Interventions to improve psychosocial well-being for children affected by HIV and AIDS: a systematic review

The Impact of Family Economic Empowerment Intervention on Psychological Difficulties and Prosocial Behavior Among AIDS-Orphaned Children in Southern Uganda

PURPOSE

Children orphaned by AIDS are more likely to have psychological and emotional problems compared to their counterparts. Poverty resulting from orphanhood is linked to the negative psychological outcomes experienced by AIDS-orphaned adolescents. No studies have investigated the impact of an economic empowerment intervention on child psychological and emotional problems and prosocial behavior. Therefore, we aimed to examine the impact of a family economic empowerment intervention on psychological difficulties and prosocial behavior among AIDS-orphaned adolescents.

METHODS

We analyzed data from a two-arm cluster randomized controlled trial conducted in 10 primary schools in southern Uganda. Schools were randomized to either bolstered usual care (n = 5 schools; 167 participants) or a family-economic empowerment intervention (Suubi-Maka; n = 5 schools; 179 individuals). We used t-test and multi-level mixed effects models to examine the impact of Suubi-Maka on psychological and behavioral outcomes.

RESULTS

No differences were observed between intervention and control groups in almost all the outcomes at baseline, 12 months, and 24 months. Simple main effects comparisons of 12 months versus baseline within each condition indicate modest to significant declines in emotional symptoms, hyperactivity, peer relationships (Δs = -1.00 to -2.11, all p < .001), and total difficulties (Δs = -4.85 to -4.89, both p < .001) across both groups.

DISCUSSION

Our analysis found no meaningful difference between intervention and control groups in child psychological difficulties and prosocial behavior postintervention. However, improvements were observed across both control and treatment groups following the intervention. Future studies should investigate the impact of different components of the intervention.

Examining the Relationship Between HIV-Related Stigma and the Health and Wellbeing of Children and Adolescents Living with HIV: A Systematic Review

Human immunodeficiency virus (HIV) affects millions of people globally. The associated stigma remains a challenge for individuals living with HIV and children and adolescents face the additional challenge of withstanding the peer, pubertal and identity challenges associated with growing up. The current systematic review aimed to define and explore the major stigma-related challenges of children and adolescents from their own perspectives. A secondary aim was to identify any challenges distinct to childhood and adolescence. Studies included individuals aged 3 to 18 years who were aware of their status. Fifteen studies met inclusion criteria. Narrative synthesis was conducted on the included studies. Five analytic themes emerged describing major stigma-related challenges: disclosure-related anxiety, medication adherence, feelings of abnormality, mental health issues and social exclusion. Disclosure-related anxiety and feelings of abnormality appeared to be largely confined to the experience of children and adolescents. Many of the themes centred around peer influence, highlighting the need to belong in youth. Results suggest that youth require tailored interventions targeting their age-specific challenges.

Child maltreatment mediates the relationship between HIV/AIDS family dysfunction trajectories and psychosocial problems among adolescents

The relationship between parental HIV/AIDS status or death and child mental health is well known, although the role of child maltreatment as a confounder or mediator in this relationship remains uncertain. This study examined the potential path mechanism through child maltreatment mediating the link between HIV/AIDS family dysfunction trajectories and psychosocial problems. A cross-sectional survey was conducted in the Lower Manya Municipal Assembly of Ghana. A questionnaire which consisted of the Strengths and Difficulties Questionnaire (SDQ), Social and Health Assessment (SAHA), Rosenberg Self-Esteem Scale (RSES) and the Conflict Tactics Scale (CTS) was completed by 291 adolescents. Controlling for relevant sociodemographic confounders, mediation analyses using linear regression were fitted to examine whether the association between family dysfunction and psychosocial problems is mediated by child maltreatment. The results indicate that, among adolescents, child maltreatment fully mediated the association between being orphaned by AIDS and self-esteem (b = .59 [95%CI .32, .91]), delinquency and risky behaviours (b = .56 [95%CI .31, .86]) and peer problems (b = .74 [95%CI .48, 1.03]). Similarly, child maltreatment fully mediated the association between living with an HIV/AIDS-infected parent and self-esteem (b = .78 [95%CI .43, 1.23]), delinquency and risky behaviours (b = .76 [95%CI .45, 1.11]), depression/emotional problems (b = .64 [95%CI .40, .92]) and peer problems (b = .94 [95%CI .66, 1.26]). Partial mediation was found for hyperactivity. Child maltreatment mediates the association between the family dysfunction trajectories of parental HIV/AIDS or death and psychosocial problems among adolescents. This implies that efforts to address child maltreatment among families affected by HIV/AIDS may be helpful in the prevention of psychosocial problems among these children, thus enhancing their wellbeing. The findings therefore underscore the need for comprehensive psychosocial interventions that addresses both the unique negative exposures of HIV/AIDS and maltreatment for children affected by HIV.

