Community-based interventions targeting multiple forms of malnutrition among adolescents in low-income and middle-income countries: protocol for a scoping review.

BACKGROUND: Adolescent malnutrition is a significant public health challenge in low-income and middle-income countries (LMICs), with long-term consequences for health and development. Community-based interventions have the potential to address multiple forms of malnutrition and improve the health outcomes of adolescents. However, there is a limited understanding of the content, implementation and effectiveness of these interventions. This scoping review aims to synthesise evidence on community-based interventions targeting multiple forms of malnutrition among adolescents in LMICs and describe their effects on nutrition and health. METHODS AND ANALYSIS: A comprehensive search strategy will be implemented in multiple databases including MEDLINE (through PubMed), Embase, CENTRAL (through Cochrane Library) and grey literature, covering the period from 1 January 2000 to 14 July 2023. We will follow the Participants, Concept and Context model to design the search strategy. The inclusion criteria encompass randomised controlled trials and quasi-experimental studies focusing on adolescents aged 10-19 years. Various types of interventions, such as micronutrient supplementation, nutrition education, feeding interventions, physical activity and community environment interventions, will be considered. Two reviewers will perform data extraction independently, and, where relevant, risk of bias assessment will be conducted using standard Cochrane risk-of-bias tools. We will follow the PRISMA Extension for Scoping Reviews checklist while reporting results. ETHICS AND DISSEMINATION: The scope of this scoping review is restricted to publicly accessible databases that do not require prior ethical approval for access. The findings of this review will be shared through publications in peer-reviewed journals, and presentations at international and regional conferences and stakeholder meetings in LMICs. SCOPING REVIEW REGISTRATION: The final protocol was registered prospectively with the Open Science Framework on 19 July 2023 (https://osf.io/t2d78).

Empowering parents for human immunodeficiency virus prevention: Health and sex education at home.

BACKGROUND: Improving health literacy amongst human immunodeficiency virus (HIV)-positive mothers could strengthen child and adolescent HIV prevention. The Amagugu intervention included health literacy materials to strengthen maternal communication and has demonstrated success in low-resource HIV-endemic settings. OBJECTIVES: Our aims were to (1) evaluate whether Amagugu materials improved health literacy leading to changes in parental behaviour towards communicating on topics such as HIV, health behaviours and sex education, and (2) explore what additional information and materials mothers would find helpful. METHOD: The Amagugu evaluation included 281 HIV-positive mothers and their HIV-uninfected children (6-10 years). Process evaluation data from exit interviews were analysed using content analysis and logistic regression techniques. RESULTS: Of 281 mothers, 276 (98.0%) requested more educational storybooks: 99 (35.2%) on moral development/future aspirations, 92 (32.7%) on general health, safety and health promotion, and 67 (23.8%) on HIV and disease management. Compared to baseline, mothers reported that the materials increased discussion on the risks of bullying from friends (150; 53.4%), teacher problems (142; 50.5%), physical abuse (147; 52.3%) and sexual abuse (126; 44.8%). Most mothers used the 'HIV Body Map' for health (274; 97.5%) and sex education (267; 95.0%). The use of a low-cost doll was reported to enhance mother-child communication by increasing mother-child play (264; 94.3%) and maternal attentiveness to the child's feelings (262; 93.6%). CONCLUSION: Parent-led health education in the home seems feasible, acceptable and effective and should be capitalised on in HIV prevention strategies. Further testing in controlled studies is recommended.

The Amagugu intervention: a qualitative investigation into maternal experiences and perspectives of a maternal HIV disclosure support intervention in rural South Africa.

