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Zani B, Luckett B, Thurman TR. COVID-19 pandemic stressors, familial discord, and anxiety among adolescents living with HIV in South Africa: pathways to non-adherence. AIDS Care 2024; 36:137-144. [PMID: 38301123 DOI: 10.1080/09540121.2024.2308025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
Adolescents living with HIV (ALHIV) have poorer adherence to antiretroviral treatment (ART). This study investigates the interconnectivity of stressors induced by the COVID-19 pandemic, anxiety and family dynamics on adolescents' adherence to ART. A telephone survey was conducted among 196 South African ALHIV previously enrolled in support groups. Generalized structural equations modeling was used to understand how pandemic-related stressors affected ART adherence. Respondents reported experiencing life stressors since the implementation of COVID-19 restrictions, including doing worse at school (32%), loss of household income (44%) and less food available (38%). Forty-two percent reported greater verbal aggression from adults at home and 60% experienced anxiety. The structural equations model demonstrated a direct path from experiencing life stressors to increased verbal aggression from caregivers, which led to anxiety and ultimately, poorer ART adherence. Each stressor experienced increased the odds of experiencing verbal aggression by 51% (OR=1.51, 95%CI=1.14-2.00) which, in turn, increased the odds of having anxiety four-fold (OR=4.1, 95%C =2.16-7.76). Anxiety was associated with a 74% reduction in the odds of being fully ART adherent (OR=0.26, 95%CI=0.08-0.81). COVID-19-induced stressors exacerbated the mental and physical vulnerability of ALHIV. Findings elucidate how both discord at home and anxiety can result in poorer ART adherence.
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Affiliation(s)
- Babalwa Zani
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
| | - Brian Luckett
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
- School of Public Health and Tropical Medicine, Department of International Health and Sustainable Development, Tulane University, New Orleans, LA, USA
| | - Tonya R Thurman
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
- School of Public Health and Tropical Medicine, Department of International Health and Sustainable Development, Tulane University, New Orleans, LA, USA
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Cluver L, Jochim J, Mapukata Y, Wittesaele C, Shenderovich Y, Mafuya S, Steventon Roberts K, Banougnin B, Sherr L, Toska E. Associations of formal childcare use with health and human capital development for adolescent mothers and their children in South Africa: A cross-sectional study. Child Care Health Dev 2024; 50:e13138. [PMID: 37287209 PMCID: PMC10952304 DOI: 10.1111/cch.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/29/2023] [Accepted: 05/10/2023] [Indexed: 06/09/2023]
Abstract
AIM This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers. BACKGROUND Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children. METHODS We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering. RESULTS Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59-6.21, p < .001), grade promotion (AOR: 2.08, 95% CIs: 1.42-3.05, p < .001) and positive future ideation (AOR: 1.58, 95% CIs: 1.01-2.49, p = .047) but no differences in mental health. Childcare use was also associated with better parenting on all measures: positive parenting (AOR: 1.66, 95% CIs: 1.16-2.38, p = .006), better parental limit-setting (AOR: 2.00, 95% CIs: 1.37-2.93, p < .001) and better positive discipline (AOR: 1.77, 95% CIs: 1.21-2.59, p = .003). For the children, there were no differences in temperament or illness, but a significant interaction showed stronger associations between childcare use and better cognitive, language and motor scores with increasing child age (AOR: 5.04, 95% CIs: 1.59-15.96, p = .006). CONCLUSIONS Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.
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Affiliation(s)
- Lucie Cluver
- Department of Social Policy and InterventionUniversity of OxfordOxfordUK
- Department of PsychiatryUniversity of Cape TownCape TownSouth Africa
| | - Janina Jochim
- Department of Social Policy and InterventionUniversity of OxfordOxfordUK
| | | | - Camille Wittesaele
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Yulia Shenderovich
- Wolfson Centre for Young People's Mental HealthUniversity of CardiffCardiffUK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social SciencesCardiff UniversityCardiffUK
| | | | - Kathryn Steventon Roberts
- Department of Social Policy and InterventionUniversity of OxfordOxfordUK
- Institute for Global HealthUniversity College LondonLondonUK
| | - Bolade Banougnin
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
| | - Lorraine Sherr
- Institute for Global HealthUniversity College LondonLondonUK
| | - Elona Toska
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Department of SociologyUniversity of Cape TownCape TownSouth Africa
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Shank LM, Grace V, Delgado J, Batchelor P, de Raadt St James A, Sundaresan A, Bouchedid L. The impact of a guided paced breathing audiovisual intervention on anxiety symptoms in Palestinian children: a pilot randomized controlled trial. Child Adolesc Ment Health 2023; 28:473-480. [PMID: 36575823 DOI: 10.1111/camh.12613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Children in Palestine may be at high risk for anxiety symptoms. However, access to mental health services is limited. Therefore, the objective of this study was to conduct a pilot randomized controlled trial to examine whether a guided audiovisual paced breathing intervention was feasible, acceptable, and improved anxiety symptoms in Palestinian children. METHODS Students (6-10 years old) in an after-school program in Palestine were randomly assigned to the intervention or control condition. All participants completed a pre- and post-intervention measure of anxiety using the Revised Children's Manifest Anxiety Scale. Participants in the intervention completed 24 sessions over 8 weeks and rated breathing ease as well as pre- and post-session relaxation on a 5-point Likert scale. To examine condition differences in post-intervention anxiety, four analyses of covariance were conducted, adjusting for age, sex, and pre-intervention anxiety. RESULTS A total of 144 participants (65.3% girls; Mage = 7.5 ± 1.2; 50% per condition) enrolled in the study. There were no differences in demographics or baseline anxiety between the two conditions (ps > .05). Participants reported that it was easy to breathe during the sessions (Ms = 4.1-4.7, SDs = 0.5-1.1). For all but the first session, participants reported being more relaxed after the breathing session than before (ps < .003). Post-intervention, participants in the intervention reported fewer anxiety symptoms compared to participants in the control condition (ps < .01). CONCLUSION A guided paced breathing audiovisual intervention was feasible and had a significant positive impact on anxiety symptoms in Palestinian children compared to a control condition. Future research should examine whether the audiovisual guided breathing intervention significantly improves long-term outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Lara Bouchedid
- The Middle East Children's Institute, Deir Ghassaneh Women's Society Building, Bani Zeid al-Gharbia, Ramallah, Palestine
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Steventon Roberts KJ, Smith C, Toska E, Cluver L, Wittesaele C, Langwenya N, Shenderovich Y, Saal W, Jochim J, Chen‐Charles J, Marlow M, Sherr L. Exploring the cognitive development of children born to adolescent mothers in South Africa. INFANT AND CHILD DEVELOPMENT 2023; 32:e2408. [PMID: 38439906 PMCID: PMC10909423 DOI: 10.1002/icd.2408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 03/11/2023]
Abstract
This study explores the cognitive development of children born to adolescent mothers within South Africa compared to existing reference data, and explores development by child age bands to examine relative levels of development. Cross-sectional analyses present data from 954 adolescents (10-19 years) and their first-born children (0-68 months). All adolescents completed questionnaires relating to themselves and their children, and standardized child cognitive assessments (Mullen Scales of Early Learning) were undertaken. Cognitive development scores of the sample were lower than USA reference population scores and relative performance compared to the reference population was found to decline with increasing child age. When compared to children born to adult mothers in the sub-Saharan African region, children born to adolescent mothers (human immunodeficiency virus [HIV] unexposed; n = 724) were found to have lower cognitive development scores. Findings identify critical periods of development where intervention may be required to bolster outcomes for children born to adolescent mothers. Highlights An exploration of the cognitive development of children born to adolescent mothers within South Africa utilizing the Mullen Scales of Early Learning.Cognitive development scores of children born to adolescent mothers within South Africa were lower compared to USA norm reference data and declined with child age.Previous studies utilizing the Mullen Scales of Early Learning within sub-Saharan Africa were summarized, and comparisons were made with the current sample.Findings highlight a potential risk of developmental delay among children born to adolescent mothers compared to children of adult mothers in the sub-Saharan African region.