Psychosocial Support Programme Improves Adherence and Health Systems Experiences for Adolescents on Antiretroviral Therapy in Mpumalanga Province, South Africa

(1) Background: Psychosocial support (PSS) plays a significant role in persistent adherence to and retention in antiretroviral therapy (ART) for adolescents living with the human immunodeficiency virus (ALHIV). This paper qualitatively explores the experiences of ALHIV on ART, who participated in a PSS programme in five public primary healthcare facilities in Mpumalanga Province in South Africa during the COVID-19 pandemic. (2) Methods: Data were collected through 24 focus group discussions with 173 ALHIV on ART and subjected to inductive thematic analysis. Informed consent was obtained before all data collection. (3) Results: The PSS programme facilitated the process of full HIV disclosure to these adolescents with the support of parents/guardians while motivating adherence through peer support groups and health education for improved treatment literacy. Participants reported positive health systems experiences, improved healthcare provider-client relations, and prompt access to health services. (4) Conclusions: The PSS programme successfully kept ALHIV engaged in ART care despite the health service disruptions encountered during the COVID-19 pandemic. We recommend rigorous evaluation of the effects of the PSS intervention on adherence to and retention in ART among ALHIV in HIV-endemic settings.

The Short-Term Impact of a Combination Intervention on Depressive Symptoms Among School-Going Adolescent Girls in Southwestern Uganda: The Suubi4Her Cluster Randomized Trial

PURPOSE

This study aims to examine the short-term impact of a combined intervention consisting of evidence-based family economic empowerment (FEE) and multiple family group (MFG) interventions on depressive symptoms among school-going adolescent girls in southwestern Uganda.

METHODS

We analyzed longitudinal data from a cluster randomized trial. The sample consisted of 1,260 adolescent girls (aged 14-17 years at enrollment) recruited from senior one and senior two classes across 47 secondary schools in the southwestern region of Uganda. Participants were randomized at the school level to either the control condition receiving bolstered standard of care or one of the two treatment conditions-the treatment one condition receiving the FEE intervention or the treatment two conditions receiving both the FEE plus MFG interventions. Descriptive statistics and a three-level mixed-effects model were conducted to examine the effect of a combination intervention on depressive symptoms.

RESULTS

At baseline, there were no significant differences between the control condition and both treatment conditions. While all three groups experienced a substantial reduction in depressive symptoms from baseline to 12 months, the reductions were stronger for the two intervention groups. However, FEE + MFG was not significantly different from FEE at 12 months.

DISCUSSION

Results imply that the FEE intervention may be a promising tool in addressing depressive symptoms among adolescent girls. Therefore, to reduce the long-term implications of adverse psychosocial health during adolescence, policymakers and program implementers should explore scaling up economic empowerment interventions in similar settings to bridge the mental health treatment gap for adolescent girls.

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

OBJECTIVE

There is an urgent need to equip community-based careworkers with the skills to address the mental health needs of orphans and vulnerable children (OVC) as an essential response to shortages in human resources for mental health in Sub-Saharan Africa. We conducted a quasi-experimental feasibility trial in South Africa to adapt and evaluate an established year-long semi-structured, manualized video-feedback caregiver intervention (the Mediational Intervention for Sensitizing Caregivers; MISC) for community-based organizations (CBOs).

METHODS

Following a year-long iterative cross-cultural adaptation of MISC, we recruited 88 OVC (ages 7-11; 45.5% girls) and their CBO careworkers (N = 18; 94.4% female). Two CBOs (45 children; 9 CBO careworkers) received 12 months of MISC, and two CBOs (43 children; 9 CBO careworkers) received treatment as usual. Child mental health and quality of caregiving were assessed at 6 months into the intervention and at completion through multi-informant questionnaires and video-recordings of careworker-child interactions. Qualitative interviews were conducted to evaluate feasibility and acceptability.

RESULTS

MISC-CBO was acceptable and feasible in terms of attendance and post-intervention interviews. MISC improved child mental health, as well as the quality of careworker caregiving in terms of interactive effects for affective and cognitive (Expanding) components of MISC, and main effects for the cognitive components of Rewarding and Provision of meaning. MISC components did not mediate the effects of the intervention.

CONCLUSIONS

The current study shows that laypersons with no tertiary education and virtually no prior training who undergo MISC training can improve caregiving quality and the mental health of OVCs.

