How do new crises impact HIV risk behaviour - exploring HIV risk behaviour according to COVID-19-related orphanhood status in South Africa?

ABSTRACTThe COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents.

Reviewing explore/exploit decision-making as a transdiagnostic target for psychosis, depression, and anxiety.

In many everyday decisions, individuals choose between trialling something novel or something they know well. Deciding when to try a new option or stick with an option that is already known to you, known as the "explore/exploit" dilemma, is an important feature of cognition that characterises a range of decision-making contexts encountered by humans. Recent evidence has suggested preferences in explore/exploit biases are associated with psychopathology, although this has typically been examined within individual disorders. The current review examined whether explore/exploit decision-making represents a promising transdiagnostic target for psychosis, depression, and anxiety. A systematic search of academic databases was conducted, yielding a total of 29 studies. Studies examining psychosis were mostly consistent in showing that individuals with psychosis explored more compared with individuals without psychosis. The literature on anxiety and depression was more heterogenous; some studies found that anxiety and depression were associated with more exploration, whereas other studies demonstrated reduced exploration in anxiety and depression. However, examining a subset of studies that employed case-control methods, there was some evidence that both anxiety and depression also were associated with increased exploration. Due to the heterogeneity across the literature, we suggest that there is insufficient evidence to conclude whether explore/exploit decision-making is a transdiagnostic target for psychosis, depression, and anxiety. However, alongside our advisory groups of lived experience advisors, we suggest that this context of decision-making is a promising candidate that merits further investigation using well-powered, longitudinal designs. Such work also should examine whether biases in explore/exploit choices are amenable to intervention.

A community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho (Early Morning Star): a cluster-randomised, controlled trial.

BACKGROUND: When caregivers live in remote settings characterised by extreme poverty, poor access to health services, and high rates of HIV/AIDS, their caregiving ability and children's development might be compromised. We aimed to test the effectiveness of a community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho. METHODS: We implemented a matched cluster-randomised, controlled trial in the Mokhotlong district in northeastern Lesotho with 34 community clusters randomly assigned to intervention or wait-list control groups within a pair. Eligible clusters were villages with non-governmental organisation partner presence and an active preschool. Participants were caregiver-child dyads, where the child was 12-60 months old at baseline. The intervention consisted of eight group sessions delivered at informal preschools to all children in each village. Mobile health events were hosted for all intervention (n=17) and control (n=17) clusters, offering HIV testing and other health services to all community members. Primary outcomes were caregiver-reported child HIV testing, child language development, and child attention. Assessments were done at baseline, immediately post-intervention (3 months post-baseline), and 12 months post-intervention. We assessed child language by means of one caregiver-report measure (MacArthur-Bates Communicative Development Inventory [CDI]) and used two observational assessments of receptive language (the Mullen Scales of Early Learning receptive language subscale, and the Peabody Picture Vocabulary Test 4th edn). Child attention was assessed by means of the Early Childhood Vigilance Task. Assessors were masked to group assignment. Analysis was by intention to treat. This trial was registered with ISRCTN.com, ISRCTN16654287 and is completed. FINDINGS: Between Aug 8, 2015, and Dec 10, 2017, 1040 children (531 intervention; 509 control) and their caregivers were enrolled in 34 clusters (17 intervention; 17 control). Compared with controls, the intervention group reported significantly higher child HIV testing at the 12-month follow-up (relative risk [RR] 1·46, 95% CI 1·29 to 1·65, p<0·0001), but not immediately post-intervention. The intervention group showed significantly higher child receptive language on the caregiver report (CDI) at immediate (effect size 3·79, 95% CI 0·78 to 6·79, p=0·028) but not at 12-month follow-up (effect size 2·96, 95% CI -0·10 to 5·98, p=0·056). There were no significant group differences for the direct assessments of receptive language. Child expressive language and child attention did not differ significantly between groups. INTERPRETATION: Integrated child health and parenting interventions, delivered by trained and supervised lay health workers, can improve both child HIV testing and child development. FUNDING: United States Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief (PEPFAR).

Long-term associations between early attachment and parenting and adolescent susceptibility to post-traumatic distress in a South African high-risk sample.