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Affiliation(s)
- Kathryn J. Steventon Roberts
- Department of Social Policy and InterventionUniversity of OxfordUK
- Institute for Global HealthUniversity College LondonUK
| | - Colette Smith
- Institute for Global HealthUniversity College LondonUK
| | - Elona Toska
- Department of Social Policy and InterventionUniversity of OxfordUK
- Centre for Social Science ResearchUniversity of Cape TownSouth Africa
- Department of SociologyUniversity of Cape TownSouth Africa
| | - Lucie Cluver
- Department of Social Policy and InterventionUniversity of OxfordUK
- Department of Psychiatry and Mental HealthUniversity of Cape TownSouth Africa
| | - Camille Wittesaele
- Department of Social Policy and InterventionUniversity of OxfordUK
- London School of Hygiene and Tropical MedicineUK
| | | | - Yulia Shenderovich
- Department of Social Policy and InterventionUniversity of OxfordUK
- Wolfson Centre for Young People's Mental HealthCardiff UniversityUK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social SciencesCardiff UniversityUK
| | - Wylene Saal
- School of HumanitiesSol Plaatje UniversitySouth Africa
| | - Janina Jochim
- Department of Social Policy and InterventionUniversity of OxfordUK
| | | | - Marguerite Marlow
- Institute of Life Course Health ResearchStellenbosch UniversitySouth Africa
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Steinert JI, Shenderovich Y, Smith M, Zhou S, Toska E, Cluver L. Economic Well-being and Associated Mediating Pathways to Improved Antiretroviral Therapy Adherence Among Adolescents Living With HIV: A Prospective Cohort Study in South Africa. J Acquir Immune Defic Syndr 2022; 91:343-352. [PMID: 35969470 PMCID: PMC9592174 DOI: 10.1097/qai.0000000000003071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adolescents living with HIV exhibit lower levels of adherence to antiretroviral therapy (ART) than other age groups. Poverty is a key barrier to ART adherence. This study aims at understanding how alleviating poverty through structural and internal pathways can help increase ART adherence among adolescents. SETTING Eastern Cape province, South Africa. METHODS One thousand forty-six adolescents living with HIV were recruited from 53 public health care facilities and interviewed at 3 data collection waves with a retention rate of 89% and a mortality rate of 3%. Data were collected by face-to-face, device-assisted interviews. Hybrid probit regressions and a structural equation path analysis were used to estimate the association between poverty reduction (increased access to basic necessities) and the pathways by which it could improve ART adherence. RESULTS Self-reported ART adherence ranged from an average of 66% (n = 615) at baseline to 75% (n = 700) in the last wave. Within-person and between-person improvements in economic well-being were associated with significant increases in adolescent ART adherence. On average, adolescents with access to 3 additional basic needs experienced a 4 percentage-point increase in the probability of ART adherence. Structural pathways to improved ART adherence included participants having enough money to travel to the clinic and sufficient food to eat when taking medication. Internal pathways included improved psychological well-being and reduced internalized HIV stigma. CONCLUSION Poverty reduction programs such as HIV-sensitive social protection can address structural and psychological pathways to increase ART adherence among economically disadvantaged adolescents by incentivizing demand-side interventions and the provision of quality essential services.
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Affiliation(s)
- Janina Isabel Steinert
- TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
| | - Yulia Shenderovich
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
- Wolfson Centre for Young People's Mental Health, Cardiff University, Cardiff, United Kingdom
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Cardiff, United Kingdom
| | - Michael Smith
- United Nations World Food Programme, Nutrition Division, Rome, Italy
| | - Siyanai Zhou
- Centre for Social Science Research
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine; and
| | - Elona Toska
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
- Centre for Social Science Research
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
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Steventon Roberts KJ, Smith C, Cluver L, Toska E, Jochim J, Wittesaele C, Marlow M, Sherr L. Adolescent mothers and their children affected by HIV-An exploration of maternal mental health, and child cognitive development. PLoS One 2022; 17:e0275805. [PMID: 36264898 PMCID: PMC9584392 DOI: 10.1371/journal.pone.0275805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 09/24/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Some children born to adolescent mothers may have developmental challenges, while others do not. Research focusing on which children of adolescent mothers are at the highest risk for cognitive delay is still required. Both maternal HIV status and maternal mental health may affect child development. An examination of maternal mental health, especially in the presence of maternal HIV infection may be timely. This study explores the relationship between the mental health of adolescent mothers (comparing those living with and not living with HIV) and the cognitive development performance scores of their children. Additional possible risk and protective factors for poor child development are explored to identify those children born to adolescent mothers who may be at the greatest risk of poor cognitive development. METHODS Cross-sectional data utilised within the analyses was drawn from a large cohort of adolescent mothers and their children residing in South Africa. Detailed study questionnaires were completed by adolescent mothers relating to their self and their child and, standardised cognitive assessments were completed by trained researchers for all children using in the Mullen Scales of Early Learning. Chi-square, t-tests (Kruskal Wallis tests, where appropriate), and ANOVA were used to explore sample characteristics and child cognitive development scores by maternal mental health status (operationalised as likely common mental disorder) and combined maternal mental health and HIV status. Multivariable linear regression models were used to explore the relationship between possible risk factors (including poor maternal mental health and HIV) and, child cognitive development scores. RESULTS The study included 954 adolescent mothers; 24.1% (230/954) were living with HIV, 12.6% (120/954) were classified as experiencing likely common mental disorder. After adjusting for covariates, maternal HIV was found to be associated with reduced child gross motor scores (B = -2.90 [95%CI: -5.35, -0.44], p = 0.02), however, no other associations were identified between maternal likely common mental disorder, or maternal HIV status (including interaction terms), and child cognitive development scores. Sensitivity analyses exploring individual maternal mental health scales identified higher posttraumatic stress symptomology scores as being associated with lower child cognitive development scores. Sensitivity analyses exploring potential risk and protective factors for child cognitive development also identified increased maternal educational attainment as being protective of child development scores, and increased child age as a risk factor for lower development scores. CONCLUSIONS This study addresses a critical evidence gap relating to the understanding of possible risk factors for the cognitive development of children born to adolescent mothers affected by HIV. This group of mothers experience a complex combination of risk factors, including HIV, likely common mental disorder, and structural challenges such as educational interruption. Targeting interventions to support the cognitive development of children of adolescent mothers most at risk may be of benefit. Clearly a basket of interventions needs to be considered, such as the integration of mental health provision within existing services, identifying multiple syndemics of risk, and addressing educational and structural challenges, all of which may boost positive outcomes for both the mother and the child.
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Affiliation(s)
- Kathryn J. Steventon Roberts
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
| | - Colette Smith
- Institute for Global Health, University College London, London, United Kingdom
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Janina Jochim
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | | | | | - Lorraine Sherr
- Institute for Global Health, University College London, London, United Kingdom
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Psychometric properties of the ASEBA Child Behaviour Checklist and Youth Self-Report in sub-Saharan Africa - A systematic review. Acta Neuropsychiatr 2022; 34:167-190. [PMID: 35466902 DOI: 10.1017/neu.2022.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Behavioural screening tools may be used to identify at-risk children in resource-limited settings in sub-Saharan Africa. The ASEBA forms (Child Behaviour Checklist and Youth Self-Report) are frequently translated and adapted for use in sub-Saharan African populations, but little is known about their measurement properties in these contexts. METHODS We conducted a systematic review of all published journal articles that used the ASEBA forms with sub-Saharan African samples. We evaluated the reported psychometric properties, as well as the methodological quality of the psychometric evaluations, using COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidelines. RESULTS Fifty-eight studies reported measurement properties of the ASEBA forms. Most studies came from Southern (n = 29, 50%) or East African (n = 25, 43%) countries. Forty-nine studies (84%) used translated versions of the tool, but details regarding the translation process, if available, were often sparse. Most studies (n = 47, 81%) only reported internal consistency (using coefficient alpha) for one or more subscale. The methodological quality of the psychometric evaluations ranged from 'very good' to 'inadequate' across all measurement properties, except for internal consistency. CONCLUSIONS There is limited good quality psychometric evidence available for the ASEBA forms in sub-Saharan Africa. We recommend (i) implementing a standardised procedure for conducting and reporting translation processes and (ii) conducting more comprehensive psychometric evaluations of the translated versions of the tools.
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Edun O, Shenderovich Y, Zhou S, Toska E, Okell L, Eaton JW, Cluver L. Predictors and consequences of HIV status disclosure to adolescents living with HIV in Eastern Cape, South Africa: a prospective cohort study. J Int AIDS Soc 2022; 25:e25910. [PMID: 35543100 PMCID: PMC9092159 DOI: 10.1002/jia2.25910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The World Health Organization recommends full disclosure of HIV-positive status to adolescents who acquired HIV perinatally (APHIV) by age 12. However, even among adolescents (aged 10-19) already on antiretroviral therapy (ART), disclosure rates are low. Caregivers often report the child being too young and fear of disclosure worsening adolescents' mental health as reasons for non-disclosure. We aimed to identify the predictors of disclosure and the association of disclosure with adherence, viral suppression and mental health outcomes among adolescents in sub-Saharan Africa. METHODS Analyses included three rounds (2014-2018) of data collected among a closed cohort of adolescents living with HIV in Eastern Cape, South Africa. We used logistic regression with respondent random-effects to identify factors associated with disclosure, and assess differences in ART adherence, viral suppression and mental health symptoms between adolescents by disclosure status. We also explored differences in the change in mental health symptoms and adherence between study rounds and disclosure groups with logistic regression. RESULTS Eight hundred and thirteen APHIV were interviewed at baseline, of whom 769 (94.6%) and 729 (89.7%) were interviewed at the second and third rounds, respectively. The proportion aware of their HIV-positive status increased from 63.1% at the first round to 85.5% by the third round. Older age (adjusted odds ratio [aOR]: 1.27; 1.08-1.48) and living in an urban location (aOR: 2.85; 1.72-4.73) were associated with disclosure between interviews. There was no association between awareness of HIV-positive status and ART adherence, viral suppression or mental health symptoms among all APHIV interviewed. However, among APHIV not aware of their status at baseline, adherence decreased at the second round among those who were disclosed to (N = 131) and increased among those not disclosed to (N = 151) (interaction aOR: 0.39; 0.19-0.80). There was no significant difference in the change in mental health symptoms between study rounds and disclosure groups. CONCLUSIONS Awareness of HIV-positive status was not associated with higher rates of mental health symptoms, or lower rates of viral suppression among adolescents. Disclosure was not associated with worse mental health. These findings support the recommendation for timely disclosure to APHIV; however, adherence support post-disclosure is important.