Intervention effect of group counseling on social support and post-stress growth of orphans and vulnerable children in China

Orphans and vulnerable children fall under the category of children who are at risk of exposure to more stressful circumstances and receive less social assistance compared to other children. This study aims to investigate the impact of group counseling based on social intervention and psychological therapy (SSGPC) on social support and the perceived stress growth of orphans and vulnerable children. In one special educational needs school in Nanning, China, the SSGPC was developed and implemented. Using the social support and post-stress growth scales, the researchers investigated the effects of SSGPC on orphans and vulnerable children. Twenty-seven orphans and vulnerable children between the ages of nine and 12 were arbitrarily assigned to the experimental and control groups. A pre-test post-test method of quasi-experimental design was applied, with 13 participants in the experimental group and 14 in the control group. The results revealed that the intervention group had significantly higher scores for social support and post-stress growth than the control group. The SSGPC had significantly improved the levels of social support for orphans. The findings indicated that the SSGPC provided an effective way to improve social support and post-stress growth of orphans and vulnerable children.

Resilience-Based Intervention to Promote Mental and Behavioral Health in Children

The resilience framework offers a powerful tool to study how individuals respond to adversity. Intervention efforts building on 40 years of resilience research show promise in promoting mental and behavioral health of children in the context of adversity. This paper provides an overview of resilience and resilience-based interventions on mental and behavioral health in children. The importance of understanding resilience through the lens of the socioecological systems theory is highlighted, and the potential benefit of multilevel interventions in promoting mental and behavioral health is discussed.

Models of lifelong care for children and adolescents with chronic conditions in low-income and middle-income countries: a scoping review

Globally, non-communicable diseases (NCDs) or chronic conditions account for one-third of disability-adjusted life-years among children and adolescents under the age of 20. Health systems must adapt to respond to the growing burden of NCDs among children and adolescents who are more likely to be marginalised from healthcare access and are at higher risk for poor outcomes. We undertook a review of recent literature on existing models of chronic lifelong care for children and adolescents in low-income and middle-income countries with a variety of NCDs and chronic conditions to summarise common care components, service delivery approaches, resources invested and health outcomes.

Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews

Background

More than half of the global population is not effectively covered by any type of social protection benefit and women's coverage lags behind. Most girls and boys living in low-resource settings have no effective social protection coverage. Interest in these essential programmes in low and middle-income settings is rising and in the context of the COVID-19 pandemic the value of social protection for all has been undoubtedly confirmed. However, evidence on whether the impact of different social protection programmes (social assistance, social insurance and social care services and labour market programmes) differs by gender has not been consistently analysed. Evidence is needed on the structural and contextual factors that determine differential impacts. Questions remain as to whether programme outcomes vary according to intervention implementation and design.

Objectives

This systematic review aims to collect, appraise, and synthesise the evidence from available systematic reviews on the differential gender impacts of social protection programmes in low and middle-income countries. It answers the following questions: 1.What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in low and middle-income countries?2.What is known from systematic reviews about the factors that determine these gender-differentiated impacts?3.What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

Search Methods

We searched for published and grey literature from 19 bibliographic databases and libraries. The search techniques used were subject searching, reference list checking, citation searching and expert consultations. All searches were conducted between 10 February and 1 March 2021 to retrieve systematic reviews published within the last 10 years with no language restrictions.

Selection Criteria

We included systematic reviews that synthesised evidence from qualitative, quantitative or mixed-methods studies and analysed the outcomes of social protection programmes on women, men, girls, and boys with no age restrictions. The reviews included investigated one or more types of social protection programmes in low and middle-income countries. We included systematic reviews that investigated the effects of social protection interventions on any outcomes within any of the following six core outcome areas of gender equality: economic security and empowerment, health, education, mental health and psychosocial wellbeing, safety and protection and voice and agency.

Data Collection and Analysis

A total of 6265 records were identified. After removing duplicates, 5250 records were screened independently and simultaneously by two reviewers based on title and abstract and 298 full texts were assessed for eligibility. Another 48 records, identified through the initial scoping exercise, consultations with experts and citation searching, were also screened. The review includes 70 high to moderate quality systematic reviews, representing a total of 3289 studies from 121 countries. We extracted data on the following areas of interest: population, intervention, methodology, quality appraisal, and findings for each research question. We also extracted the pooled effect sizes of gender equality outcomes of meta-analyses. The methodological quality of the included systematic reviews was assessed, and framework synthesis was used as the synthesis method. To estimate the degree of overlap, we created citation matrices and calculated the corrected covered area.