The World Health Organization recommends disclosure of parental HIV to children aged 6-12 years. The maternal HIV-disclosure intervention (Amagugu), a lay counsellor-led, home-based intervention with six sessions, was implemented. The intervention included provision of disclosure tools, training and support for mothers, a family session and health promotion clinic visit for mothers and children. Amagugu demonstrated success as a maternal disclosure support programme but less is known about the experiences of participants. A sub-sample of HIV-infected mothers (n = 20) with primary school-aged HIV-uninfected children, from Amagugu, was purposely selected. Using semi-structured interviews and interview-guide, we explored maternal perceptions of disclosure prior to participation and experiences of participating in Amagugu. Audio-recorded interviews conducted in participants' homes, in isiZulu, were transcribed, and content analysis was undertaken. The most common reasons for prior non-disclosure were concerns about children's developmental capacity to understand HIV, fear of HIV-related stigma towards mothers and their families, and lack of skills to undertake disclosure. Intervention materials, rapport with counsellors, and flexibility of the proposed disclosure process motivated mothers to participate. While expressing satisfaction with the intervention, some mothers remained concerned about their children's understanding of HIV and ability to maintain confidentiality. Mothers also requested support in discussing sex-related topics with their children. Despite prior high rates of disclosure to other adults, mothers had little awareness about the importance of disclosure to children and lacked skills to undertake this. The intervention approach, rapport with counsellors, and practicality of the materials, helped overcome child disclosure barriers. Mothers reported their children as very supportive following disclosure and stated they would advise other women to disclose to children for practical support around HIV treatment adherence. This qualitative evaluation suggests that mothers with primary school-aged children may require structured support when disclosing to children, which could be achieved through supportive home-based counselling and user-friendly materials.

The Amagugu Intervention: A Conceptual Framework for Increasing HIV Disclosure and Parent-Led Communication about Health among HIV-Infected Parents with HIV-Uninfected Primary School-Aged Children.

Advances in access to HIV prevention and treatment have reduced vertical transmission of HIV, with most children born to HIV-infected parents being HIV-uninfected themselves. A major challenge that HIV-infected parents face is disclosure of their HIV status to their predominantly HIV-uninfected children. Their children enter middle childhood and early adolescence facing many challenges associated with parental illness and hospitalization, often exacerbated by stigma and a lack of access to health education and support. Increasingly, evidence suggests that primary school-aged children have the developmental capacity to grasp concepts of health and illness, including HIV, and that in the absence of parent-led communication and education about these issues, HIV-exposed children may be at increased risk of psychological and social problems. The Amagugu intervention is a six-session home-based intervention, delivered by lay counselors, which aims to increase parenting capacity to disclose their HIV status and offer health education to their primary school-aged children. The intervention includes information and activities on disclosure, health care engagement, and custody planning. An uncontrolled pre-post-evaluation study with 281 families showed that the intervention was feasible, acceptable, and effective in increasing maternal disclosure. The aim of this paper is to describe the conceptual model of the Amagugu intervention, as developed post-evaluation, showing the proposed pathways of risk that Amagugu aims to disrupt through its intervention targets, mechanisms, and activities; and to present a summary of results from the large-scale evaluation study of Amagugu to demonstrate the acceptability and feasibility of the intervention model. This relatively low-intensity home-based intervention led to: increased HIV disclosure to children, improvements in mental health for mother and child, and improved health care engagement and custody planning for the child. The intervention model demonstrates the potential for disclosure interventions to include pre-adolescent HIV education and prevention for primary school-aged children.

Living with HIV, disclosure patterns and partnerships a decade after the introduction of HIV programmes in rural South Africa.