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Affiliation(s)
- Olanrewaju Edun
- MRC Centre for Global Infectious Disease AnalysisSchool of Public HealthImperial College LondonLondonUK
| | - Yulia Shenderovich
- Wolfson Centre for Young People's Mental HealthCardiff UniversityCardiffUK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer)School of Social SciencesCardiff UniversityCardiffUK
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUK
| | - Siyanai Zhou
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
| | - Elona Toska
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUK
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- AIDS and Society Research UnitUniversity of Cape TownCape TownSouth Africa
| | - Lucy Okell
- MRC Centre for Global Infectious Disease AnalysisSchool of Public HealthImperial College LondonLondonUK
| | - Jeffrey W. Eaton
- MRC Centre for Global Infectious Disease AnalysisSchool of Public HealthImperial College LondonLondonUK
| | - Lucie Cluver
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUK
- Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
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Roberts KJ, Smith C, Cluver L, Toska E, Zhou S, Boyes M, Sherr L. Adolescent Motherhood and HIV in South Africa: Examining Prevalence of Common Mental Disorder. AIDS Behav 2022; 26:1197-1210. [PMID: 34570313 PMCID: PMC8940800 DOI: 10.1007/s10461-021-03474-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 01/25/2023]
Abstract
The mental health of adolescents (10–19 years) remains an overlooked global health issue, particularly within the context of syndemic conditions such as HIV and pregnancy. Rates of pregnancy and HIV among adolescents within South Africa are some of the highest in the world. Experiencing pregnancy and living with HIV during adolescence have both been found to be associated with poor mental health within separate explorations. Yet, examinations of mental health among adolescents living with HIV who have experienced pregnancy/parenthood remain absent from the literature. As such, there exists no evidence-based policy or programming relating to mental health for this group. These analyses aim to identify the prevalence of probable common mental disorder among adolescent mothers and, among adolescents experiencing the syndemic of motherhood and HIV. Analyses utilise data from interviews undertaken with 723 female adolescents drawn from a prospective longitudinal cohort study of adolescents living with HIV (n = 1059) and a comparison group of adolescents without HIV (n = 467) undertaken within the Eastern Cape Province, South Africa. Detailed study questionnaires included validated and study specific measures relating to HIV, adolescent motherhood, and mental health. Four self-reported measures of mental health (depressive, anxiety, posttraumatic stress, and suicidality symptomology) were used to explore the concept of likely common mental disorder and mental health comorbidities (experiencing two or more common mental disorders concurrently). Chi-square tests (Fisher’s exact test, where appropriate) and Kruskal Wallis tests were used to assess differences in sample characteristics (inclusive of mental health status) according to HIV status and motherhood status. Logistic regression models were used to explore the cross-sectional associations between combined motherhood and HIV status and, likely common mental disorder/mental health comorbidities. 70.5% of participants were living with HIV and 15.2% were mothers. 8.4% were mothers living with HIV. A tenth (10.9%) of the sample were classified as reporting a probable common mental disorder and 2.8% as experiencing likely mental health comorbidities. Three core findings emerge: (1) poor mental health was elevated among adolescent mothers compared to never pregnant adolescents (measures of likely common mental disorder, mental health comorbidities, depressive, anxiety and suicidality symptoms), (2) prevalence of probable common mental disorder was highest among mothers living with HIV (23.0%) compared to other groups (Range:8.5–12.8%; Χ2 = 12.54, p = 0.006) and, (3) prevalence of probable mental health comorbidities was higher among mothers, regardless of HIV status (HIV & motherhood = 8.2%, No HIV & motherhood = 8.2%, Χ2 = 14.5, p = 0.002). Results identify higher mental health burden among adolescent mothers compared to never-pregnant adolescents, an increased prevalence of mental health burden among adolescent mothers living with HIV compared to other groups, and an elevated prevalence of mental health comorbidities among adolescent mothers irrespective of HIV status. These findings address a critical evidence gap, highlighting the commonality of mental health burden within the context of adolescent motherhood and HIV within South Africa as well as the urgent need for support and further research to ensure effective evidence-based programming is made available for this group. Existing antenatal, postnatal, and HIV care may provide an opportunity for mental health screening, monitoring, and referral.
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Affiliation(s)
| | - Colette Smith
- Institute for Global Health, University College London, London, UK
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Siyanai Zhou
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Mark Boyes
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Bentley, Perth, Australia
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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Post-Intensive Care Syndrome in Children: A Concept Analysis. J Pediatr Nurs 2021; 61:417-423. [PMID: 34687989 DOI: 10.1016/j.pedn.2021.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 11/21/2022]
Abstract
PROBLEM Post-intensive care syndrome in paediatrics (PICS-p) is a term used to describe newly acquired or worsened impairment in one or more aspects of a child's physical, psychological, cognitive, and social functioning after discharge from the paediatric intensive care unit (PICU). However, consensus, conceptual insights, and assessment guidance are lacking for this syndrome. Therefore, this analysis aimed to define the concept of PICS-p to help practitioners and researchers understand the syndrome in detail using the Walker and Avant approach. ELIGIBILITY CRITERIA We reviewed studies retrieved from several databases, namely PubMed, Google Scholar, Web of Science, Ovid, ScienceDirect, and the Springer database, using the following keywords: 'post-intensive care syndrome', 'PICU', 'children', 'PICS-p', and 'concept analysis'. Both quantitative and qualitative studies on PICS-p were included in the search. The articles were limited to those published up to November 21, 2020. SAMPLE Of the 762 publications selected, 24 publications met the inclusion criteria. RESULTS PICS-p is defined on the basis of the following aspects: (1) Physical dysfunction; (2) Cognitive dysfunction; (3) Psychological dysfunction; and (4) Social dysfunction. CONCLUSION With the increasing success rate of PICU treatment, reduced case fatality is no longer the only outcome of critical illness in children. The long-term outcomes in children discharged from hospitals have attracted attention from families, hospitals, and communities. IMPLICATIONS A clear definition of PICS-p will help medical staff understand PICS-p in detail and provide a theoretical basis for the diagnosis and treatment of this syndrome.
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Boyes ME, Pantelic M, Casale M, Toska E, Newnham E, Cluver LD. Prospective associations between bullying victimisation, internalised stigma, and mental health in South African adolescents living with HIV. J Affect Disord 2020; 276:418-423. [PMID: 32871672 DOI: 10.1016/j.jad.2020.07.101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/26/2020] [Accepted: 07/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adolescents living with HIV may be at elevated risk of psychological problems, which are correlated with negative health outcomes. In cross-sectional research with HIV-affected adolescents, bullying victimisation and internalised HIV stigma have been associated with poorer psychological health. We extended these findings and tested longitudinal associations between bullying victimisation, internalised stigma, and mental health among adolescents living with HIV. We also tested whether relationships between bullying victimisation and psychological symptoms were mediated by internalised stigma. METHOD Adolescents living with HIV (n = 1060, 10-19 years, 55% female), who had ever initiated HIV treatment in 53 public health facilities in the Eastern Cape, South Africa, were interviewed and followed up 18 months later (n = 995, 94% retention). Participants completed well-validated measures of depression, anxiety, posttraumatic stress, bullying victimisation, and internalised stigma. RESULTS After adjusting for baseline mental health and sociodemographic characteristics, baseline internalised stigma prospectively predicted poorer outcomes on all psychological measures. Bullying victimisation at baseline was not directly associated with any psychological measures at follow up; however, it was indirectly associated with all psychological measures via internalised stigma. LIMITATIONS Reliance on self-report measures and poor reliability of the depression scale. CONCLUSIONS Bullying victimisation is associated with internalised stigma, which in turn predicts psychological symptoms over time. Interventions reducing internalised stigma and associated psychological distress are needed, and these should be integrated into HIV care to ensure optimal HIV management. The implementation of bullying prevention programs may reduce internalised stigma and promote mental health among adolescents living with HIV.
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Affiliation(s)
- Mark E Boyes
- School of Psychology, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia.
| | - Marija Pantelic
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom; Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Marisa Casale
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom; School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom; Centre for Social Science Research, University of Cape Town, Cape Town, South Africa; Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Elizabeth Newnham
- School of Psychology, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia 6845, Australia; FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, United States
| | - Lucie D Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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12
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The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review. Glob Ment Health (Camb) 2020; 7:e29. [PMID: 33489245 PMCID: PMC7786273 DOI: 10.1017/gmh.2020.18] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 01/10/2023] Open
Abstract
Despite the progress made in HIV treatment and prevention, HIV remains a major cause of adolescent morbidity and mortality in sub-Saharan Africa. As perinatally infected children increasingly survive into adulthood, the quality of life and mental health of this population has increased in importance. This review provides a synthesis of the prevalence of mental health problems in this population and explores associated factors. A systematic database search (Medline, PsycINFO, Scopus) with an additional hand search was conducted. Peer-reviewed studies on adolescents (aged 10-19), published between 2008 and 2019, assessing mental health symptoms or psychiatric disorders, either by standardized questionnaires or by diagnostic interviews, were included. The search identified 1461 articles, of which 301 were eligible for full-text analysis. Fourteen of these, concerning HIV-positive adolescents, met the inclusion criteria and were critically appraised. Mental health problems were highly prevalent among this group, with around 25% scoring positive for any psychiatric disorder and 30-50% showing emotional or behavioral difficulties or significant psychological distress. Associated factors found by regression analysis were older age, not being in school, impaired family functioning, HIV-related stigma and bullying, and poverty. Social support and parental competence were protective factors. Mental health problems among HIV-positive adolescents are highly prevalent and should be addressed as part of regular HIV care.