Main Results

Most reviews examined more than one type of social protection programme. The majority investigated social assistance programmes (77%, N = 54), 40% (N = 28) examined labour market programmes, 11% (N = 8) focused on social insurance interventions and 9% (N = 6) analysed social care interventions. Health was the most researched (e.g., maternal health; 70%, N = 49) outcome area, followed by economic security and empowerment (e.g., savings; 39%, N = 27) and education (e.g., school enrolment and attendance; 24%, N = 17). Five key findings were consistent across intervention and outcomes areas: (1) Although pre-existing gender differences should be considered, social protection programmes tend to report higher impacts on women and girls in comparison to men and boys; (2) Women are more likely to save, invest and share the benefits of social protection but lack of family support is a key barrier to their participation and retention in programmes; (3) Social protection programmes with explicit objectives tend to demonstrate higher effects in comparison to social protection programmes without broad objectives; (4) While no reviews point to negative impacts of social protection programmes on women or men, adverse and unintended outcomes have been attributed to design and implementation features. However, there are no one-size-fits-all approaches to design and implementation of social protection programmes and these features need to be gender-responsive and adapted; and (5) Direct investment in individuals and families' needs to be accompanied by efforts to strengthen health, education, and child protection systems. Social assistance programmes may increase labour participation, savings, investments, the utilisation of health care services and contraception use among women, school enrolment among boys and girls and school attendance among girls. They reduce unintended pregnancies among young women, risky sexual behaviour, and symptoms of sexually transmitted infections among women. Social insurance programmes increase the utilisation of sexual, reproductive, and maternal health services, and knowledge of reproductive health; improve changes in attitudes towards family planning; increase rates of inclusive and early initiation of breastfeeding and decrease poor physical wellbeing among mothers. Labour market programmes increase labour participation among women receiving benefits, savings, ownership of assets, and earning capacity among young women. They improve knowledge and attitudes towards sexually transmitted infections, increase self-reported condom use among boys and girls, increase child nutrition and overall household dietary intake, improve subjective wellbeing among women. Evidence on the impact of social care programmes on gender equality outcomes is needed.

Authors' Conclusions

Although effectiveness gaps remain, current programmatic interests are not matched by a rigorous evidence base demonstrating how to appropriately design and implement social protection interventions. Advancing current knowledge of gender-responsive social protection entails moving beyond effectiveness studies to test packages or combinations of design and implementation features that determine the impact of these interventions on gender equality. Systematic reviews investigating the impact of social care programmes, old age pensions and parental leave on gender equality outcomes in low and middle-income settings are needed. Voice and agency and mental health and psychosocial wellbeing remain under-researched gender equality outcome areas.

Effects of a Multilevel Resilience-Based Intervention on Mental Health for Children Affected by Parental HIV: A Cluster Randomized Controlled Trial

The present study aimed to examine the efficacy of the Child-Caregiver-Advocacy Resilience (ChildCARE) intervention, a multilevel resilience-based psychosocial intervention, on mental health outcomes, including depressive symptoms, school anxiety, and loneliness, among children affected by parental HIV in central China. Seven hundred and ninety children (51.6% boys, 6-17 years of age) affected by parental HIV were randomly assigned by cluster to a control group or one of three intervention groups designed to test the three conditions of the ChildCARE intervention (child-only, child + caregiver, child + caregiver + community). Linear mixed-effects modeling was performed to test the intervention effect at 6, 12, and 18 months. The intervention did not yield significant changes in mental health outcomes in the child-only group at any follow-ups, whereas significant reductions in depressive symptoms and loneliness were observed in the child + caregiver group at 12 months. The observed intervention effects were not sustained at 18 months. Also, children who received the additional community component that, was implemented after 12 months did not show larger improvements in mental health outcomes than the control group at 18 months. Lastly, older children (i.e., ≥12 years) were found to benefit more from the intervention than their younger counterparts (i.e., <12 years). Overall, the findings provide some support for the promise of multilevel resilience-based interventions in improving mental health of children affected by parental HIV, but more research is needed to further determine whether multilevel resilience-based interventions can yield sustained effects on mental health.

Mental health outcomes of a pilot 2-arm randomized controlled trial of a HIV-prevention program for South African adolescent girls and young women and their female caregivers

Background

South African adolescent girls and young women (AGYW) report significant mental distress and sexual and reproductive health concerns. Mental health problems and trauma symptoms are consistently associated with sexual and reproductive health behavior. Despite their intersection, few interventions address them simultaneously or engage female caregivers (FC) as collaborators. This study presents findings from a pilot test of an empirically supported culturally adapted family-based HIV-prevention program, Informed Motivated Aware and Responsible Adolescents and Adults- South Africa (IMARA-SA), on AGYW anxiety, depression, and trauma.