BACKGROUND: It has been proposed that children and young people living in low- and middle-income countries (LMICs) are not only exposed more frequently to trauma but also have a higher likelihood of encountering traumas of greater severity than those living in high-income countries (HICs). This may lead to higher rates of post-traumatic stress symptoms (PTSS). However, developmental pathways to risk or resilience after trauma exposure in LMICs are underresearched. METHODS: We examined early parenting and attachment as potentially important formative factors for later stress reactivity in a longitudinal cohort of South African children (N = 449). Parenting and attachment were assessed at child age 18 months, and interpersonal trauma exposure, PTSS and parenting stress were measured at 13 years (N = 333; core sample with data on all measures: N = 213). Following a vulnerability-stress approach, separate regression models were run to investigate whether parent-child attachment at 18 months, parental sensitivity and intrusiveness during play at 12 months, and current parenting stress at 13 years, interacted with adolescents' extent of interpersonal trauma exposure to predict their PTSS levels at 13 years. RESULTS: We found no predictive effects of either early attachment or current parenting stress in relation to child PTSS. There was some evidence for predictive influences of parental early intrusiveness and sensitivity on adolescent outcomes, though associations were unexpectedly positive for the latter. No interaction effects supporting a vulnerability-stress model were found. CONCLUSIONS: Overall, we found limited evidence that elements of the early parent-child environment predict child risk/resilience to trauma in LMIC children. Future studies should include more frequent assessments of relevant constructs to capture changes over time and consider further what comprises adaptive parenting in high-risk contexts.

Using WhatsApp support groups to promote responsive caregiving, caregiver mental health and child development in the COVID-19 era: A randomised controlled trial of a fully digital parenting intervention.

Objective: Digital interventions hold important potential for supporting parents when face-to-face interventions are unavailable. We assessed the feasibility and effectiveness of a digital parenting intervention in Zambia and Tanzania. Methods: Using a randomised controlled trial, we evaluated the Sharing Stories digital parenting intervention for caregivers of children aged 9-32 months with access to a smartphone in their household. Caregivers were stratified based on child age and randomly assigned to the intervention or waitlist control arm. The intervention was delivered via facilitated WhatsApp groups over 6 weeks to promote caregiver wellbeing and responsive caregiving through shared reading activities. Primary outcomes were caregiver-reported responsive caregiving, child language and socio-emotional development. Secondary outcomes were caregiver mental health and parental stress. Masked assessors conducted assessments at baseline and immediate follow-up. Results: Between October 2020 and March 2021, we randomly assigned 494 caregiver-child dyads to the intervention (n = 248) or waitlist control (n = 246) arm. Caregivers in the intervention group reported more responsive caregiving (OR = 2.55, 95% CI: 1.15-5.66, p = 0.02), time reading or looking at books (ß = 0.45, p = 0.04) and telling stories (ß = 0.72, p = 0.002). Intervention caregivers reported significantly lower symptoms of depression (ß = -0.64, p = 0.05) and anxiety (ß = -0.65, p = 0.02). Child development and parental stress did not differ significantly between groups. Conclusions: Digital parenting interventions using WhatsApp can effectively promote responsive caregiving and caregiver mental health in low-resource settings, with great potential for scalability. Trial registration: ISRCTN database, ISRCTN77689525.

Community Health Workers' experiences of a package providing increased support and supervision - a qualitative study of a home visiting model in rural South Africa.

Deploying Community Health Workers is a crucial strategy to improve health at a community level in low and middle income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW's experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using a qualitative study embedded within a cluster randomized controlled trial of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa. We interviewed CHWs (n = 16) and two supervisors. Three overarching areas and five sub-themes emerged from our interviews. CHW knowledge and confidence increased through additional training, that CHW motivation and community acceptance improved because of added logistical support, and that CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively.

'Community health workers are unable to work because they don't have supervisors' - mid-level providers' experiences of a CHW program in rural South Africa.

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

Protocol for the OCAY study: a cohort study of orphanhood and caregiver loss in the COVID-19 era to explore the impact on children and adolescents.

INTRODUCTION: Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa. METHODS AND ANALYSIS: Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12-18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision. ETHICS AND DISSEMINATION: This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.

Parenting in Adversity: Effects of Older Caregivers, Biological Carers and Troubled Carers on Child Outcomes in High HIV-Affected Communities.