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Meinck F, Orkin FM, Cluver L. Does free schooling affect pathways from adverse childhood experiences via mental health distress to HIV risk among adolescent girls in South Africa: a longitudinal moderated pathway model. J Int AIDS Soc 2019; 22:e25262. [PMID: 30869202 PMCID: PMC6416665 DOI: 10.1002/jia2.25262] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 02/20/2019] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Adolescent girls are at high risk of HIV infection in sub-Saharan Africa. Mental health distress, driven by adverse childhood experiences (ACEs) such as abuse, poverty and family HIV, may be an important driver of HIV risk behaviour among adolescent girls, while education may mitigate these risks. This study aimed to develop an empirically based theoretical model between ACEs, mental health distress and HIV risk behaviour among adolescent girls in South Africa and to investigate the potential moderating effects of free schooling provision. METHODS Self-report questionnaires using validated scales were completed by adolescent girls aged 12 to 17 at baseline in two provinces in South Africa in 2011, with a 99% one-year follow-up in 2012 (n = 1498). Sampling included every household in randomly selected census enumeration areas of four deprived health districts. Confirmatory factor analysis was employed to identify measurement models and a structural equation model was developed to test pathways of risk and protection. RESULTS Internalizing and externalizing mental health distress fully mediated the positive relationship between ACEs at baseline and HIV risk behaviour at follow-up among adolescent girls. Internalizing mental health distress was associated with increased sexual risk at follow-up via higher externalizing problems. Free schooling provision at baseline and follow-up eliminated the pathway from internalizing to externalizing mental health distress by moderating the pathway between ACEs and internalizing mental health distress. It also weakened the pathway from externalizing mental health distress to HIV risk behaviour at follow-up through a direct negative effect on externalizing mental health distress. CONCLUSIONS Reducing ACEs and adolescent mental health distress is essential for reducing HIV risk behaviour among girls in South Africa. Free schooling provision may be an important tool for reducing these problems and mitigating negative pathways to HIV risk among vulnerable adolescent girls.
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Affiliation(s)
- Franziska Meinck
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- OPTENTIAFaculty of Health SciencesNorth‐West UniversityVanderbijlparkSouth Africa
| | - FM Orkin
- MRC Developmental Pathways for Health Research UnitSchool of Clinical MedicineUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lucie Cluver
- Centre for Evidence‐Based InterventionDepartment of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
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14
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Stoner MCD, Rucinski KB, Edwards JK, Selin A, Hughes JP, Wang J, Agyei Y, Gomez-Olive FX, MacPhail C, Kahn K, Pettifor A. The Relationship Between School Dropout and Pregnancy Among Adolescent Girls and Young Women in South Africa: A HPTN 068 Analysis. HEALTH EDUCATION & BEHAVIOR 2019; 46:559-568. [PMID: 30819011 DOI: 10.1177/1090198119831755] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Prevention of both school dropout and teen pregnancy represent clear public health priorities for South Africa, yet their complex and potentially cyclical relationship has not been fully explored. Objective. To further understand how this relationship operates, we analyzed data from a randomized trial of young women aged 13 to 20 years enrolled in school in rural South Africa to estimate the association between pregnancy and subsequent dropout and between dropout and subsequent pregnancy. Method. We examined inverse probability (IP) of exposure-weighted survival curves for school dropout by pregnancy and for pregnancy by school dropout. We used weighted curves to calculate 1-, 2-, and 3-year risk differences and risk ratios. Additionally, we used an IP-weighted marginal structural cox model to estimate a hazard ratio (HR) for each relationship. Results. Dropout from school was associated with subsequent pregnancy (HR 3.58; 95% confidence interval [CI] [2.04, 6.28]) and pregnancy was associated with subsequent school dropout (HR 2.36; 95% CI [1.29, 4.31]). Young women who attended school but attended fewer days had a higher hazard of pregnancy than those who attended more school (HR 3.64; 95% CI [2.27, 5.84]). Conclusion. Pregnancy is both a cause and a consequence of school dropout. Consideration of school attendance and academic performance could ultimately enhance pregnancy prevention efforts in this population. Programs should be tailored differently for (1) girls who have dropped out of school, (2) those who are in school and at risk for pregnancy, and (3) those who are in school and become pregnant.
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Affiliation(s)
- Marie C D Stoner
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jessie K Edwards
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda Selin
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James P Hughes
- 3 University of Washington, Seattle, WA, USA.,4 Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jing Wang
- 4 Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yaw Agyei
- 2 Johns Hopkins University, Baltimore, MD, USA
| | - F Xavier Gomez-Olive
- 5 University of the Witwatersrand, Johannesburg, South Africa.,6 INDEPTH Network, Accra, Ghana
| | - Catherine MacPhail
- 5 University of the Witwatersrand, Johannesburg, South Africa.,7 University of Wollongong, Wollongong, New South Wales, Australia
| | - Kathleen Kahn
- 5 University of the Witwatersrand, Johannesburg, South Africa.,6 INDEPTH Network, Accra, Ghana.,8 Umeå University, Umeå, Sweden
| | - Audrey Pettifor
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,5 University of the Witwatersrand, Johannesburg, South Africa
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15
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Age-disparate partnerships and incident HIV infection in adolescent girls and young women in rural South Africa. AIDS 2019; 33:83-91. [PMID: 30289813 DOI: 10.1097/qad.0000000000002037] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Adolescent girls and young women (AGYW) have a much higher risk of HIV infection than young men of the same age. One hypothesis for this disparity is AGYW are more likely to be in sexual partnerships with older men with HIV; however, evidence has been inconclusive. DESIGN We used longitudinal data from a randomized trial in South Africa (HPTN 068) to determined whether partner age difference is associated with incident HIV infection in AGYW. METHODS Age difference was examined continuously and dichotomously (≥5 years). We examined inverse probability of exposure weighted survival curves and calculated time-specific risk differences and risk ratios over 5.5 years of follow-up. We also used a marginal structural Cox model to estimate hazard ratios over the entire study period. RESULTS Risk of HIV was higher in AGYW with an age-disparate partnership versus not and the risk difference was largest at later time points. At 5.5 years, AGYW with an age-disparate partnership had a 12.6% (95% confidence interval 1.9-23.3) higher risk than AGYW with no age-disparate partnerships. The weighted hazard ratio was 1.91 (95% confidence interval 1.33-2.74), an association that remained after weighting for either transactional or condomless sex, and after examining continuous age-differences. CONCLUSION Age-disparate partnerships increased risk of HIV infection, even after accounting for transactional sex and condomless sex. The relationship between age-disparate partnerships and HIV infection may be explained by increased exposure to infection from men in a higher HIV prevalence pool rather than differences in sexual behaviour within these partnerships.
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16
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West N, Schwartz S, Mudavanhu M, Hanrahan C, France H, Nel J, Mutunga L, Bernhardt S, Bassett J, Van Rie A. Mental health in South African adolescents living with HIV. AIDS Care 2018; 31:117-124. [PMID: 30304947 DOI: 10.1080/09540121.2018.1533222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We examined the prevalence of mental health conditions, social support, and associated factors among adolescents living with HIV. We conducted a cross-sectional analysis with adolescents (ages 9-19) attending a primary care clinic in Johannesburg, South Africa. We analyzed the results of four self-report tools: Children's Depression Inventory-Short, Revised Manifest Anxiety Scale, Child Post-Traumatic Stress Disorder (PTSD) Checklist, and a modified version of the Medical Outcomes Study Social Support Scale. We used robust Poisson regression to quantify the association between social support and mental health. Among 278 adolescents, the majority were perinatally infected with HIV (92%), and had at least one deceased parent (59%). Depression symptom threshold scores were found among 8% of adolescents, and 7% screened positive for symptoms of anxiety. Few (1%) met the criteria for PTSD. Overall, 12% of adolescents screened positive for symptoms of depression, anxiety or PTSD. Older adolescents reported less social support than younger adolescents. Adolescents were less likely to have mental health symptoms if they had higher measures of social support (adjusted Prevalence Ratio 0.38, 95% CI 0.20-0.73). Attention should be paid to social support for adolescents living with HIV as this may play an important role in their mental health.
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Affiliation(s)
- Nora West
- a Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , MD , USA
| | - Sheree Schwartz
- a Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , MD , USA
| | - Mutsa Mudavanhu
- b Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Colleen Hanrahan
- a Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , MD , USA
| | - Holly France
- b Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Jeremy Nel
- c Department of Infectious Diseases , Helen Joseph Hospital , Johannesburg , South Africa
| | - Lillian Mutunga
- b Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | | | - Jean Bassett
- b Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Annelies Van Rie
- d University of Antwerp , Antwerp , Belgium.,e Department of Epidemiology , University of North Carolina at Chapel Hill, Gillings School of Global Public Health , Chapel Hill , USA
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17
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Boyes ME, Cluver LD, Meinck F, Casale M, Newnham E. Mental health in South African adolescents living with HIV: correlates of internalising and externalising symptoms. AIDS Care 2018; 31:95-104. [PMID: 30241443 DOI: 10.1080/09540121.2018.1524121] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Although declining in all other age groups, AIDS-related deaths among adolescents are increasing. In the context of HIV, mental health problems are associated with negative health outcomes, including non-adherence to life-saving ART. For effective programming it is essential to identify factors associated with psychological outcomes in this population. Adopting a socioecological perspective, we aimed to identify correlates of internalising and externalising symptoms in a large, representative sample of South African adolescents living with HIV. HIV-positive adolescents (n = 1060), who received care in public health facilities in South Africa's Eastern Cape, completed measures of internalising and externalising symptoms. Hypothesised correlates included HIV and health-related factors (physical health, mode of infection, medication side-effects, disclosure, stigma), health-service related factors (negative interactions with clinic staff, clinic support group), interpersonal factors (abuse, bullying victimisation, social support), parenting-related factors (orphanhood, positive parenting, parental monitoring, parent communication), as well as individual and demographic-related factors (self-efficacy, age, gender, urban/rural location, poverty). Correlates operating across a variety of contexts were identified. Bullying victimisation, self-efficacy, and positive parenting may be particularly salient intervention targets as they were associated with better outcomes on most or all mental health measures, can be addressed without directly targeting adolescents living with HIV (reducing the chances of accidental exposure and stigma), and are associated with better adolescent mental health in South Africa more generally.