Methods

Sixty 15–19-year-old AGYW (mean age = 17.1 years) and their FC from outside Cape Town were randomized to IMARA-SA or a health promotion control program. AGYW reported their anxiety using the GAD-7, depression using the PHQ-9, and trauma using the PC-PTSD-5 at baseline and follow-up (6–10 months post). Both interventions were delivered by Xhosa-speaking Black South African women in groups over 2 days for approximately 10 h. We examined intervention effects using zero-inflated negative binomial regression for anxiety, multinomial logistic regression for depression, and logistic regression for trauma.

Results

At baseline, groups did not differ in demographic characteristics but AGYW randomized to IMARA-SA had higher depression scores than controls (p = 0.04) and a greater proportion screened positive for PTSD (p = .07). Controlling for baseline mental health scores, AGYW who received IMARA-SA compared to controls had significantly fewer anxiety symptoms at follow-up (adjusted incidence rate ratio for count model = 0.54, 95% CI = 0.29–0.99, p = 0.05), were less likely to report at least one depressive symptom relative to no symptoms (relative risk ratio = 0.22, 95% CI = 0.05, 0.95, p = 0.04), and were less likely to report symptoms of PTSD relative to no symptoms, but this difference was not statistically significant.

Conclusions

Mental health is implicated in risky sexual behavior, and reducing emotional distress can mitigate exposure to poor sexual and reproductive health outcomes. This pilot study yielded promising findings for the mental health impact of IMARA-SA, justifying replication in a larger randomized trial.

Trial registration

ClinicalTrials.gov Number NCT04758390, accepted 17/02/2021.

Maternal depression and infant social withdrawal as predictors of behaviour and development in vertically HIV-infected children at 3.5 years

BACKGROUND

In low- and middle-income countries, there is a high prevalence of post-partum depression and it is often associated with HIV status. Maternal depression negatively affects mothering and can lead to social withdrawal in infants. Maternal depression and infant social withdrawal can have deleterious long-term effects on children's behaviour and neurodevelopmental trajectories.

AIM

To investigate whether maternal depression and infant social withdrawal at 10-12 months post-partum were significant predictors of child behaviour and development at 42 months.

METHOD

Seventy-four mother-infant dyads living with HIV were followed in a prospective, longitudinal design. Mothers were assessed for depression using the Center for Epidemiologic Studies Depression scale (CES-D). Infant social withdrawal was assessed by the modified Alarm Distress Baby Scale (m-ADBB), and development and behaviour were evaluated by the Griffiths Mental Development Scales (GMDS) and the Child Behavior Checklist (CBCL), respectively.

RESULTS

Maternal depression  explained 4.8% of the variance in child behaviour (β = 0.98, t = 2.05, p < 0.05) and 10.3% of the variance in development   (β = -0.30, t = -2.66, p < 0.05). Infant social withdrawal   was not a significant predictor of behaviour   (β = 3.27, t = 1.36, p = 0.18), but it did uniquely explain 7% of the variance in development (β = -1.32, t = -2.48, p < 0.05).

CONCLUSION

In the context of HIV, screening for maternal depression and the quality of mother-infant interactions are important (especially in the 1st year post-partum), given the significant long-term impact they have on behaviour and neurodevelopment.

ABBREVIATIONS

ANOVA: analysis of variance; ART: antiretroviral therapy; CBCL: Child Behavioral Checklist; CES-D: Center for Epidemiologic Studies Depression Scale; CHEI: children HIV-exposed and infected; CHER: Children with HIV Early Antiretroviral Treatment Trial; CHEU: children HIV-exposed and uninfected; CHUU: children HIV-unexposed and -uninfected; GMDS: Griffiths Mental Development Scales; HIV: human immunodeficiency virus; LMIC: low- and middle-income countries; m-ADBB: modified Alarm Distress Baby Scale; NRF: National Research Foundation; SAMRC: South African Medical Research Council; WHO: World Health Organization.

Addressing the Mental and Emotional Health Impacts of COVID-19 on Children and Adolescents: Lessons From HIV/AIDS