Caregiving by older adults is a common phenomenon, enhanced in the era of HIV infection. This longitudinal study was set up to examine the effect of caregiver age, relationship and mental wellbeing on child (4-13 years) outcomes (psychosocial and cognitive) in a sample of 808 caregiver- child dyads in South Africa and Malawi. Respondents were drawn from consecutive attenders at Community Based Organisations (CBOs) and interviewed with standardised inventories at baseline and followed up 12-15 months later. Analysis focused on three separate aspects of the caregiver; age, relationship to the child, and mental wellbeing, results are stratified with regard to these factors. Results showed that compared to younger caregivers, over 50 years were carrying a heavy load of childcare, but caregiver age for the most part was not associated with child outcomes. Being biologically related to the child (such as biological grandparenting) was also not a significant factor in child outcomes measured. However, irrespective of age and relationship, caregiver mental health was associated with differences in child outcome - those children of caregivers with a greater mental health burden were found to report experiencing more physical and psychologically violent discipline. Over time, the use of violent discipline was found to reduce. These data suggest that older caregivers and grandparents are providing comparable care to younger caregivers, for young children in the face of the HIV epidemic and that interventions should focus on mental health support for all caregivers, irrespective of age or relationship to the child.

Does pre-COVID impulsive behaviour predict adherence to hygiene and social distancing measures in youths following the COVID-19 pandemic onset? Evidence from a South African longitudinal study.

BACKGROUND: Engagement in protective behaviours relating to the COVID-19 pandemic has been proposed to be key to infection control. This is particularly the case for youths as key drivers of infections. A range of factors influencing adherence have been identified, including impulsivity and risk taking. We assessed the association between pre-COVID impulsivity levels and engagement in preventative measures during the COVID-19 pandemic in a longitudinal South African sample, in order to inform future pandemic planning. METHODS: Data were collected from N = 214 youths (mean age at baseline: M = 17.81 (SD = .71), 55.6% female) living in a South African peri-urban settlement characterised by high poverty and deprivation. Baseline assessments were taken in 2018/19 and the COVID follow-up was conducted in June-October 2020 via remote data collection. Impulsivity was assessed using the Balloon Analogue Task (BART), while hygiene and social distancing behaviours were captured through self-report. Stepwise hierarchical regression analyses were performed to estimate effects of impulsivity on measure adherence. RESULTS: Self-rated engagement in hygiene behaviours was high (67.1-86.1% "most of the time", except for "coughing/sneezing into one's elbow" at 33.3%), while engagement in social distancing behaviours varied (22.4-57.8% "most of the time"). Higher impulsivity predicted lower levels of hygiene (ß = .14, p = .041) but not social distancing behaviours (ß = -.02, p = .82). This association was retained when controlling for a range of demographic and COVID-related factors (ß = .14, p = .047) and was slightly reduced when including the effects of a life-skills interventions on hygiene behaviour (ß = -.13, p = .073). CONCLUSIONS: Our data indicate that impulsivity may predict adolescent engagement in hygiene behaviours post COVID-19 pandemic onset in a high risk, sub-Saharan African setting, albeit with a small effect size. For future pandemics, it is important to understand predictors of engagement, particularly in the context of adversity, where adherence may be challenging. Limitations include a small sample size and potential measure shortcomings.

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.

Measurement of Mental Health Among Adolescents at the Population Level: A Multicountry Protocol for Adaptation and Validation of Mental Health Measures.

PURPOSE: Mental disorders are among the leading causes of disability among adolescents aged 10-19 years. However, data on prevalence of mental health conditions are extremely sparse across low- and middle-income countries, even though most adolescents live in these settings. This data gap is further exacerbated because few brief instruments for adolescent mental health are validated in these settings, making population-level measurement of adolescent mental health especially cumbersome to carry out. In response, the UNICEF has undertaken the Measurement of Mental Health Among Adolescents at the Population Level (MMAP) initiative, validating open-access brief measures and encouraging data collection in this area. METHODS: This protocol presents the MMAP mixed-methods approach for cultural adaptation and clinical validation of adolescent mental health data collection tools across settings. Qualitative activities include an initial translation and adaptation, review by mental health experts, focus-group discussions with adolescents, cognitive interviews, synthesis of findings, and back-translation. An enriched sample of adolescents with mental health problems is then interviewed with the adapted tool, followed by gold-standard semistructured diagnostic interviews. RESULTS: The study protocol is being implemented in Belize, Kenya, Nepal, and South Africa and includes measures for anxiety, depression, functional limitations, suicidality, care-seeking, and connectedness. Analyses, including psychometrics, will be conducted individually by country and combined across settings to assess the MMAP methodological process. DISCUSSION: This protocol contributes to closing the data gap on adolescent mental health conditions by providing a rigorous process of cross-cultural adaptation and validation of data collection approaches.