Prevention of mother-to-child Transmission and HIV Treatment programmes were scaled-up in resource-constrained settings over a decade ago, but there is still much to be understood about women's experiences of living with HIV and their HIV disclosure patterns. This qualitative study explored women's experiences of living with HIV, 6-10 years after being diagnosed during pregnancy. The area has high HIV prevalence, and an established HIV treatment programme. Participants were enrolled in a larger intervention, "Amagugu", that supported women (n = 281) to disclose their HIV status to their children. Post-intervention we conducted individual in-depth interviews with 20 randomly selected women, stratified by clinic catchment area, from the total sample. Interviews were entered into ATLAS.ti computer software for coding. Most women were living with their current sexual partner and half were still in a relationship with the child's biological father. Household exposure to HIV was high with the majority of women knowing at least one other HIV-infected adult in their household. Eighteen women had disclosed their HIV status to another person; nine had disclosed to their current partner first. Two main themes were identified in the analyses: living with HIV and the normalisation of HIV treatment at a family level; and the complexity of love relationships, in particular in long-term partnerships. A decade on, most women were living positively with HIV, accessing care, and reported experiencing little stigma. However, as HIV became normalised new challenges arose including concerns about access to quality care, and the need for family-centred care. Women's sexual choices and relationships were intertwined with feelings of love, loyalty and trust and the important supportive role played by partners and families was acknowledged, however, some aspects of living with HIV presented challenges including continuing to practise safe sex several years after HIV diagnosis.

Maternal HIV disclosure to young HIV-uninfected children: an evaluation of a family-centred intervention in South Africa.

OBJECTIVES: Sub-Saharan Africa has large populations of HIV-infected parents who need support to raise their HIV-uninfected children. This research evaluates the 'Amagugu Intervention' aimed at supporting mothers to disclose their own HIV diagnosis to their HIV-uninfected children. DESIGN: Uncontrolled pre and post-intervention evaluation. SETTING: Africa Centre for Health and Population Studies, South Africa. PARTICIPANTS: Two hundred and eighty-one HIV-infected women and their HIV-uninfected children aged 6-10 years. INTERVENTION: This lay counsellor-led intervention included six sessions conducted with mothers at home, providing printed materials and child-friendly activities to support disclosure of their diagnosis. MAIN OUTCOME MEASURE: The primary outcome was disclosure to the child (full, partial, none). The secondary outcomes included maternal mental health (General Health Questionnaire) and child mental health (Child Behaviour Checklist). RESULTS: One hundred and seventy-one (60%) women 'fully' disclosed and 110 (40%) women 'partially' disclosed their HIV status to their child. Women who perceived their health to be excellent were less likely to 'fully' disclose compared to those considering their health to be poorer [adjusted odds ratio 0.50 (0.26-0.98), P = 0.042]. [corrected]. Compared to those not in a current partnership, those with a current partner were almost three times more likely to 'fully' disclose [adjusted odds ratio 2.92 (1.33-6.40), P = 0.008]. Mothers reported that most children reacted calmly to 'full' (79%) or 'partial' disclosure (83%). Compared to 'partial' disclosure, 'full' disclosure was associated with more children asking questions about maternal death (18 versus 8%). CONCLUSIONS: This intervention is acceptable in resource-limited settings and shows promise. Further research using a controlled design is needed to test this intervention.

Maternal HIV disclosure to HIV-uninfected children in rural South Africa: a pilot study of a family-based intervention.

BACKGROUND: As access to treatment increases, large numbers of HIV-positive parents are raising HIV-negative children. Maternal HIV disclosure has been shown to have benefits for mothers and children, however, disclosure rates remain low with between 30-45% of mothers reporting HIV disclosure to their children in both observational and intervention studies. Disclosure of HIV status by parent to an HIV-uninfected child is a complex and challenging psychological and social process. No intervention studies have been designed and tested in Southern Africa to support HIV-positive parents to disclose their status, despite this region being one of the most heavily affected by the HIV epidemic. METHOD: This paper describes the development of a family-centred, structured intervention to support mothers to disclose their HIV status to their HIV-negative school-aged children in rural South Africa, an area with high HIV prevalence. The intervention package includes printed materials, therapeutic tools and child-friendly activities and games to support age-appropriate maternal HIV disclosure, and has three main aims: (1) to benefit family relationships by increasing maternal HIV disclosure; (2) to increase children's knowledge about HIV and health; (3) to improve the quality of custody planning for children with HIV-positive mothers. We provide the theoretical framework for the intervention design and report the results of a small pilot study undertaken to test its acceptability in the local context. RESULTS: The intervention was piloted with 24 Zulu families, all mothers were HIV-positive and had an HIV-negative child aged 6-9 years. Lay counsellors delivered the six session intervention over a six to eight week period. Qualitative data were collected on the acceptability, feasibility and the effectiveness of the intervention in increasing disclosure, health promotion and custody planning. All mothers disclosed something to their children: 11/24 disclosed fully using the words "HIV" while 13/24 disclosed partially using the word "virus". CONCLUSION: The pilot study found the intervention was feasible and acceptable to mothers and counsellors, and provides preliminary evidence that participation in the intervention encouraged disclosure and health promotion. The pilot methodology and small sample size has limitations and further research is required to test the potential of this intervention. A larger demonstration project with 300 families is currently underway.