The COVID-19 pandemic has led to lasting mental health and psychosocial consequences just as were experienced with the HIV epidemic. A rapid review of published systematic reviews on HIV/AIDS and mental health outcomes and responses among children and adolescents was used to identify lessons for the COVID-19 pandemic response. The review found that HIV/AIDS responses to promote mental health, prevent ill-health and treat mental health conditions included diverse interventions at the structural or national, community, household and individual levels. Some of these responses can be easily replicated, others require substantial adaptation, and some can inform development of new innovative offline and online responses to mitigate impact of COVID-19 on mental health of children and adolescents. Programs that mitigate economic impacts including child grants, income generating activities for caregivers, food distribution, health care vouchers, and other economic empowerment interventions can be replicated with minor adjustments. Helplines for vulnerable or abused children and shelters for victims of gender-based violence can be scaled up to respond to the COVID pandemic, with minimal adaptation to adhere to prevention of contagion. Mass media campaigns to combat stigma and discrimination were successfully employed in the HIV response, and similar interventions could be developed and applied in the COVID context. Some programs will need more substantial adjustments. In health facilities, mainstreaming child-sensitive mental health training of frontline workers and task sharing/shifting to community volunteers and social workers as was done for HIV with community health workers, could advance mental illness detection, particularly among abuse victims, but requires adaptation of protocols. At the community and household levels, expansion of parenting programs can help caregivers navigate negative mental health effects on children, however, these are not often operating at scale, nor well-linked to services. Programs requiring innovation include converting adolescent and youth safe physical spaces into virtual spaces particularly for at-risk girls and young women; organizing virtual community support groups, conversations, and developing online resources. Re-opening of schools and introduction of health and hygiene policies, provides another opportunity for innovation - to provide mental health and psychosocial support to all children as a standard package of care and practice.

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.

Examining the relationship between physical and sexual violence and psychosocial health in young people living with HIV in rural South Africa

Introduction

Experiences of violence during youth contravene young people’s rights and increase the risk of depression and poor human immunodeficiency virus (HIV) care outcomes among youth living with HIV (YLWH). Intervention targets for mitigating the negative psychosocial effects of violence are needed, particularly in areas like rural South Africa where violence remains pervasive and mental healthcare is limited. This study aims to quantify the associations between physical and sexual violence and depressive symptoms in YLWH in rural South Africa and explore the modification of these associations by key measures of psychosocial well‐being.

Methods

We conducted a cross‐sectional survey among 362 YLWH ages 12 to 24 in rural South Africa to ascertain participants’ history of physical and sexual violence, current depressive symptoms (Center for Epidemiological Studies‐Depression Scale) and levels of social support (Medical Outcomes Social Support Scale), resilience (Conner‐Davidson Resilience Scale) and self‐esteem (Rosenberg Self‐Esteem Scale). Log‐binomial regression was used to estimate the association between history of physical or sexual violence and clinically meaningful depressive symptoms (scores ≥16). Effect measure modification by high versus low resilience, social support and self‐esteem was assessed using likelihood ratio tests (α = 0.20).

Results

A total of 334 individuals with a median age of 21 (interquartile range: 16 to 23) were included in this analysis. Most participants were female (71.3%), single (81.4%) and attending school (53.0%). Ninety‐four participants (28.1%) reported a history of physical or sexual violence and 92 individuals (27.5%) had clinically meaningful depressive symptoms. Meaningful depressive symptoms were significantly higher among participants with a history of physical or sexual violence as compared to those with no history of violence (adjusted prevalence ratio: 2.01; 95% CI: 1.43, 2.83). However, this association was significantly modified by social support (p = 0.04) and self‐esteem (p = 0.02).

Conclusions

In this setting, the prevalence of meaningful depressive symptoms was significantly higher among YLWH with a history of physical or sexual violence as compared to those without a history of violence. However, higher levels of self‐esteem or social support appeared to mitigate this association. Programmes to improve self‐esteem and social support for youth have the potential to minimize depressive symptoms in YLWH who have experienced physical or sexual violence.

Evaluating potential mediators for the impact of a family-based economic intervention (Suubi+Adherence) on the mental health of adolescents living with HIV in Uganda

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi + Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.

METHOD

We utilized data from Suubi + Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N = 702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi + Adherence intervention on adolescents' mental health.

RESULTS

Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.

CONCLUSIONS

Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.

The Impact of a Family-Based Economic Intervention on the Mental Health of HIV-Infected Adolescents in Uganda: Results From Suubi + Adherence

PURPOSE

This study examines the extent to which three mental health measures (hopelessness, depression, and poor self-concept) are improved through a family-based economic intervention implemented among adolescents living with HIV in Uganda.

METHODS

We used repeated measures from Suubi + Adherence, a large-scale 6-year (2012-2018) longitudinal randomized controlled trial. Bivariate analyses were conducted to test for observable group differences between the intervention and control conditions. Multilevel piecewise repeated measure mixed models were then conducted to assess hypothesized time × intervention interaction in changes in hopelessness, depression, and self-concept using participant-specific follow-up intervals.