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Affiliation(s)
- Mark E Boyes
- a School of Psychology, Faculty of Health Sciences , Curtin University , Perth , Australia.,b Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK
| | - Lucie D Cluver
- b Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,c Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - Franziska Meinck
- b Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,d Faculty of Health Sciences , North-West University , Vanderbijlpark , South Africa
| | - Marisa Casale
- b Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , UK.,e School of Public Health , University of the Western Cape , Cape Town , South Africa
| | - Elizabeth Newnham
- a School of Psychology, Faculty of Health Sciences , Curtin University , Perth , Australia.,f FXB Center for Health and Human Rights , Harvard T.H. Chan School of Public Health , Boston , United States
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18
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Stoner MCD, Edwards JK, Miller WC, Aiello AE, Halpern CT, Julien A, Rucinski KB, Selin A, Twine R, Hughes JP, Wang J, Agyei Y, Gómez-Olivé FX, Wagner RG, Laeyendecker O, Macphail C, Kahn K, Pettifor A. Does Partner Selection Mediate the Relationship Between School Attendance and HIV/Herpes Simplex Virus-2 Among Adolescent Girls and Young Women in South Africa: An Analysis of HIV Prevention Trials Network 068 Data. J Acquir Immune Defic Syndr 2018; 79:20-27. [PMID: 29847479 PMCID: PMC6092209 DOI: 10.1097/qai.0000000000001766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE School attendance prevents HIV and herpes simplex virus-2 (HSV-2) in adolescent girls and young women, but the mechanisms to explain this relationship remain unclear. Our study assesses the extent to which characteristics of sex partners, partner age, and number mediate the relationship between attendance and risk of infection in adolescent girls and young women in South Africa. DESIGN We use longitudinal data from the HIV Prevention Trials Network 068 randomized controlled trial in rural South Africa, where girls were enrolled in early adolescence and followed in the main trial for more than 3 years. We examined older partners and the number of partners as possible mediators. METHODS We used the parametric g-formula to estimate 4-year risk differences for the effect of school attendance on the cumulative incidence of HIV/HSV-2 overall and the controlled direct effect (CDE) for mediation. We examined mediation separately and jointly for the mediators of interest. RESULTS We found that young women with high attendance in school had a lower cumulative incidence of HIV compared with those with low attendance (risk difference = -1.6%). Partner age difference (CDE = -1.2%) and the number of partners (CDE = -0.4%) mediated a large portion of this effect. In fact, when we accounted for the mediators jointly, the effect of schooling on HIV was almost removed, showing full mediation (CDE = -0.3%). The same patterns were observed for the relationship between school attendance and cumulative incidence of HSV-2 infection. CONCLUSION Increasing school attendance reduces the risk of acquiring HIV and HSV-2. Our results indicate the importance of school attendance in reducing partner number and partner age difference in this relationship.
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Affiliation(s)
- Marie C D Stoner
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - William C Miller
- Division of Epidemiology, The Ohio State University, Columbus, OH
| | - Allison E Aiello
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Carolyn T Halpern
- Department of Maternal and Child Health, University of North Carolina, Chapel Hill, NC
| | - Aimée Julien
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Amanda Selin
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jing Wang
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yaw Agyei
- School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, MD
| | - Catherine Macphail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
- Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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19
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Meinck F, Boyes ME, Cluver L, Ward CL, Schmidt P, DeStone S, Dunne MP. Adaptation and psychometric properties of the ISPCAN Child Abuse Screening Tool for use in trials (ICAST-Trial) among South African adolescents and their primary caregivers. CHILD ABUSE & NEGLECT 2018; 82:45-58. [PMID: 29860107 DOI: 10.1016/j.chiabu.2018.05.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 04/24/2018] [Accepted: 05/26/2018] [Indexed: 05/14/2023]
Abstract
Child abuse prevention research has been hampered by a lack of validated multi-dimensional non-proprietary instruments, sensitive enough to measure change in abuse victimization or behavior. This study aimed to adapt the ICAST child abuse self-report measure (parent and child) for use in intervention studies and to investigate the psychometric properties of this substantially modified tool in a South African sample. First, cross-cultural and sensitivity adaptation of the original ICAST tools resulted in two preliminary measures (ICAST-Trial adolescents: 27 items, ICAST-Trial caregivers: 19 items). Second, ICAST-Trial data from a cluster randomized trial of a parenting intervention for families with adolescents (N = 1104, 552 caregiver-adolescent dyads) was analyzed. Confirmatory factor analysis established the hypothesized 6-factor (adolescents) and 4-factor (caregivers) structure. Removal of two items for adolescents and five for caregivers resulted in adequate model fit. Concurrent criterion validity analysis confirmed hypothesized relationships between child abuse and adolescent and caregiver mental health, adolescent behavior, discipline techniques and caregiver childhood abuse history. The resulting ICAST-Trial measures have 25 (adolescent) and 14 (caregiver) items respectively and measure physical, emotional and contact sexual abuse, neglect (both versions), and witnessing intimate partner violence and sexual harassment (adolescent version). The study established that both tools are sensitive to measuring change over time in response to a parenting intervention. The ICAST-Trial should have utility for evaluating the effectiveness of child abuse prevention efforts in similar socioeconomic contexts. Further research is needed to replicate these findings and examine cultural appropriateness, barriers for disclosure, and willingness to engage in child abuse research.
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Affiliation(s)
- Franziska Meinck
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford Barnett House, 32 Wellington Square, Oxford, OX1 2ER, United Kingdom; OPTENTIA, Faculty of Health Sciences, North-West University, 1174 Hendrick Van Eck Boulevard, 1900 Vanderbijlpark, South Africa.
| | - Mark E Boyes
- Faculty of Health Sciences, School of Psychology, Curtin University, Perth, Australia.
| | - Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford Barnett House, 32 Wellington Square, Oxford, OX1 2ER, United Kingdom; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - Catherine L Ward
- Department of Psychology and Safety and Violence Initiative, University of Cape Town, Cape Town, South Africa.
| | - Peter Schmidt
- Institut für Politikwissenschaft, Justus-Liebig-Universität Gießen, Gießen, Germany.
| | - Sachin DeStone
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.
| | - Michael P Dunne
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
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20
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Sherr L, Cluver LD, Toska E, He E. Differing psychological vulnerabilities among behaviourally and perinatally HIV infected adolescents in South Africa - implications for targeted health service provision. AIDS Care 2018; 30:92-101. [PMID: 29848010 DOI: 10.1080/09540121.2018.1476664] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
HIV infections are growing the fastest amongst adolescents, especially in sub Saharan Africa. On reaching adolescence, perinatally-infected youth may have different needs to those who acquired infection behaviourally. Yet both have sub-optimal adherence with implications for their own health as well as onward transmission. This study uses the world's largest community-based study of HIV-positive adolescents from the Eastern Cape, South Africa. Clinic records at N = 53 district health facilities generated a log of all ART-initiated adolescents who were then interviewed in the community: N = 1058 (90%) were tracked and participated. Ethical approval, informed consent and data collector training preceded data gathering. Inventories comprised validated measures of mental health (depression, anxiety, suicidality and internalised stigma), substance use, ART adherence, and clinic attendance. Analyses were conducted using SPSS25 and STATA15. Perinatally-infected adolescents (n = 792, 77.3%) were significantly more likely to be ART adherent (OR = 1.54 95%CI: 1.14-2.07 p = 0.005), retained in healthcare (OR = 1.59 95%CI1.18-2.14 p = 0.002), and treated well by clinic staff (OR = 2.12 95%CI1.59-3.07 p ≤ 0.001). Behaviourally-infected adolescents were more likely to be depressed (B = 0.81 p ≤ 0.001), anxious (B = 1.36 p ≤ 0.001), report internalised stigma (B = 0.91 p ≤ 0.001), express suicidal ideation (OR = 3.65 95%CI: 1.96-6.82 p ≤ 0.001) and report excessive substance use in the past year (OR = 9.37 95%CI5.73-15.35 p ≤ 0.001). Being older explained most of these differences, with female adolescents living with HIV more likely to report suicidal ideation. However, behaviourally-infected adolescents were more likely to report substance use (OR = 2.69 95%CI: 1.48-4.91 p = 0.001), depression (B = 0.406, p = 0.022), anxiety (B = 1.359, p ≤ 0.001), and internalised stigma (B = 0.403, p = 0.007) in multivariate regression analyses, controlling for covariates. Moderation analyses (adjusting for multiple testing) suggest that behaviourally-infected HIV-positive adolescents who are also maternal orphans are more likely to report higher rates of depression (B = 1.075, p < 0.001). These notable differences by mode of infection suggest that studies which conflate HIV-positive adolescents may blur the clinical and psychological experiences of these two different sub-populations. Drivers of non-adherence, poor retention in care, and mental health problems may differ by mode of infection, requiring tailored interventions. Health and social service provision, if it is to be effective, needs to address these different youth profiles to ensure optimal adherence, development and wellbeing throughout the life course.
