Pregnancy and STI/HIV prevention intervention preferences of South African adolescent girls: findings from a cultural consensus modelling qualitative study.

South African adolescent girls experience high rates of unintended pregnancy and sexually transmitted infections including HIV. To inform culturally-tailored dual protection interventions to prevent both unintended pregnancy and STIs/HIV, this study qualitatively examined girls' sexual health intervention preferences. Participants were aged 14-17 years old and Sesotho-speaking (N = 25). To elucidate shared cultural beliefs, individual interviews examined participants' perceptions about other adolescent girls' pregnancy and STI/HIV prevention intervention preferences. Interviews were conducted in Sesotho and translated into English. Two independent coders identified key themes in the data using a conventional content analysis approach with discrepancies resolved by a third coder. Participants indicated that intervention content should include efficacious pregnancy and STI/HIV prevention methods and ways to navigate peer pressure. Interventions should be accessible, avoid criticism and provide high-quality information. Preferred intervention formats included online, SMS/text, or delivery by social workers or older, knowledgeable peers, with mixed acceptability for delivery by parents or same-age peers. Schools, youth centres and sexual health clinics were preferred intervention settings. Results highlight the importance of cultural context in tailoring dual protection interventions to address the reproductive health disparities among adolescent girls in South Africa.

Impact of the Mediational Intervention for Sensitizing Caregivers on Mentalizing in Orphans and Vulnerable Children in South Africa.

The Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalization-based intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa working with Community-Based Organization (CBO) careworkers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child's early environment as critical resources for enhancing children's mentalizing capacity. In this study we evaluated the treatment effect of MISC on children's mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.

Black Women's Perceptions Towards Infant and Child Male Circumcision.

OBJECTIVE: The objective of this article was to analyse women's perceptions of ICMC and to propose a framework for ICMC decision-making that can inform ICMC policies. METHOD: Using qualitative interviews, this study investigated twenty-five Black women's perceptions of ICMC decisionmaking in South Africa. Black women who had opted not to circumcise their sons, were selected through purposive and snowball sampling. Underpinned by the Social Norms Theory, their responses were analysed through in-depth interviews and a framework analysis. We conducted the study in the townships of Diepsloot and Diepkloof, Gauteng, South Africa. RESULTS: Three major themes emerged: medical mistrust, inaccurate knowledge leading to myths and misconceptions, and cultural practices related to traditional male circumcision. Building Black women's trust in the public health system is important for ICMC decision-making. CONCLUSIONS FOR PRACTICE: Policies should address misinformation through platforms that Black women share. There should be an acknowledgement of the role that cultural differences play in the decision-making process. This study developed an ICMC perception framework to inform policy.

'Being a mother is not child's play': The capabilities of mothers in a low-resource setting in South Africa.

BACKGROUND: The importance of a child's first 1000 days has now been widely accepted by the medical fraternity. Yet, we do not know much about caring practices in low-resource settings. AIM: This study aimed to investigate the caring capabilities of mothers in a low-resource setting. METHOD: In this study, in-depth interviews were conducted with 18 mothers with children aged 30 months or younger to better understand the arrangements, means and ends that inform developmental health in a low-resource setting in South Africa. The study was conducted in a low-income area, the former black township of Mangaung in Bloemfontein. The mothers were recruited via pamphlets, and two interviews followed. Because of Covid-19, interviews took place via mobile phones, in Sesotho, the local language in the area. Trained fieldworkers conducted, translated and transcribed the interviews. We used thematic analysis and the capabilities approach as the theoretical framework to analyse the responses from the mothers. FINDINGS: We used the following organizing themes: pregnancy and ante-natal care, nutrition, cognitive and physical development, the home environment and access to health care. Although short-term reactions to pregnancy were often negative, the longer-term responses showed that the respondents have agency. Most of them could change their nutrition habits, breastfeed and receive adequate nutrition support from the public health system. Most experienced joy when their children reached milestones (cognitive and others), although they became anxious if milestones were not reached. They emphasized children's play and had dreams for their children's futures. Technology was often mentioned as playing a role in their children's development. A large proportion of the respondents had disrupted homes (because of absent or abusive fathers), but some had stable homes. Most of them showed substantial capability to overcome adverse home environments. The public health system helped them deal with their health problems and their children's health problems, although it also created anxiety in many cases. Our data show how they develop their capabilities and overcome obstacles organically in the face of resource limitations. Despite pregnancies being unexpected and unplanned and fathers being absent, the respondents accepted the pregnancy, adjusted their diets and social behaviour, showed agency by attending primary healthcare facilities and ensured that their children received the required vaccinations. Their extended families played an important role in providing care. Despite the sacrifices, the respondents expressed joy and helped their children function by eating, playing, socializing, learning and using their senses. CONCLUSION: Our sample of mothers have the agency to adapt to the demands of parenthood and childcare and overcome adversity. Our data support the notion that mothers are held disproportionately and unfairly responsible for achieving the first 1000 days ideals. Despite considerable curtailment of their functionings and capabilities, they nevertheless showed agency to ensure their health and their children's health. A holistic approach should consider these findings in designing policy interventions for children's developmental health. PATIENT AND PUBLIC CONTRIBUTION: We used paid fieldworkers to interact with the research participants.