RESULTS

At 24-month postintervention initiation, adolescents in the intervention condition reported a statistically significant lower hopelessness score than adolescents in the control condition (4.79 vs. 5.56; p = .018; N = 358). At 36-month follow-up, the intervention condition reported a statistically significant lower score on depression in the depression subgroup (N = 344) than the control condition (4.94 vs. 5.81; p = .029).

CONCLUSIONS

The results indicate that family-based economic interventions such as Suubi + Adherence can effectively improve the mental health of adolescents living with HIV who evidenced mental health challenges at baseline. Given the promising positive effects of these interventions, at least in the short term, future studies should investigate strategies to promote the sustainability of these mental health benefits.

Impact of Adverse Childhood Events on the Psychosocial Functioning of Children Affected by Parental HIV in Rural China

Introduction: Children affected by parental HIV are more likely than unaffected peers to experience trauma and are at-risk for negative psychological and social outcomes. This study aimed to examine the relationship between adverse childhood events and psychosocial functioning among children affected by parental HIV. Methods: A total of 790 children ages 6-17 from Henan, China were enrolled in a longitudinal, randomized controlled trial of a resilience-based psychosocial intervention. At baseline, children reported on numerous psychosocial factors, including trauma exposure, symptoms of anxiety and depression, and peer social functioning. We used linear regression analysis to test the direct effect of trauma exposure on peer social functioning. We then tested whether depression and anxiety symptoms served as two potential parallel mediators in the association between trauma exposure and peer social functioning. Results: Trauma exposure was significantly associated with poor peer social functioning (β = -0.10, p = 0.005) when controlling for key covariates. When depression and anxiety symptoms were added to the model, the association between trauma exposure and peer social functioning became nonsignificant. Instead, there were significant indirect effects from trauma exposure to peer social functioning via depression (β = -0.06, 95%CI[-0.09, -0.03]) and anxiety (β = -0.02, 95%CI[-0.04, -0.00]). Conclusion: This study is among the first to link trauma exposure to peer social functioning deficits for children affected by parental HIV and demonstrates that symptoms of anxiety and depression mediate this relationship. Findings underscore the need for comprehensive psychosocial support for children affected by HIV, including screening for trauma exposure and mental health disorders.

Play profiles of children with HIV/Aids: A comparative study

INTRODUCTION

Despite play being widely used in occupational therapy practice as a means and ends in intervention, no research has explored how the play of children with HIV/AIDS is affected. Therefore, the specific processes through which play can be used in therapy with children with HIV/AIDS remains underexplored, especially in low resourced settings. This study aims to compare the level of playfulness of children with HIV/AIDS to that of age and gender matched typically developing children living in the same low resourced community.

METHODS

The Test of Playfulness (ToP) was used to examine the differences and similarities of play between children aged 4-7 years who are typically developing children (n = 52) and children with HIV/AIDS who receive antiretroviral treatment (n = 44). Each child was video recorded playing with a familiar playmate both indoors and outdoors. The videos were scored by two independent raters who were blinded to all aspects of the study. Scores were subjected to Rasch analysis to calculate interval level measure scores. Independent t-tests were used to compare differences between the means of the groups.

RESULTS

Typically developing children scored significantly higher when playing outdoors, as compared to children with HIV [t (94) = 3.57, p = .001]. There was no significant difference between mean measure scores for indoor play when comparing typically developing children and children with HIV. Children who are HIV positive scored significantly lower than typically developing children on items related to the ability to suspend reality and framing in both indoor and outdoor environments.

CONCLUSIONS

Children with HIV/AIDS exhibited lower levels of playfulness when compared to typically developing children. This study provides insight on the play profiles of children with HIV/AIDS, highlighting play deficits and differences between indoor and outdoor play. Occupational therapy can play a significant role in promoting playfulness in children with HIV/AIDS.

Prospective associations between bullying victimisation, internalised stigma, and mental health in South African adolescents living with HIV

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.

Individual Psychosocial Resilience, Neighborhood Context, and Cardiovascular Health in Black Adults: A Multilevel Investigation From the Morehouse-Emory Cardiovascular Center for Health Equity Study

BACKGROUND

Despite well-documented cardiovascular disparities between racial groups, within-race determinants of cardiovascular health among Black adults remain understudied. Factors promoting cardiovascular resilience among Black adults in particular warrant further investigation. Our objective was to examine whether individual psychosocial resilience and neighborhood-level cardiovascular resilience were associated with better cardiovascular health in Black adults, measured utilizing Life's Simple 7 (LS7) scores.

METHODS

We assessed LS7 scores in 389 Black adults (mean age, 53±10 years; 39% men) living in Atlanta, Georgia. A composite score of individual psychosocial resilience was created by assessing environmental mastery, purpose in life, optimism, resilient coping, and depressive symptoms. Neighborhood-level cardiovascular resilience was separately determined by the census tract-level rates of cardiovascular mortality/morbidity events. Generalized linear mixed regression models were used to examine the association between individual psychosocial resilience, neighborhood cardiovascular resilience, and LS7 scores.