Implications for Mental Health Promotion and Prevention Interventions: Findings From Adolescent Focus Group Discussions in Belize, Kazakhstan, and South Africa.

PURPOSE: This study aimed to understand 10- to 19-year-old adolescents' conceptions of mental health and well-being, and suggestions for appropriate interventions, in three low- and middle-income countries to inform the design of adolescent-responsive preventive and promotive mental health programming. METHODS: Ninety-one adolescents participated in focus group discussions in Belize, Kazakhstan, and South Africa. The discussions were recorded, transcribed, translated, and analyzed using thematic analysis. RESULTS: Adolescents were active contributors to the discussions and provided important information and solutions for improving adolescents' mental health from interpersonal skills training to interventions in schools and communities. Adolescents identified a need for social emotional skills development, particularly regarding interpersonal relationships and navigating peer pressure and bullying. Furthermore, the discussions highlighted the need for programming to be tailored to the local context regarding language, contextual challenges faced by adolescents, and choice of program facilitators. Adolescents valued supportive interactions with adults in their lives and recommended that programs should include teacher/parent training on interacting with adolescents. CONCLUSIONS: These findings highlight that adolescents are valuable partners in developing adolescent health interventions and show that social emotional skills are key components in such interventions. These programs should be culturally and locally appropriate and include components for teachers and parents.

Detecting Depression and Anxiety Among Adolescents in South Africa: Validity of the isiXhosa Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7.

PURPOSE: Screening tools such as the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) could potentially be used in resource-limited settings to identify adolescents who need mental health support. We examined the criterion validity of the isiXhosa versions of the PHQ-9 and GAD-7 in detecting depression and anxiety among adolescents (10-19 years) in South Africa. METHODS: Adolescents were recruited from the general population and from nongovernmental organizations working with adolescents in need of mental health support. The PHQ-9 and GAD-7 were culturally adapted and translated into isiXhosa and administered to 302 adolescents (56.9% female). The Kiddie Schedule for Affective Disorders and Schizophrenia was administered by trained clinicians as the gold standard diagnostic measure for depression and anxiety. RESULTS: For the PHQ-9, the area under the curve was 0.88 for the full sample of adolescents (10-19 years old). A score of ≥10 had 91% sensitivity and 76% specificity for detecting adolescents with depression. For the GAD-7, the area under the curve was 0.78, and cutoff scores with an optimal sensitivity-specificity balance were low (≥6). A score of ≥6 had 67% sensitivity and 75% specificity for detecting adolescents with anxiety. DISCUSSION: The culturally adapted isiXhosa version of the PHQ-9 can be used as a valid measure for depression in adolescents. Further research on the GAD-7 for use with adolescents is recommended.

Predictors of COVID-related changes in mental health in a South African sample of adolescents and young adults.