Rapid testing may not improve uptake of HIV testing and same day results in a rural South African community: a cohort study of 12,000 women.

BACKGROUND: Rapid testing of pregnant women aims to increase uptake of HIV testing and results and thus optimize care. We report on the acceptability of HIV counselling and testing, and uptake of results, before and after the introduction of rapid testing in this area. METHODS AND PRINCIPAL FINDINGS: HIV counsellors offered counselling and testing to women attending 8 antenatal clinics, prior to enrolment into a study examining infant feeding and postnatal HIV transmission. From August 2001 to April 2003, blood was sent for HIV ELISA testing in line with the Prevention of Mother-to-Child Transmission (PMTCT) programme in the district. From May 2003 to September 2004 women were offered a rapid HIV test as part of the PMTCT programme, but also continued to have ELISA testing for study purposes. Of 12,323 women counselled, 5,879 attended clinic prior to May 2003, and 6,444 after May 2003 when rapid testing was introduced; of whom 4,324 (74.6%) and 4,810 (74.6%) agreed to have an HIV test respectively. Of the 4,810 women who had a rapid HIV test, only 166 (3.4%) requested to receive their results on the same day as testing, the remainder opted to return for results at a later appointment. Women with secondary school education were less likely to agree to testing than those with no education (AOR 0.648, p<0.001), as were women aged 21-35 (AOR 0.762, p<0.001) and >35 years (AOR 0.756, p<0.01) compared to those <20 years. CONCLUSIONS: Contrary to other reports, few women who had rapid tests accepted their HIV results the same day. Finding strategies to increase the proportion of pregnant women knowing their HIV results is critical so that appropriate care can be given.

Early cessation of breastfeeding to prevent postnatal transmission of HIV: a recommendation in need of guidance.

AIM: Early and rapid cessation of breastfeeding has been recommended by WHO to reduce mother-to-child transmission of HIV. This study assessed how HIV-infected mothers planned and experienced breastfeeding cessation as part of an HIV prevention strategy and how counsellors facilitated this process. METHODS: A qualitative study was conducted among HIV-infected mothers and counsellors from local clinics and an intervention research project in Durban, South Africa. RESULTS: Mothers enrolled in the research setting reported many success stories in contrast to mothers attending routine services. Consistent counselling and ongoing support from counsellors facilitated this, though specific advice on how to stop breastfeeding and introduce complementary feeds was inadequate amongst both sets of counsellors. Few mothers had a plan for what they were actually going to do on the day when they had decided to stop breastfeeding. Their primary motivation for wanting to rapidly stop breastfeeding, even with the difficulties involved, was to avoid infecting their child with HIV. Both counsellors and HIV-infected mothers expressed concern about practical issues, including social consequences, associated with early cessation. Mothers who had stopped breastfeeding offered some, albeit limited, recommendations to assist and guide other women. CONCLUSION: The experiences of HIV-infected mothers planning for and stopping breastfeeding early illustrate the complexity of this recommendation and demonstrate that counsellors are ill-prepared to support mothers accomplish this safely. Guidance that acknowledges the cultural context and psychological stresses is urgently needed to direct policy, training and service delivery.