between fatigue and demographic and psychosocial variables to further the understanding of the symptom experience and associated factors. We recruited consecutive attenders at ART clinics in the Western Cape, South Africa (N = 134, age 11-18 years). Participants completed a battery of questionnaires including measures of fatigue, insomnia and mood disturbance. Just under a quarter (24.6%) of adolescents reported elevated levels of fatigue that affected their functioning. The linear combination of age, depression, and insomnia explained 40.6% of the variance in fatigue. Amongst adolescents with HIV, fatigue seems a problematic symptom associated with poor sleep and mood disturbance. Timely identification and management of these potentially disabling symptoms are needed to attain better health outcomes and retention in care in this group. Interventions aimed at ameliorating these symptoms are needed.

The Use of a Brief, Active Visualisation Intervention to Improve Adherence to Antiretroviral Therapy in Non-adherent Patients in South Africa.

Non-adherence remains the largest cause of treatment failure to antiretroviral therapy (ART). Despite having the largest HIV pandemic, few successful adherence interventions have been conducted in South Africa. Active visualisation is a novel intervention approach that may help effectively communicate the need for consistent adherence to ART. The current study tested an active visualisation intervention in a sample of non-adherent patients. 111 patients failing on first- or second-line ART were recruited from two sites in the Western Cape, South Africa. Participants were randomly allocated to receive the intervention or standard care (including adherence counselling). The primary outcome was adherence as measured by plasma viral load (VL). There was a clinically significant difference (p = 0.06) in VL change scores between groups from baseline to follow-up, where the intervention had a greater decrease in log VL (Madj = - 1.92, CI [- 2.41, - 1.43), as compared to the control group (Madj = - 1.24, [- 1.76, - 0.73]). Participants in the intervention group were also significantly more likely to have a 0.5 log improvement in VL at follow-up ([Formula: see text] = 4.82, p = 0.028, ɸ = 0.28). This study provides initial evidence for the utility of this novel, brief intervention as an adjunct to standard adherence counselling, for improving adherence to ART.

Barriers to and Facilitators of Adherence to Exclusive Breastfeeding Practices Among HIV Infected and Non-Infected Women in Jos, Nigeria.

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

Video observations of treatment administration to children on antiretroviral therapy in rural KwaZulu-Natal.

For children younger than five years, caregivers are responsible for the measurement and administration of antiretroviral medication doses to children. Failure to adhere to the regimen as prescribed may lead to high viral loads (VLs), immune suppression and ultimately drug resistance. In the content of this study, adherence refers to adequate dosing of the medication by a caregiver. Acquired drug resistance to antiretroviral therapy (ART) is prevalent amongst children in South Africa, and poor adherence to the dosing regimen by caregivers may be associated with this problem. In this qualitative study, we purposively recruited 33 caregiver-child dyads from the Hlabisa HIV Treatment and Care Programme database. Children were divided into three groups based on their VL at the time of recruitment. Children with a VL ≥ 400 cps/ml were grouped as unsuppressed (n = 11); children with a VL ≤ 400 cps/ml were grouped as suppressed (n = 12); and children with no VL data were grouped as newly initiated (n = 10). Caregiver-child dyads were visited at their households twice to document, by means of video recording, how treatment was administered to the child. Observational notes and video recordings were entered into ATLAS.ti v 7 and analysed thematically. Results were interpreted through the lens of Ecological Systems Theory and the information-motivation-behavioural skills model was used to understand and reflect on several of the factors influencing adherence within the child's immediate environment as identified in this study. Thematic video analysis indicated context- and medication-related factors influencing ART adherence. Although the majority of children in this sample took their medicine successfully, caregivers experienced several challenges with the preparation and administration of the medications. In the context of emerging drug resistance, efforts are needed to carefully monitor caregiver knowledge of treatment administration by healthcare workers during monthly clinic visits.

Shortcomings of adherence counselling provided to caregivers of children receiving antiretroviral therapy in rural South Africa.

In order to achieve optimal benefits of antiretroviral therapy (ART), caregivers of children receiving ART are required to attend routine clinic visits monthly and administer medication to the child as prescribed. Yet, the level of adherence to these behaviours varies considerably in many settings. As a way to achieve optimal adherence in rural KwaZulu-Natal, caregivers are required to attend routine counselling sessions at HIV treatment clinics that are centred on imparting information, motivation, and behavioural skills related to medication administration. According to the information-motivation-behavioural skills model, information related to adherence, motivation, and behavioural skills are necessary and fundamental determinants of adherence to ART. The purpose of the study was to observe and document the content of adherence counselling sessions that caregivers attending rural clinics in KwaZulu Natal receive. We observed 25 adherence counselling sessions, which lasted on average 8.1 minutes. Counselling typically consisted of counsellors recording patient attendance, reporting CD4 count and viral load results to caregivers, emphasising dose times, and asking caregivers to name their medications and dosage amounts. Patients were seldom asked to demonstrate how they measure the medication. They were also not probed for problems regarding treatment, even when an unsuppressed VL was reported to a caregiver. This paper calls attention to the sub-optimal level of counselling provided to patients on ART and the urgent need to standardise and improve the training, support, and debriefing provided to counsellors.