Hope and mental health problems among orphans and vulnerable children in South Africa.

ABSTRACTThere are over three million orphaned and vulnerable children (OVC) currently living in South Africa. OVC are at high risk for a number of negative outcomes, including poor mental health. Hope has been associated with well-being among youth, including youth in South Africa. However, the relationships between hope and mental health in high-adversity populations such as OVC has not been adequately described. The present study sought to address this research gap by evaluating the relationship between hope and mental health, controlling for gender, age, and orphan status, among OVC. This study includes 8- to 12-year-old OVC (N = 61) in Manguang, Free State, South Africa. Hope was assessed using the Children's Hope Scale (CHS) and mental health outcomes were assessed using the Strengths and Difficulties Questionnaire (SDQ). Hope was significantly, inversely associated with mental health outcomes after controlling for other variables in linear regression analysis. In contrast to previous research, this study found that increased hope scores were associated with adverse mental health outcomes among OVC in South Africa. Hope may be contextualized differently in this population due to resource scarcity and high rates of adversity including HIV-AIDS related stigma and poverty.

Parental decision-making in infant and child male circumcision: a case study in two townships in Gauteng, South Africa.

Parental decision-making in infant and child male circumcision is influenced by complex, interrelated factors on many levels. Several studies have highlighted reasons for the acceptance and non-acceptance of child male circumcision. This study investigates the factors that influence parental decision-making in this matter and proposes a parental decision-making framework. The study was conducted in the townships of Diepsloot and Diepkloof in Gauteng, South Africa, using 48 in-depth interviews with parents, grandparents and uncles of the boys, as well as government officials and members of civil society as part of an explorative case study. Purposive and snowball sampling were used to select the participants. Thematic analysis was used to analyse the data by applying the conceptual framework of Bronfenbrenner's ecological systems theory. Three main themes emerged from the data: microsystem factors related to health and hygiene, the father's circumcision status, cultural expectations, pain, the child's autonomy and the extended family; mesosystem factors related to early childhood development centres; and exosystem factors related to circumcision policies and financial considerations.

Housing and Child Health in South Africa: The Value of Longitudinal Research.

Research investigating the link between housing and health often produces mixed results. It does not always prove that good housing improves health. The results suggest a complex set of factors play a role, and the findings are sometimes contradictory. Two ways of addressing these concerns are longitudinal research, where the relationship between housing and health is measured in the short and medium terms, and a focus on children. We use the children's housing and health data from the five waves of the National Income and Distribution Survey (NIDS) survey in South Africa, 2008 to 2017. We investigate the effect that continued living in informal housing over the five waves has had on these children's health. Our results show a statistically significant relationship between prolonged residence in poor housing and poor health outcomes for some health indicators. The results call for a closer understanding of health issues in housing policy in South Africa.

Mediational Intervention for Sensitizing Caregivers to Improve Mental Health Outcomes in Orphaned and Vulnerable Children.

OBJECTIVE: There is an urgent need to equip community-based careworkers with the skills to address the mental health needs of orphans and vulnerable children (OVC) as an essential response to shortages in human resources for mental health in Sub-Saharan Africa. We conducted a quasi-experimental feasibility trial in South Africa to adapt and evaluate an established year-long semi-structured, manualized video-feedback caregiver intervention (the Mediational Intervention for Sensitizing Caregivers; MISC) for community-based organizations (CBOs). METHODS: Following a year-long iterative cross-cultural adaptation of MISC, we recruited 88 OVC (ages 7-11; 45.5% girls) and their CBO careworkers (N = 18; 94.4% female). Two CBOs (45 children; 9 CBO careworkers) received 12 months of MISC, and two CBOs (43 children; 9 CBO careworkers) received treatment as usual. Child mental health and quality of caregiving were assessed at 6 months into the intervention and at completion through multi-informant questionnaires and video-recordings of careworker-child interactions. Qualitative interviews were conducted to evaluate feasibility and acceptability. RESULTS: MISC-CBO was acceptable and feasible in terms of attendance and post-intervention interviews. MISC improved child mental health, as well as the quality of careworker caregiving in terms of interactive effects for affective and cognitive (Expanding) components of MISC, and main effects for the cognitive components of Rewarding and Provision of meaning. MISC components did not mediate the effects of the intervention. CONCLUSIONS: The current study shows that laypersons with no tertiary education and virtually no prior training who undergo MISC training can improve caregiving quality and the mental health of OVCs.