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Affiliation(s)
- L Sherr
- a UCL , London , United Kingdom
| | - L D Cluver
- b Dept of Social Policy and Intervention , University of Oxford , Oxford , United Kingdom.,c Dept of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - E Toska
- b Dept of Social Policy and Intervention , University of Oxford , Oxford , United Kingdom.,d AIDS and Society Research Unit , University of Cape Town , Cape Town , South Africa
| | - E He
- e Washington University in St. Louis , St Louis , MO , USA
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Visser MJ, Hecker HE, Jordaan J. A comparative study of the psychological problems of HIV-infected and HIV-uninfected children in a South African sample. AIDS Care 2018; 30:596-603. [PMID: 29353488 DOI: 10.1080/09540121.2017.1417530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
According to research children living with HIV experience elevated levels of depression, anxiety, ADHD and disruptive behavioural disorders. Although South Africa's paediatric population that is infected with the human immunodeficiency virus (HIV) is the largest worldwide, little research has been conducted on their mental health challenges. However, attributing high levels of mental health problems solely to their HIV status can be problematic as there may be other contributory factors. This research explored the mental health problems of HIV-infected children and compared these to the mental health problems of their HIV-unaffected peers from similar backgrounds. Data was gathered from two samples of child and caregiver pairs. HIV-infected children (aged 6-12 years) and their caregivers/mothers (n = 54) were recruited from the Kalafong paediatric clinic where they received medical treatment and routine ART. A comparison group of 113 HIV-uninfected children and their uninfected mothers were recruited from primary care clinics in the same community. Caregivers completed the Child Behaviour Checklist (CBCL) to assess children's mental health. Children completed the Self-Description Questionnaire (SDQ-I) and the Revised Children's Manifest Anxiety Scale (RCMAS). The scores of the psychometric sub-scales of the two groups were compared using parametric and non-parametric statistics. HIV-infected children experienced more somatic and affective problems, physiological anxiety, less ADHD and lower self-esteem than HIV-uninfected children in the comparison group, while controlling for age differences. The high levels of mental health problems of both groups of children may be attributed to similar difficult socio-economic circumstances. The fact that most infected children were not aware of their HIV-status could have influenced the results. Mental health services should not be limited to HIV-infected children but should form part of all health care services.
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Affiliation(s)
- M J Visser
- a Department of Psychology , University of Pretoria , Pretoria , South Africa
| | - H E Hecker
- a Department of Psychology , University of Pretoria , Pretoria , South Africa
| | - J Jordaan
- b Department of Statistics , University of Pretoria , Pretoria , South Africa
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Sharer M, Cluver L, Shields JJ, Ahearn F. The power of siblings and caregivers: under-explored types of social support among children affected by HIV and AIDS. AIDS Care 2017; 28 Suppl 2:110-7. [PMID: 27392006 PMCID: PMC5004198 DOI: 10.1080/09540121.2016.1178942] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Children affected by HIV and AIDS have significantly higher rates of mental health problems than unaffected children. There is a need for research to examine how social support functions as a source of resiliency for children in high HIV-prevalence settings such as South Africa. The purpose of this research was to explore how family social support relates to depression, anxiety, and post-traumatic stress (PTS). Using the ecological model as a frame, data were drawn from a 2011 cross-sectional study of 1380 children classified as either orphaned by AIDS and/or living with an AIDS sick family member. The children were from high-poverty, high HIV-prevalent rural and urban communities in South Africa. Social support was analyzed in depth by examining the source (e.g. caregiver, sibling) and the type (e.g. emotional, instrumental, quality). These variables were entered into multiple regression analyses to estimate the most parsimonious regression models to show the relationships between social support and depression, anxiety, and PTS symptoms among the children. Siblings emerged as the most consistent source of social support on mental health. Overall caregiver and sibling support explained 13% variance in depression, 12% in anxiety, and 11% in PTS. Emotional support was the most frequent type of social support associated with mental health in all regression models, with higher levels of quality and instrumental support having the strongest relation to positive mental health outcomes. Although instrumental and quality support from siblings were related to positive mental health, unexpectedly, the higher the level of emotional support received from a sibling resulted in the child reporting more symptoms of depression, anxiety, and PTS. The opposite was true for emotional support provided via caregivers, higher levels of this support was related to lower levels of all mental health symptoms. Sex was significant in all regressions, indicating the presence of moderation.
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Affiliation(s)
- Melissa Sharer
- a John Snow Research & Training Institute , Arlington , VA, USA.,b The National Catholic School of Social Service , The Catholic University of America , Washington , DC , USA
| | - Lucie Cluver
- c Department of Social Policy & Intervention , University of Oxford , Oxford , UK.,d Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - Joseph J Shields
- b The National Catholic School of Social Service , The Catholic University of America , Washington , DC , USA
| | - Frederick Ahearn
- b The National Catholic School of Social Service , The Catholic University of America , Washington , DC , USA
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Stoner MCD, Pettifor A, Edwards JK, Aiello AE, Halpern CT, Julien A, Selin A, Twine R, Hughes JP, Wang J, Agyei Y, Gomez-Olive FX, Wagner RG, MacPhail C, Kahn K. The effect of school attendance and school dropout on incident HIV and HSV-2 among young women in rural South Africa enrolled in HPTN 068. AIDS 2017; 31:2127-2134. [PMID: 28692544 PMCID: PMC5599334 DOI: 10.1097/qad.0000000000001584] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the association between school attendance, school dropout, and risk of incident HIV and herpes simplex virus type 2 (HSV-2) infection among young women. DESIGN We used longitudinal data from a randomized controlled trial in rural Mpumalanga province, South Africa, to assess the association between school days attended, school dropout, and incident HIV and HSV-2 in young women aged 13-23 years. METHODS We examined inverse probability of exposure weighted survival curves and used them to calculate 1.5, 2.5, and 3.5-year risk differences and risk ratios for the effect of school attendance on incident HIV and HSV-2. A marginal structural Cox model was used to estimate hazard ratios for the effect of school attendance and school dropout on incident infection. RESULTS Risk of infection increased over time as young women aged, and was higher in young women with low school attendance (<80% school days) compared with high (≥80% school days). Young women with low attendance were more likely to acquire HIV [hazard ratio (HR): 2.97; 95% confidence interval (CI): 1.62, 5.45] and HSV-2 (HR: 2.47; 95% CI: 1.46, 4.17) over the follow-up period than young women with high attendance. Similarly, young women who dropped out of school had a higher weighted hazard of both HIV (HR 3.25 95% CI: 1.67, 6.32) and HSV-2 (HR 2.70; 95% CI 1.59, 4.59). CONCLUSION Young women who attend more school days and stay in school have a lower risk of incident HIV and HSV-2 infection. Interventions to increase frequency of school attendance and prevent dropout should be promoted to reduce risk of infection.
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Affiliation(s)
- Marie C D Stoner
- aDepartment of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA bMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa cDepartment of Maternal and Child Health, University of North Carolina, Chapel Hill, North Carolina, USA dEpidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden eDepartment of Biostatistics, University of Washington fFred Hutchinson Cancer Research Center, Seattle, Washington gDepartment of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA hINDEPTH Network, Accra, Ghana, West Africa iSchool of Health and Society, University of Wollongong, New South Wales, Australia jWits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
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Woollett N, Cluver L, Bandeira M, Brahmbhatt H. Identifying risks for mental health problems in HIV positive adolescents accessing HIV treatment in Johannesburg. J Child Adolesc Ment Health 2017; 29:11-26. [PMID: 28287023 DOI: 10.2989/17280583.2017.1283320] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mental health problems of adolescents are underserved in low and middle-income countries where they account for a significant proportion of disease burden. Perinatally infected HIV-positive adolescents have a high prevalence of mental health disorders; however, little is known about those retained in care in South Africa. METHODS HIV-positive adolescents aged 13-19 years (n = 343) accessing five paediatric antiretroviral clinics in Johannesburg were assessed using standardized measures for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidality. Descriptive and bivariate analyses were conducted on all variables using Statistica v13. RESULTS Twenty-seven percent were symptomatic for depression, anxiety, or PTSD; 24% reported suicidality. Peer violence was significantly correlated to all mental health problems, as was hunger, being inappropriately touched, being hit, and being female. Those reporting sickness in the past year were more symptomatic. High exposure to violence was evident. Additionally, not feeling safe at home or in the community increased risk for all mental health disorders. Knowing one's HIV status was protective as was having dreams for the future. CONCLUSION HIV-positive adolescents accessing care demonstrated high levels of mental health problems that are largely unrecognized and could potentially be addressed within health systems. Mental health difficulties are driven by social challenges that require attention.
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Affiliation(s)
- Nataly Woollett
- a Wits School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa.,b Wits Reproductive Health and HIV Institute, University of the Witwatersrand , Johannesburg , South Africa.,c Wits School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
| | - Lucie Cluver
- d Centre for Evidence-Based Intervention, Department of Social Policy and Intervention , University of Oxford , Oxford , United Kingdom
| | | | - Heena Brahmbhatt
- b Wits Reproductive Health and HIV Institute, University of the Witwatersrand , Johannesburg , South Africa.,f Department of Population, Reproductive and Family Health, Bloomberg School of Public Health , Johns Hopkins University , Baltimore , USA
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Collishaw S, Gardner F, Lawrence Aber J, Cluver L. Predictors of Mental Health Resilience in Children who Have Been Parentally Bereaved by AIDS in Urban South Africa. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2017; 44:719-30. [PMID: 26329481 DOI: 10.1007/s10802-015-0068-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Children parentally bereaved by AIDS experience high rates of mental health problems. However, there is considerable variability in outcomes, and some show no mental health problems even when followed over time. Primary aims were to identify predictors of resilient adaptation at child, family and community levels within a group of AIDS-orphaned children, and to consider their cumulative influence. A secondary aim was to test whether predictors were of particular influence among children orphaned by AIDS relative to non-orphaned and other-orphaned children. AIDS-orphaned (n = 290), other-orphaned (n = 163) and non-orphaned (n = 202) adolescents living in informal settlements in Cape Town, South Africa were assessed on two occasions 4 years apart (mean age 13.5 years at Time 1, range = 10-19 years). Self-report mental health screens were used to operationalise resilience in AIDS-orphaned children as the absence of clinical-range symptoms of PTSD, anxiety, depression, conduct problems, and suicidality. A quarter of AIDS-orphaned children (24 %) showed no evidence of mental health problems at either wave. Child physical health, better caregiving quality, food security, better peer relationship quality, and lower exposure to community violence, bullying or stigma at baseline predicted sustained resilience. There were cumulative influences across predictors. Associations with mental health showed little variation by child age or gender, or between orphaned and non-orphaned children. Mental health resilience is associated with multiple processes across child, family and community levels of influence. Caution is needed in making causal inferences.