Quality of life among South African patients receiving antiretroviral therapy in the Western Cape Province.

Compared to patients not receiving treatment, antiretroviral therapy (ART) users may experience a lower viral load, an increased CD4 count, slower disease progression, fewer opportunistic infections, and more rapid recovery time from HIV-related illnesses. As such, health related quality of life (HR-QOL) is likely to be considerably greater for ART users than patients not receiving treatment. The dearth of QOL research in sub-Saharan Africa brings into focus the need for and importance of documenting the various dimensions of well-being among persons living with HIV in this region of the world. We thus sought to report on the performance of South African patients enrolled in a public government funded antiretroviral therapy (ART) program. We administered the Functional Assessment of HIV Infection (FAHI) to a convenience sample of patients receiving ART in the Western Cape in South Africa. We used confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) to determine the factor structure of the FAHI amongst South African ART users. The CFA revealed a poor model fit of the data. However the EFA factor structure closely approximated the subscales of the measure, indicating the dimensions of physical, emotional, functional, and social well-being and cognitive functioning. We identified problematic items contributing to the poor model fit and contribute to the knowledge base on QOL amongst ART users in South Africa.

Barriers and facilitators to paediatric adherence to antiretroviral therapy in rural South Africa: a multi-stakeholder perspective.

Poor adherence to antiretroviral therapy (ART) contributes to the development of drug resistance. HIV-infected children, especially those 5 years and under, are dependent on a caregiver to adhere to ART. However, characteristics of the caregiver, child, regimen, clinic and social context affect clinic attendance and medication-taking, both of which constitute adherent behaviour. We conducted nine interviews and three focus groups to determine how doctors, nurses, counsellors, traditional healers and caregivers understood the barriers and facilitators to ART adherence among children residing in rural South Africa. The data were transcribed, translated into English from isiZulu where necessary, and coded using Atlas.ti version 7. Results were interpreted through the lens of Bronfenbrenner's Ecological Systems Theory. We found that at the micro-level, palatability of medication and large volumes of medication were problematic for young children. Characteristics of the caregiver including absent mothers, grandmothers as caregivers and denial of HIV amongst fathers were themes related to the micro-system. Language barriers and inconsistent attendance of caregivers to monthly clinic visits were factors affecting adherence in the meso-system. Adherence counselling and training were the most problematic features in the exo-system. In the macro-system, the effects of food insecurity and the controversy surrounding the use of traditional medicines were most salient. Increased supervision and regular training amongst lay adherence counsellors are needed, as well as regular monitoring of the persons attending the clinic on the child's behalf.

Lessons learned from conducting mental health intervention research in schools in the global south: Our experiences in South Africa and Kenya.

Most of the world's population of young people live in lower-and middle-income countries (LMICs; (Weine, Horvath Marques, Singh, & Pringle, 2020)), and these young people experience heightened rates of known risk factors for developing mental disorders such as poverty and exposure to trauma (Atwoli, Stein, Koenen, & McLaughlin, 2015). Access to professional psychological treatments is limited in LMICs due to structural barriers (e.g., a dearth of trained professionals) and cultural factors like stigma and beliefs about mental health and illness. Therefore, schools, which are widely attended, may be a good location for providing mental health interventions, and it is important that we develop and evaluate feasible, acceptable, effective, and scalable interventions for use in this context. Yet under 10% of clinical trials of psychotherapies (Venturo-Conerly, Eisenman, Wasil, Singla, & Weisz, 2022) have been conducted in LMICs. And there are particular challenges to conducting research in schools, as has been highlighted in the UK context by Moore et al. (2022). Building on that commentary, our aim herein is to share our learnings from conducting psychotherapy research in schools in Kenya and South Africa.

Family functioning and problematic usage of the internet in youth: A cross-sectional investigation.