Targeting for male medical circumcision: profiles from two South African cities.

Male circumcision is considered by some to be an acceptable global approach to reduce HIV infections. Consequently, many governments in sub-Saharan Africa run voluntary male circumcision programmes. South Africa also provides male circumcision for free at state clinics and hospitals. Very little is known about the men who use this service. This study uses data from Cape Town, a sample of 1194 in 2016, and from Mangaung, a sample of 277 in 2017 and 2018, to fill this gap. The study finds that age targeting is inadequate, risk targeting is absent, and religious and cultural factors have a negative effect on the cost-efficiency of the service in the long run.

Cultural Consensus Modeling to Understand South African Adolescent Girls' Attitudes, Awareness, and Uptake of Dual Protection Strategies.

PURPOSE: This study used cultural consensus modeling to elucidate culturally relevant factors associated with dual protection use (strategies to prevent both pregnancy and sexually transmitted infection [STI]/HIV) among South African adolescent girls aged 14-17 years. METHODS: In Phase 1, participants (N = 50) completed a free-listing survey assessing pregnancy and STI/HIV methods used by peers. In Phase 2, participants (N = 100) completed a rating survey to examine perceived peer acceptability of Phase 1 pregnancy and STI/HIV prevention methods. In Phase 3, qualitative individual interviews (N = 25) gathered in-depth information regarding the cultural acceptability of pregnancy and STI/HIV prevention strategies. In Phase 4, participants (N = 300) completed the Phase 2 rating survey for individual beliefs regarding the acceptability of pregnancy and STI/HIV prevention methods. RESULTS: In Phase 1, 41 pregnancy and 29 STI/HIV prevention strategies, along with 16 factors influencing pregnancy prevention method acceptability were endorsed; male condoms were the most commonly endorsed pregnancy and STI/HIV prevention method. In Phase 2, using cultural consensus analysis, participants were consistent in the perceived acceptability of pregnancy and STI/HIV prevention methods (73.4% variance accounted for in single cultural model). In Phase 3, qualitative findings provided in-depth information regarding factors influencing commonly used pregnancy (e.g., injectable contraception) and STI/HIV (e.g., condoms) prevention methods. In Phase 4, a single cultural model was identified (56.3% variance accounted for), with similar acceptability ratings as Phase 2. CONCLUSIONS: A singular cultural model of pregnancy and STI/HIV prevention method acceptability was observed, with little awareness of dual protection. The findings highlight cultural factors for future culturally tailored dual protection interventions for South African adolescent girls.

Community-Based Caregiver and Family Interventions to Support the Mental Health of Orphans and Vulnerable Children: Review and Future Directions.

The goal of this paper was to conduct a review of studies from 2008 to 2019 that evaluated community-based caregiver or family interventions to support the mental health of orphans and vulnerable children (OVC) in sub-Saharan Africa, across four domains: (a) study methodology, (b) cultural adaptation and community participation, (c) intervention strategies, and (d) effects on child mental health. Ten interventions were identified. Findings revealed that the majority of studies used a randomized controlled trial or quasi-experimental design, but few conducted long-term follow-up; that all programs undertook cultural adaptation of the intervention using community participatory methods, or were locally developed; that the majority of interventions targeted caregiving behavior and/or caregiver-child relationships using behavioral and cognitive-behavioral strategies, or were home visiting interventions; and that interventions had mixed effects on OVC mental health. Progress and gaps revealed by these findings are discussed, as are suggestions for possible new directions in this area of intervention science.

A qualitative study on teachers' perceptions of their learners' mental health problems in a disadvantaged community in South Africa.