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Affiliation(s)
- Stephan Collishaw
- Child and Adolescent Psychiatry, Institute of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Hadyn Ellis Building, Cardiff, CF24 4HQ, UK.
| | - Frances Gardner
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - J Lawrence Aber
- Steinhardt School of Culture, Education and Human Development, New York University, New York, NY, USA
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,University of Cape Town, Cape Town, South Africa
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Meinck F, Cluver LD, Orkin FM, Kuo C, Sharma AD, Hensels IS, Sherr L. Pathways From Family Disadvantage via Abusive Parenting and Caregiver Mental Health to Adolescent Health Risks in South Africa. J Adolesc Health 2017; 60:57-64. [PMID: 27793729 PMCID: PMC5182105 DOI: 10.1016/j.jadohealth.2016.08.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 06/29/2016] [Accepted: 08/10/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Adolescent health is a major concern in low- and middle-income countries, but little is known about its predictors. Family disadvantage and abusive parenting may be important factors associated with adolescent psychological, behavioral, and physical health outcomes. This study, based in South Africa, aimed to develop an empirically based theoretical model of relationships between family factors such as deprivation, illness, parenting, and adolescent health outcomes. METHODS Cross-sectional data were collected in 2009-2010 from 2,477 adolescents (aged 10-17) and their caregivers using stratified random sampling in KwaZulu-Natal, South Africa. Participants reported on sociodemographics, psychological symptoms, parenting, and physical health. Multivariate regressions were conducted, confirmatory factor analysis employed to identify measurement models, and a structural equation model developed. RESULTS The final model demonstrated that family disadvantage (caregiver AIDS illness and poverty) was associated with increased abusive parenting. Abusive parenting was in turn associated with higher adolescent health risks. Additionally, family disadvantage was directly associated with caregiver mental health distress which increased adolescent health risks. There was no direct effect of family disadvantage on adolescent health risks but indirect effects through caregiver mental health distress and abusive parenting were found. CONCLUSIONS Reducing family disadvantage and abusive parenting is essential in improving adolescent health in South Africa. Combination interventions could include poverty and violence reduction, access to health care, mental health services for caregivers and adolescents, and positive parenting support. Such combination packages can improve caregiver and child outcomes by reducing disadvantage and mitigating negative pathways from disadvantage among highly vulnerable families.
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Affiliation(s)
- Franziska Meinck
- Department of Social Policy and Intervention, Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom.
| | - Lucie Dale Cluver
- Department of Social Policy and Intervention, Centre for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom; Department of Psychiatry and Mental Health, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Frederick Mark Orkin
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Kuo
- Department of Psychiatry and Mental Health, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Department of Behavioral and Social Sciences, Centre for Alcohol and Addiction Studies, Brown University School of Public Health, Rhode Island
| | - Amogh Dhar Sharma
- Department of International Development, University of Oxford, Oxford, United Kingdom
| | - Imca Sifra Hensels
- Department of Infection and Population Health, Royal Free Hospital, University College London, London, United Kingdom
| | - Lorraine Sherr
- Department of Infection and Population Health, Royal Free Hospital, University College London, London, United Kingdom
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Gamarel KE, Kuo C, Boyes ME, Cluver LD. The dyadic effects of HIV stigma on the mental health of children and their parents in South Africa. JOURNAL OF HIV/AIDS & SOCIAL SERVICES 2017; 16:351-366. [PMID: 29238272 PMCID: PMC5724576 DOI: 10.1080/15381501.2017.1320619] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
HIV stigma - both 'self-stigma' towards positive individuals and 'stigma by association' towards their families - is linked with adverse mental health. This study examined how stigma was associated with the mental health of parents and children in South Africa. Parent-child dyads (n=2477 dyads) in South Africa participated in a cross-sectional survey. For both parents and children, greater stigma was associated with their own reports of greater anxious and depressive symptoms. Parents reports of stigma was associated with children's greater anxious and depressive symptoms. Children's reports of stigma was related to parents greater anxious and depressive symptoms. There was a significant interaction, such that the association between parent stigma and depression was stronger when children also reported high levels of stigma. Findings provide support the effect of HIV stigma on the mental health of families and illustrate the importance of taking a family-based approach to stigma-reduction interventions to alleviate mental health problems.
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Affiliation(s)
- Kristi E. Gamarel
- Department of Behavioral and Social Sciences, Brown University School of Public, 121 South Main Street, Providence, RI 02130
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI 02130
| | - Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University School of Public, 121 South Main Street, Providence, RI 02130
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 South Main Street, Providence, RI 02130
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Mark E. Boyes
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, United Kingdom
- Department of Social Policy and Intervention, Barnett House, 32 Wellington Square, Oxford, OX1 2ER, United Kingdom
| | - Lucie D. Cluver
- Department of Social Policy and Intervention, Barnett House, 32 Wellington Square, Oxford, OX1 2ER, United Kingdom
- School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Perth, Western Australia
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Psychometric Properties of Disaster Event Reaction Items From the Crisis Counseling Individual/Family Encounter Log. Disaster Med Public Health Prep 2016; 10:822-831. [PMID: 27515401 DOI: 10.1017/dmp.2016.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this article was to examine the psychometric properties of the Crisis Counseling Assistance and Training Program (CCP) data collection instrument, the Individual/Family Encounter Log (IFEL). Data collected from disaster survivors included how they reacted to events in emotional, behavioral, physical, and cognitive domains. These domains are based on conceptual categorization of event reactions and allow CCP staff to provide survivors with referrals to appropriate behavioral health support resources, if warranted. METHODS This study explored the factor structure of these survey items to determine how best to use the available information as a screen of disaster-related behavioral health indicators. Specifically, our first research question explored and confirmed the optimal factor structure of the event reaction items, and our second question examined whether the new factor structure was similar across disaster types: hurricanes, tornadoes, floods, and wildfires. Using a factor analytic technique, we tested whether our event reaction outcomes achieved consistent and reliable measurement across different disaster situations. Finally, we assessed how the new subscales were correlated with the type of risk to which CCP disaster survivors were exposed. RESULTS Our analyses revealed 3 factors: (1) depressive-like, (2) anxiety-like, and (3) somatic. In addition, we found that these factors were coherent for hurricanes, floods, and wildfires, although the basic factor structure was not equivalent for tornadoes. CONCLUSION Implications for use of the IFEL in disaster preparedness, response, and recovery are discussed. (Disaster Med Public Health Preparedness. 2016;10:822-831).
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Structural drivers and social protection: mechanisms of HIV risk and HIV prevention for South African adolescents. J Int AIDS Soc 2016; 19:20646. [PMID: 27086838 PMCID: PMC4834365 DOI: 10.7448/ias.19.1.20646] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 02/12/2016] [Accepted: 03/15/2016] [Indexed: 11/08/2022] Open
Abstract
Introduction Social protection is high on the HIV-prevention agenda for youth in sub-Saharan Africa. However, questions remain: How do unconditional cash transfers work? What is the effect of augmenting cash provision with social care? And can “cash plus care” social protection reduce risks for adolescents most vulnerable to infection? This study tackles these questions by first identifying mediated pathways to adolescent HIV risks and then examining potential main and moderating effects of social protection in South Africa. Methods This study was a prospective observational study of 3515 10-to-17-year-olds (56.7% female; 96.8% one-year retention). Within randomly selected census areas in four rural and urban districts in two South African provinces, all homes with a resident adolescent were sampled between 2009/2010 and 2011/2012. Measures included 1) potential structural drivers of HIV infection such as poverty and community violence; 2) HIV risk behaviours; 3) hypothesized psychosocial mediating factors; and 4) types of social protection involving cash and care. Using gender-disaggregated analyses, longitudinal mediation models were tested for potential main and moderating effects of social protection. Results Structural drivers were associated with increased onset of adolescent HIV risk behaviour (p<0.001, B=0.06, SE=0.01), fully mediated by increased psychosocial problems. Both cash and care aspects of social protection were associated with reductions in HIV risk behaviour and psychosocial deprivations. In addition, cash social protection moderated risk pathways: for adolescent girls and boys experiencing more acute structural deprivation, social protection had the greatest associations with HIV risk prevention (e.g. moderation effects for girls: B=−0.08, p<0.002 between structural deprivation and psychosocial problems, and B=−0.07, p<0.001 between psychosocial problems and HIV risk behaviour). Conclusions Adolescents with the greatest structural deprivation are at higher risk of HIV, but social protection has the greatest prevention effects for the most vulnerable. Social protection comprising unconditional cash plus care was associated with reduced risk pathways through moderation and main effects, respectively. Our findings suggest the importance of social protection within a combination package of HIV-prevention approaches.