BACKGROUND: Problematic usage of the internet (PUI) refers to maladaptive use of the Internet linked to functional impairment as a growing concern in many countries. Youths are often considered more vulnerable to PUI than other age groups. The relationship between PUI and family dynamics is likely bidirectional and complex, warranting further research. Using a cross-sectional study design, we aimed to determine the rate of PUI and the association between PUI and family functioning in a South African sample between the ages of 18 and 30 years. METHODS: South African youths were recruited via email and social media. Respondents completed an online survey as part of a cross-sectional study to assess the extent and the types of activities for which they use the internet, as well as the quality of their family relationships and functioning, employing standardised questionnaires (including the IAT-10) and the General Functioning Scale of the Family Assessment Device (GF-FAD). The sample included 814 participants (65% female; aged 21 years; SD 3 years). RESULTS: 15.5% of our sample presented with PUI. There was a significant, moderate positive correlation between totals on the IAT-10 and GF-FAD (r = 0.33, p < .001). An independent samples t-test found that individuals with self-reported PUI (GF-FAD: M = 2.57, SD = 0.51) had significantly poorer quality family functioning than individuals without PUI (GF-FAD: M = 2.13, SD = 0.61; t (812) = -7.52, p < .001; Cohen's d = -0.73, 95% CI [-0.92, -0.54]). Correlations were found between increased time spent on various online activities, including pornography (r = 0.20, p < 0.001), cyberbullying (r = 0.17, p < 0.001), social networking (r = 0.11, p = 0.003), and streaming media (r = 0.11, p = 0.003), and poorer quality family functioning. CONCLUSION: PUI is common in South African youth. Presence of PUI and increased PUI severity were associated with worse family functioning in this sample. We recommend using family-based approaches in promoting a healthy family environment, and in the prevention of PUI and mitigation of its effects, with the goal of striking a balance between the benefits of the internet and its potential role in compromising aspects of family relationships.

The development of an inventory to assess the structural barriers to clinic attendance and pill-taking amongst users of antiretroviral therapy.

In addition to personal and psychological factors, structural factors may reduce the likelihood of optimal adherence to antiretroviral therapy (ART) among persons living with HIV. In this mixed-method study we report on the development of a scale to assess the salience of various structural barriers to ART adherence. After following conventional guidelines for scale development, two scales measuring structural barriers to adherence to clinic attendance and pill-taking were administered to 291 patients receiving ART at a public hospital in South Africa. Both exploratory and higher order factor analysis indicated that a single underlying general factor was appropriate for both scales. The final scales consisted of 12 items for the structural barriers to clinic attendance scale and 13 items for the structural barriers to medication-taking scale. Both scales displayed excellent internal consistency with Cronbach alpha coefficients above 0.80. Research to determine the construct validity of the scales may be a next step in this line of research.

Willing and unwilling digital cyborg assemblages: University students talk about mental health apps.

Objective: Explore how students talk about mental health mobile applications (i.e., apps). Methods: Data collected in focus group interviews with 51 students (all self-identifying as having mental health problems) and analysed using inductive thematic content analysis. Results: Participants describe mental health apps as an anti-dote to the loss of control, vulnerability, helplessness, impotence, isolation, conspicuousness, and shame which characterise their experience of mental illness. They describe the on-campus clinic as inaccessible and associated with "serious" problems, while configuring psychologists and psychotherapy as out of reach, scarce, formal, structured and anxiety provoking. In contrast, they imagine mental health apps as informal, relaxed, inviting, and accessible. Participants expressed openness and optimism about using apps to improve their mental health. They idealise technology as a means to connect effortlessly, anonymously, and informally, as well as learn skills, assert agency, and act responsibly. They also articulate reluctance to trust technology, show cognisance of participating in a capitalist economy, demonstrate scepticism about the legitimacy of mental health apps, and call for regulation, thereby resisting the position of responsible neoliberal subjects. Conclusion: Participants express ambivalence towards mental health apps without surrendering to either technophobia or technophilia. They express faith in technologies' potential to support mental health while questioning the implicit assumption that people are competent to manage their own mental health. In talking about mental health apps students reproduce broader cultural discourses (including techno-optimism, techno-solutionism, somatopiamism, neo-liberalism, responsibilisationism, technoscepticism, and discourses about neuroplasticity and self-help) thus presenting themselves as both willing and unwilling digital cyborgs.

Understanding the subjective experiences of South African women with recurrent breast cancer: A qualitative study.

This study explored the subjective experiences of 12 South African women diagnosed with recurrent breast cancer. Women were invited to take part in unstructured narrative interviews, and to complete a diary in which they could reflect on their breast cancer experiences. Most responded to their recurrence with an optimistic stance. Religious beliefs and support structures were important coping strategies. Women's perceptions of their changed bodies varied from being of least concern, to becoming the most distressing aspect. The findings highlight the complexity of illness experience and the different ways in which women make sense of a second episode of cancer.