BACKGROUND: The combination of extensive poverty, violence and HIV has potential mental health impacts on children in Southern Africa. This article is nested in a broader study to evaluate the strength and difficulties questionnaire (SDQ) among Sotho speakers, and assess the mental health status of children made orphans by AIDS. OBJECTIVES: The aim of this study was to describe the mental health problems that the teachers perceive among learners in their classrooms, to understand what the teachers saw as causing these problems and to identify potential approaches to address these problems within the school setting. METHOD: As part of the larger study, 10 teachers were purposively selected to write a report describing the mental health problems among learners in their class. These findings were discussed at two later meetings with a larger grouping of teachers to validate the findings and obtain additional input. RESULTS: The teachers were concerned about the emotional state of their pupils, especially in relation to depression, anxiety, substance abuse, scholastic problems and aggression. These problems were felt to arise from the children's lived context; factors such as poverty, death of parents and caregivers from AIDS and trauma, parental substance abuse and child abuse. The teachers expressed a desire to assist the affected learners, but complained that they did not get support from the state services. CONCLUSION: Many learners were evaluated by teachers as struggling with mental health issues, arising from their social context. The teachers felt that with support, schools could provide assistance to these learners.

School connectedness as psychological resilience factor in children affected by HIV/AIDS.

Children affected by HIV/AIDS are at high risk for poor mental health outcomes. Social and psychological connectedness to school has been identified as an important resilience factor for youth affected by adversity (Centers for Disease Control and Prevention. (2009). School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services). Defined as "the belief by students that adults in the school care about their learning as well as about them as individuals" (Centers for Disease Control and Prevention. (2009). School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services), school connectedness has been shown to be associated with higher academic performance, increased mental health, and quality of life. However, few studies have examined school connectedness in sub-Saharan Africa, and none have examined school connectedness in relation to mental health in children orphaned by HIV/AIDS. Further, existing studies have relied on self-report measures. Against this background, the aim of the current study was to examine orphan status, school connectedness, and their interaction in relation to child mental health by using a multimethod design. 750 children between the ages of 7-11, recruited through South African community-based organizations (224 AIDS/HIV orphans, 276 non-AIDS/HIV orphans, 250 non-orphans; 51.2% girls), completed measures of school connectedness; children, caregivers, and teachers reported on child well-being using the Strengths and Difficulties Questionnaire. AIDS/HIV and non-AIDS/HIV orphans reported lower school connectedness than non-orphans. However, results demonstrated significant relations between school connectedness and overall mental health regardless of group, suggesting that school connectedness buffers against negative mental health outcomes regardless of orphan status. This study identifies a strategic point of intervention to build resilience against the cascading effects of HIV/AIDS and poverty in children in sub-Saharan Africa.

Caregiver alcohol use and mental health among children orphaned by HIV/AIDS in South Africa.

Research in the developed world suggests that parental alcohol use negatively impacts child mental health. However, little research has examined these relations among children in the developing world and no studies to date have done so in the context of AIDS-orphanhood. Therefore, the present study tested the interactive effect of AIDS-orphan status with caregiver alcohol use on child mental health. The sample included 742 children (51.2% female; Mage = 9.18; age range: 7-11 years; 29.8 AIDS-orphans; 36.8% orphaned by causes other than AIDS; 33.4% non-orphaned) recruited from Mangaung in the Free State Province of South Africa. Child mental health was assessed via child self-report, caregiver, and teacher reports; and caregiver alcohol use via self-report. Path analyses, via structural equation modeling, revealed significant direct effects for AIDS-orphan status on caregiver-reported child mental health; and for caregiver alcohol-use problems on teacher-reported child mental health. However, the interaction effect of AIDS-orphan status with caregiver alcohol use did not reach significance on all three reports of child mental health problems. These results suggest that orphan status and caregiver alcohol use may independently relate to mental health problems in children and that the effects of both should be considered in the context of the mental health needs of children in AIDS-affected countries.

Orphanhood by AIDS-Related Causes and Child Mental Health: A Developmental Psychopathology Approach.

While the number of new HIV infections has declined, the number of orphans as a result of AIDS-related deaths continues to increase. The aim of this paper was to systematically review empirical research on the mental health of children affected by HIV/AIDS in the developing world, specifically with an eye on developing a theoretical framework to guide intervention and research. Articles for review were gathered by following the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA standards), reviewed and then organized and synthesized with a Developmental Psychopathology framework. Results showed that the immediate and longterm effects of AIDS orphanhood are moderated by a number of important risk and protective factors that may serve as strategic targets for intervention. Research and clinical implications are discussed.

Socio-economic status and socio-emotional health of orphans in South Africa.

