Digital delivery of behavioural activation therapy to overcome depression and facilitate social and economic transitions of adolescents in South Africa (the DoBAt study): protocol for a pilot randomised controlled trial.

INTRODUCTION: Scalable psychological treatments to address depression among adolescents are urgently needed. This is particularly relevant to low-income and middle-income countries where 90% of the world's adolescents live. While digital delivery of behavioural activation (BA) presents a promising solution, its feasibility, acceptability and effectiveness among adolescents in an African context remain to be shown. METHODS AND ANALYSIS: This study is a two-arm single-blind individual-level randomised controlled pilot trial to assess the feasibility, acceptability and initial efficacy of digitally delivered BA therapy among adolescents with depression. The intervention has been coproduced with adolescents at the study site. The study is based in the rural northeast of South Africa in the Bushbuckridge subdistrict of Mpumalanga province. A total of 200 adolescents with symptoms of mild to moderately severe depression on the Patient Health Questionnaire Adolescent Version will be recruited (1:1 allocation ratio). The treatment group will receive BA therapy via a smartphone application (the Kuamsha app) supported by trained peer mentors. The control group will receive an enhanced standard of care. The feasibility and acceptability of the intervention will be evaluated using a mixed methods design, and signals of the initial efficacy of the intervention in reducing symptoms of depression will be determined on an intention-to-treat basis. Secondary objectives are to pilot a range of cognitive, mental health, risky behaviour and socioeconomic measures; and to collect descriptive data on the feasibility of trial procedures to inform the development of a further larger trial. ETHICS AND DISSEMINATION: This study has been approved by the University of the Witwatersrand Human Research Ethics Committee (MED20-05-011) and the Oxford Tropical Research Ethics Committee (OxTREC 34-20). Study findings will be published in scientific open access peer-reviewed journals, presented at scientific conferences and communicated to participants, their caregivers, public sector officials and other relevant stakeholders. TRIAL REGISTRATION NUMBERS: This trial was registered on 19 November 2020 with the South African National Clinical Trials Registry (DOH-27-112020-5741) and the Pan African Clinical Trials Registry (PACTR202206574814636).

International evidence to inform decision making on implementing urgent response social protection measures.

This paper summarises evidence from a rapid review of international findings on the effects of cash transfers. The learnings were used to inform the design of urgent response social protection during the COVID-19 pandemic. The summary demonstrates that in response to widespread disruption, cash transfers have broad benefits for children, adults, and the wider economy. First, cash grants for child support have been shown to reduce hunger, increase dietary diversity, and reduce secondary school dropout. Transfers may also reduce child malnutrition. Second, there is some evidence that cash grants could encourage job search and economic activity. By contrast, there is little evidence that grants discourage adults from working, or increase spending on temptation goods (alcohol, tobacco). Third, for the wider economy, there is little evidence that grants will increase inflation, while some studies find that transfers create a fiscal multiplier and stimulate the local economy. Finally, we review evidence on design considerations and find that unconditional cash transfers (UCTs) are particularly well suited to rapid response when compared to conditional cash transfers (CCTs). Outside crisis settings, there is some evidence that getting recipients to enrol children in school or attend health check-ups improves these outcomes more than unconditional grants. However, the differences are small and the additional costs of implementing conditions outweigh these benefits in circumstances where response is required urgently. Comparing evidence on cash grants and food vouchers suggests both achieve similar improvements in nutrition; however, cash transfers are likely to be more cost-effective for governments, especially where a system to distribute grants is already set up.

Can Simple Psychological Interventions Increase Preventive Health Investment?

Behavioral constraints may explain part of the low demand for preventive health products. We test the effects of two light-touch psychological interventions on water chlorination and related health and economic outcomes using a randomized controlled trial among 3,750 women in rural Kenya. One intervention encourages participants to visualize alternative realizations of the future, and the other builds participants' ability to make concrete plans. After 12 weeks, visualization increases objectively measured chlorination, reduces diarrhea episodes among children, and increases savings. Effects on chlorination and savings persist after almost 3 years. Effects of the planning intervention are weaker and largely insignificant. Analysis of mechanisms suggests both interventions increase self-efficacy-beliefs about one's ability to achieve desired outcomes. Visualization also increases participants' skill in forecasting their future utility. The interventions do not differentially affect beliefs and knowledge about chlorination. Results suggest simple psychological interventions can increase future-oriented behaviors, including use of preventive health technologies.

Power to participants: methodological and ethical reflections from a decade of adolescent advisory groups in South Africa.

ABSTRACTWhilst the HIV response has made significant progress in increasing representation of adults affected by HIV, the meaningful inclusion of children and adolescents has lagged. But this may be a pivotal moment of change. We report on a decade of conducting adolescent advisory groups in South Africa, to reflect on youth advisory processes. Data was collected from 2008 to 2018 from adolescent advisors (n = 60) and researchers (n = 25), and included feedback sessions, social media, anonymous "post-boxes" and interviews. Findings include the value of adolescent involvement in multiple stages of research co-creation and engagement in policy processes, the need for a safe environment and supporting adolescents living in extreme vulnerability. We also discuss the reconfiguring of power and personal relationships, and logistical and financial needs of adolescent advisory groups. Findings suggest that adolescent co-creation of research is feasible, even with very vulnerable adolescents, although ethical considerations need to be carefully addressed. Benefits include increased methodological rigour, enhanced adolescent acceptability of research and the recalibration of research dynamics for the empowerment of their target beneficiaries. Future studies could benefit from meaningfully involving adolescents through youth advisory groups.

Measuring self-efficacy, executive function, and temporal discounting in Kenya.

Developing countries have low adherence to medical regimens like water chlorination or antenatal and postnatal care, contributing to high infant and child mortality rates. We hypothesize that high levels of stress affect adherence through temporal discounting, self-efficacy, and executive control. Measurement of these constructs in developing countries requires adaptation of existing measures. In the current study, we adapt psychological scales and behavioral tasks, measuring each of these three constructs, for use among adults in Kenya. We translated and back-translated each measure to Kiswahili and conducted cognitive interviewing to establish cultural acceptability, refined existing behavioral tasks, and developed new ones. Then, in a laboratory session lasting 3 h, participants (N=511) completed the adapted psychological inventories and behavioral tasks. We report the psychometric properties of these measures. We find relatively low reliability and poor correlational evidence between psychological scales and behavioral tasks measuring the same construct, highlighting the challenges of adapting measures across cultures, and suggesting that assays within the same domain may tap distinct underlying processes.