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Psychometric properties of the RCMAS-2 in pediatric cancer patients. Eur J Oncol Nurs 2015; 20:36-41. [PMID: 26233436 DOI: 10.1016/j.ejon.2015.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/18/2015] [Accepted: 07/16/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE OF THE RESEARCH The Revised Children's Manifest Anxiety Scale, second edition (RCMAS-2) is widely used internationally to assess anxiety. However, there is little data regarding its validity for pediatric cancer patients. This study evaluated the psychometric properties of the RCMAS-2 in pediatric cancer patients. METHODS AND SAMPLE This cross-sectional study included 370 pediatric cancer patients (aged 6-19 years) that were recruited from three medical centers between August 2008 and March 2011 in Taiwan. Reliability was evaluated by internal consistency. Confirmatory factor analysis was performed to examine the factor structure. Construct validity was examined by known-groups analyses. KEY RESULTS The internal consistency of the full scale was good (α = 0.90) but the scores of Physiological Anxiety subscale was low (α = 0.65). Using known-groups validity, significant differences in anxiety were observed between genders and between patients that were on and off treatment. The hypothesized three-factor model did not adequately fit (χ(2)/d.f = 2.4; p < 0.01, GFI = 0.80, CFI = 0.71, RMSEA = 0.06, SRMR = 0.01). CONCLUSIONS The RCMAS-2 demonstrated reliability and validity for use with pediatric cancer patients aged 6 and 19 years. Further structure evaluation of the RCMAS-2 in pediatric oncology population is needed, and the scores of the Physiological Anxiety subscale should be interpreted with caution.
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Cluver L, Orkin M, Boyes ME, Sherr L. Child and Adolescent Suicide Attempts, Suicidal Behavior, and Adverse Childhood Experiences in South Africa: A Prospective Study. J Adolesc Health 2015; 57:52-9. [PMID: 25936843 DOI: 10.1016/j.jadohealth.2015.03.001] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 03/01/2015] [Accepted: 03/03/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE This is the first known prospective study of child suicidal behavior in sub-Saharan Africa. Aims were to determine whether (1) cumulative exposure to adverse childhood experiences (ACEs) predicts later suicidality and (2) heightened risks are mediated by mental health disorder and drug/alcohol misuse. METHODS Longitudinal repeated interviews were conducted 1 year apart (97% retention) with 3,515 adolescents aged 10-18 years in South Africa (56% female; <2.5% refusal). Random selection of census enumeration areas from urban/rural sites within two provinces and door-to-door sampling included all homes with a resident adolescent. Measures included past-month suicide attempts, planning, and ideation, mental health disorders, drug/alcohol use, and ACE, for example, parental death by AIDS or homicide, abuse, and exposure to community violence. Analyses included multivariate logistic regression and multiple mediation tests. RESULTS Past-month suicidality rates were 3.2% of adolescents attempting, 5.8% planning, and 7.2% reporting ideation. After controlling for baseline suicidality and sociodemographics, a strong, graded relationship was shown between cumulative ACE and all suicide behaviors 1 year later. Baseline mental health, but not drug/alcohol misuse, mediated relationships between ACE and subsequent suicidality. Suicide attempts rose from 1.9% among adolescents with no ACE to 6.3% among adolescents with >5 ACEs (cumulative odds ratio [OR], 2.46; confidence interval [CI], 1.00-6.05); for suicide planning, from 2.4% to 12.5% (cumulative OR, 4.40; CI, 2.08-9.29); and for suicide ideation, from 4.2% to 15.6% (cumulative OR, 2.99; CI, 1.68-5.53). CONCLUSIONS Preventing and mitigating childhood adversities have the potential to reduce suicidality. Among adolescents already exposed to adversities, effective mental health services may buffer against future suicidality.
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Affiliation(s)
- Lucie Cluver
- Department of Social Policy and Intervention, Center for Evidence-Based Intervention, University of Oxford, Oxford, United Kingdom; Department of Psychiatry and Mental Health, University of Cape Town, South Africa.
| | - Mark Orkin
- DST-NRF Centre of Excellence in Human Development, University of Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Mark E Boyes
- School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Lorraine Sherr
- Department of Infection and Population Health, University College London, London, United Kingdom
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Boyes ME, Bowes L, Cluver LD, Ward CL, Badcock NA. Bullying victimisation, internalising symptoms, and conduct problems in South African children and adolescents: a longitudinal investigation. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2015; 42:1313-24. [PMID: 24882504 DOI: 10.1007/s10802-014-9888-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Bullying victimisation has been prospectively linked with mental health problems among children and adolescents in longitudinal studies in the developed world. However, research from the developing world, where adolescents face multiple risks to social and emotional development, has been limited by cross-sectional designs. This is the first longitudinal study of the psychological impacts of bullying victimisation in South Africa. The primary aim was to examine prospective relationships between bullying victimisation and internalising and externalising symptoms in South African youth. Secondary aims were to examine gender and age-related differences in experiences of bullying victimisation. Children and adolescents (10-17 years, 57 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up 1 year later (97 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces and door-to-door sampling included all households with a resident child/adolescent. Exposure to multiple experiences of bullying victimisation at baseline predicted internalising symptoms and conduct problems 1 year later. Additionally, baseline mental health scores predicted later bullying victimisation, demonstrating bi-directionality of relationships between bullying victimisation and mental health outcomes in this sample. Expected gender differences in physical, verbal, and relational bullying victimisation were evident and predicted declines in bullying victimisation over time were observed. In the developed world, school-based anti-bullying programmes have been shown to be effective in reducing bullying and victimisation. Anti-bullying programmes should be implemented and rigorously evaluated in South Africa, as this may promote improved mental health among South African children and adolescents.
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Affiliation(s)
- Mark E Boyes
- Health Psychology and Behavioural Medicine Research Group, School of Psychology and Speech Pathology, Curtin University, GPO Box U1987, Perth, Western Australia, 6845,
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Boyes ME, Cluver LD. Relationships between familial HIV/AIDS and symptoms of anxiety and depression: the mediating effect of bullying victimization in a prospective sample of South African children and adolescents. J Youth Adolesc 2014; 44:847-59. [PMID: 24996836 DOI: 10.1007/s10964-014-0146-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/24/2014] [Indexed: 11/24/2022]
Abstract
South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms. Poverty and HIV/AIDS-related stigma are additional risk factors for these negative mental health outcomes. Community level factors, such as poverty and stigma, are difficult to change in the short term and identifying additional potentially malleable mechanisms linking familial HIV/AIDS with mental health is important from an intervention perspective. HIV/AIDS-affected children are also at increased risk of bullying victimization. This longitudinal study aimed to determine whether prospective relationships between familial HIV/AIDS and both anxiety symptoms and depressive symptoms operate indirectly via bullying victimization. Adolescents (M = 13.45 years, 56.67 % female, n = 3,515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up one year later (n = 3,401, 96.70 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces, and door-to-door sampling included all households with a resident child/adolescent. Familial HIV/AIDS at baseline assessment was not directly associated with mental health outcomes 1 year later. However, significant indirect effects operating via bullying victimization were obtained for both anxiety and depression scores. Importantly, these effects were independent of poverty, HIV/AIDS-related stigma, and baseline mental health, which highlight bullying victimization as a potential target for future intervention efforts. The implementation and rigorous evaluation of bullying prevention programs in South African communities may improve mental health outcomes for HIV/AIDS-affected children and adolescents and this should be a focus of future research and intervention.
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Affiliation(s)
- Mark E Boyes
- Health Psychology and Behavioural Medicine Research Group, School of Psychology and Speech Pathology, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia,
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Orkin M, Boyes ME, Cluver LD, Zhang Y. Pathways to poor educational outcomes for HIV/AIDS-affected youth in South Africa. AIDS Care 2013; 26:343-50. [PMID: 23965029 DOI: 10.1080/09540121.2013.824533] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A recent systematic review of studies in the developing world has critically examined linkages from familial HIV/AIDS and associated factors such as poverty and child mental health to negative child educational outcomes. In line with several recommendations in the review, the current study modelled relationships between familial HIV/AIDS, poverty, child internalising problems, gender and four educational outcomes: non-enrolment at school, non-attendance, deficits in grade progression and concentration problems. Path analyses reveal no direct associations between familial HIV/AIDS and any of the educational outcomes. Instead, HIV/AIDS-orphanhood or caregiver HIV/AIDS-sickness impacted indirectly on educational outcomes via the poverty and internalising problems that they occasioned. This has implications for evidence-based policy inferences. For instance, by addressing such intervening variables generally, rather than by seeking to target families affected by HIV/AIDS, interventions could avoid exacerbating stigmatisation, while having a more direct and stronger impact on children's educational outcomes. This analytic approach also suggests that future research should seek to identify causal paths, and may include other intervening variables related to poverty (such as child housework and caring responsibilities) or to child mental health (such as stigma and abuse), that are linked to both familial HIV/AIDS and educational outcomes.
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Affiliation(s)
- Mark Orkin
- a School of Public and Development Management , University of the Witwatersrand , Johannesburg , South Africa
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Boyes ME, Mason SJ, Cluver LD. Validation of a brief stigma-by-association scale for use with HIV/AIDS-affected youth in South Africa. AIDS Care 2012; 25:215-22. [DOI: 10.1080/09540121.2012.699668] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Mark E. Boyes
- a Department of Social Policy and Intervention, Centre for Evidence-Based Intervention , University of Oxford , Oxford , UK
| | - Sally J. Mason
- b Department of Psychiatry , Institute for Juvenile Research, University of Illinois at Chicago , Chicago , IL , USA
| | - Lucie D. Cluver
- a Department of Social Policy and Intervention, Centre for Evidence-Based Intervention , University of Oxford , Oxford , UK
- c Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
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