This paper investigates the relationship between socio-economic status and emotional well-being of orphans in Mangaung, South Africa. Five hundred orphans aged 7-11 years participated in the cross-sectional study between 2009 and 2012. Data was collected by trained fieldworkers, who conducted face-to-face interviews and questionnaires with the orphans, their teachers and caregivers, and the heads of the households where the orphans resided. The caregivers, children and teachers all completed the Strengths and Difficulties Questionnaire in order to measure the orphans' mental health, while heads of household provided information about socio-economic indicators. STATA version 12 was used to perform multivariate data analyses to identify socio-economic factors associated with the mental health of orphans. Food security, access to medical services and a male caregiver were factors associated with better emotional well-being of orphans, whereas other variables such as household asset index and monthly household expenditure were not linked with the orphans' mental health. Two of the three variables (food security and access to medical services) associated with better emotional well-being of orphans are also government interventions to assist orphans. Further research is needed to determine whether other government programs also impact the emotional well-being of orphans.

Community-based mental health support for orphans and vulnerable children in South Africa: A triangulation study.

Community-based care is receiving increasing global attention as a way to support children who are orphaned or vulnerable due to the HIV/AIDS pandemic. Using both qualitative and quantitative methodology, this study assesses community-based responses to the well-being of orphans and vulnerable children (OVC) and compares these responses with the actual mental health of OVC in order to evaluate the South African government's approach of funding community-based organisations (CBOs) that support and care for OVC. The study results show that the activities of CBOs mainly extend government services and address poverty. Although this should not be seen as insignificant, the paper argues that CBOs give very little attention to the mental health of OVC.

First evaluation of a population-based screen to detect emotional-behavior disorders in orphaned children in Sub-Saharan Africa.

Due to the HIV/AIDS pandemic which has left 12 million children orphaned in Sub-Saharan Africa, children are at increased risk for mental health problems. Currently, no validity data exist for any screening measure of emotional-behavior disorders in pre-adolescent children in Sub-Saharan Africa. The aims of the current study were to evaluate the construct validity of the caregiver-, teacher-, and self-report versions of the one-page Strengths and Difficulties Questionnaire (SDQ) in 466 orphans in South Africa between the ages of 7 and 11 (M age = 9.23 years, SD = 1.33, 51.93 % female) and to provide, for the first time, clinical cut-offs for this population. Findings demonstrated support for the caregiver SDQ, but not the teacher and self-report versions. We provide clinical cut-offs, but caution their use before further research is conducted. There remains a critical need for further psychometric studies of the SDQ in the developing world.

Assessing the value of and contextual and cultural acceptability of the Strength and Difficulties Questionnaire (SDQ) in evaluating mental health problems in HIV/AIDS affected children.

BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is a robust, powerful and internationally recognised diagnostic screening tool for emotional and behaviour problems among children, with the particular advantage that it can be used by non-health professionals. This makes it useful in a South African context characterized by shortages of professional mental health carers. However the cultural and contextual acceptability and potential uses of the SDQ have not yet been examined in the South African context. METHODS: The aim of the current study was to evaluate the acceptability of the SDQ in a Sesotho speaking area of South Africa. As part of a larger study to standardise the SDQ for use among Sotho speakers, teachers were asked to use the tool to assess learners in their class. Ten teachers were then asked to write a report on their experience of the SDQ and how useful and applicable they found it for their school setting. These findings were discussed at two later meetings with larger groupings of teachers. Reports were analysed using a modified contextualised interpretative content analysis method. RESULTS: Teachers found the SDQ very useful in the classroom and easy to administer and understand. They found it contextually relevant and particularly useful in gaining an understanding of the learners and the challenges that learners were facing. It further allowed them to differentiate between scholastic and emotional problems, assisting them in developing relationships with the pupils and facilitating accurate referrals. There were very few concerns raised, with the major problem being that it was difficult to assess items concerning contexts outside of the school setting. The teachers expressed interest in obtaining further training in the interpretation of the SDQ and a greater understanding of diagnostic labels so as to assist their learners. CONCLUSION: The SDQ was found to be acceptable and useful in the context of this very disadvantaged community. The teachers felt it assisted them in their role as teachers by providing a greater understanding of emotional and behaviour problems among learners. However, lack of places for referral and their own lack of appropriate skills and time did generate frustration.

Housing conditions and mental health of orphans in South Africa.

Literature from the developed world suggests that poor housing conditions and housing environments contribute to poor mental health outcomes, although research results are mixed. This study investigates the relationship between housing conditions and the socio-emotional health of orphans and vulnerable children (OVC) in South Africa. The results of the study are mainly inconclusive, although it is suggested that methodological considerations play a vital role in explaining the mixed results. However, a positive relationship was found between living in informal settlements and better socio-emotional health of the OVC. We speculate that the historical context of informal settlement formation in South Africa helps to explain this unexpected result.