The COVID-19 pandemic has substantially affected the lives of young people living in sub-Saharan Africa (SSA), leading to poorer short-term mental health outcomes. However, longitudinal data investigating changes in mental health from pre-COVID levels and their predictors are lacking. Our longitudinal sample comprised N = 233 young people (mean age: 17.8 years at baseline, 55.6% female) living in a deprived neighbourhood near Cape Town, South Africa. Symptoms of depression (PHQ-9), anxiety (GAD-7) and alcohol use (AUDIT) were assessed during two waves of data collection, pre-pandemic (2018/19) and via phone interviews in June to October 2020, during South Africa's first COVID wave and subsequent case decline. Latent change score models were used to investigate predictors of changes in mental health. Controlling for baseline levels, we found increases in depression and anxiety but not alcohol use symptoms during the COVID-19 pandemic. Higher baseline symptoms were associated with smaller increases on all measures. Socio-economic deprivation (lack of household income, food insecurity) before and during COVID were associated with higher anxiety and depression symptom increases. Having had more positive experiences during COVID was associated with lower post-COVID onset anxiety and depression increases, and marginally with less alcohol use, while negative experiences (household arguments, worries) were linked to stronger symptom increases. Overall, in a sample of young people from an adverse environment in South Africa, we found increased mental health difficulties during the COVID-19 pandemic, though higher baseline symptoms did not necessarily predict stronger increases. Several factors pre- and post-COVID onset were identified that could be relevant for determining risk and resilience. In the long term, it will be key to address these structural drivers of well-being and to ensure mental health needs of young people are being met to support SSA countries in building back successfully from COVID-19 and preparing for future shock events.

Accelerating progress towards improved mental health and healthy behaviours in adolescents living in adversity: findings from a longitudinal study in South Africa.

Adolescents exposed to high levels of adversity are vulnerable to developing mental health challenges, with long-lasting adverse consequences. Promoting the psychological well-being of adolescents and protecting them from adverse experiences is crucial for their quality of life. There is a need for evidence on which combinations of protective factors can improve the wellbeing of adolescents to inform future programming efforts. We used data from a longitudinal study that took place in Khayelitsha, South Africa, a semi-urban impoverished community in Cape Town. Data were collected from adolescents when they were 12-14 years of age (n = 333) and again at follow-up when they were aged 16-19 years (n = 314). A path analysis was used to estimate associations between access to service, food security, safe environment, family support, and social support and five outcomes related to adolescent mental health and risky behaviours. The fitted model was used to calculate adjusted mean differences comparing different combinations of risk factors. Two protective factors (food security and safe environment) were positively associated with three outcomes relating to mental health and the absence of risky behaviours. Further investigation revealed that the presence of high food security and safer environments was associated with higher adjusted mean scores: +16.2% (p < .0001) in no substance use; +16.5% (p < .0001) in no internalising behaviour, +19.5% (p < .0001) in self-esteem; +12.2% (p < .0001) in positive peer relationships; and +11.4% (p < .0001) in no suicidal ideation. Interventions targeting adolescents, that aim to improve food security together with improving the safety of their environment, are likely to impact their well-being.

Community health workers' experiences of supervision in maternal and child health programmes in low- and middle-income countries: A qualitative evidence synthesis.

Maternal and child health programmes often use Community Health Workers (CHWs) to help address poor access to health care, particularly in low- and middle-income countries (LMIC). Supervision has long been recognised as a critical ingredient of successful CHW programmes, yet it is often reported as either of poor quality or absent. There is little research on CHWs' own perception of supervision and to the best of our knowledge, there are no reviews synthesising the evidence of CHWs' experiences of supervision. This review identified and synthesised qualitative research evidence about the experiences and perceptions of supervision by CHWs in programmes targeting maternal and child health (MCH) in LMIC. Electronic searches were performed in the following databases: EMBASE, Medline, PsycINFO, ASSIA, ERIC and CINAHL. This review included studies during the period from 2000 to 2021. In total, 10,505 titles were screened for inclusion, of which 177 full-text articles were retrieved and assessed. Ultimately, 19 articles were included in this review. Data extraction was based on the thematic synthesis approach: coding the text of included studies line-by-line; developing descriptive themes; and generating analytical themes. Four themes emerged: (1) frequency of supervision, (2) type of supervision, (3) supervision and motivation and (4) supportive supervision. Careful consideration needs to be taken of the model of supervision used, as primary care facility-based supervisors (usually nurses), although skilled, may not have sufficient time to supervise. Employing supervisors whose sole responsibility is to supervise CHWs may be a good strategy to alleviate these issues. Sufficient time and resources need to be allocated to supervisors and they should be expected to perform regular in-the-field supervision. Involving some aspects of community oversight should also be considered. Supervisor skills and training and the long-term retention of trained supervisors also need to be an important area of focus.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review.

PURPOSE: Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice. METHODS: We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work. RESULTS: From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services). DISCUSSION: A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Are we listening to community health workers? Experiences of the community health worker journey in rural South Africa.

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