RESULTS

Higher individual psychosocial resilience was significantly associated with higher LS7 (β=0.38 [0.16-0.59] per 1 SD) after adjustment for sociodemographic factors. Similarly, higher neighborhood-level cardiovascular resilience was significantly associated with higher LS7 (β=0.23 [0.02-0.45] per 1 SD). When jointly examined, high individual psychosocial resilience (>median) was independently associated with higher LS7 (β=0.73 [0.31-1.17]), whereas living in high-resilience neighborhoods (>median) was not. The largest difference in LS7 score was between those with high and low psychosocial resilience living in low-resilience neighborhoods (8.38 [7.90-8.86] versus 7.42 [7.04-7.79]).

CONCLUSIONS

Individual psychosocial resilience in Black adults is associated with better cardiovascular health.

Depressive symptoms among children attending community based support in South Africa - pathways for disrupting risk factors

Children in Southern Africa are exposed to high rates of structural and family adversities. This study tests whether services from Community Based Organisations (CBOs) in South Africa can promote children's resilience against depression exposed to such adversities. Two linked longitudinal studies were conducted, comprising n = 1848 children aged 9 to 13 years. One group received CBO services, whilst the other (quasi-control) did not. Analyses used interaction terms in regression models to test for potential moderation effects of CBO attendance, and marginal effects models to interpret significant interactions. Two interaction effects were shown, demonstrating moderation effects of CBO attendance on common structural disadvantages. First, children exposed to community violence showed increased depression (contrast = 0.62 [95%CI 0.43, 0.82], p < .001), but this association was removed by CBO access (contrast = 0.07 [95%CI -0.28, 0.43], p = .682). Second, children living in informal housing showed increased depression (contrast = 0.63 [95%CI 0.42, 0.85], p < .001), however, this association was removed by CBO access (contrast = 0.01 [95%CI -0.55, 0.56], p = .977). CBO attendance is associated with fewer depressive symptoms, and can buffer against important structural adversities of poor housing and violence that are common in high HIV-prevalence areas. However, CBO attendance was not able to remove the increased psychosocial distress associated with some family-level vulnerabilities such as orphanhood and abuse. These findings highlight the centrality of CBO-provided psychosocial support for children in Southern Africa, and suggest areas for bolstering provision.

A Rehabilitation Framework for Children Living With HIV in South Africa: Reaching Consensus for a Resource-Poor Community

Although rehabilitation frameworks for adults living with HIV are developing steadily, interventions to ensure the integration of rehabilitation into the routine care of children living with HIV-related disabilities lags. We sought to explore perceptions of, and gain expert consensus on, a rehabilitation framework for children living with HIV. Experts in HIV pediatric care in South Africa engaged in a Delphi survey, based on findings from a context-specific rehabilitation framework for adults. Consensus was determined by an a priori threshold of 80% agreement and an interquartile range of 1 or lower on criteria to be included as essential or useful in the framework. Experts agreed that enhancing access to patient-centered care through decentralization and training of health care and community care workers in the use of disability screening tools at each point of care needed to be included in the framework. Strengthening multiprofessional team collaboration was also seen as fundamental.

Teachers' quality of work life and attitudes toward implementing a psychosocial intervention for children affected by parental HIV/AIDS: roles of self-efficacy and burnout

ABSTRACT Several studies have highlighted that facilitators' attitudes toward interventions are crucial for implementing innovative psychosocial interventions. However, in the emerging implementation science field, little research has examined how organizational and individual factors may influence teachers' positive attitudes and readiness toward evidence-based interventions. The current study investigated the association between teachers' quality of work life and their attitudes toward an innovative psychosocial intervention for children affected by parental HIV/AIDS; the study also probed the potential indirect roles of self-efficacy and burnout. A total of 157 teachers with different levels of involvement in the intervention study were recruited from 47 schools. Our results revealed that teachers' quality of work life was positively associated with their attitudes toward the intervention directly and indirectly through enhanced self-efficacy and reduced burnout. The findings highlight the importance of organizational and individual factors in successfully implementing innovative psychosocial interventions for vulnerable children in organizations such as schools. Researchers should work with organizations to provide the necessary quality of work life and sufficient training to semi-professionals in order to boost their self-efficacy, reduce their burnout, and improve their attitudes toward innovative intervention programs to achieve the expected effectiveness of the interventions, particularly in resource-limited regions.

Effects of psychosocial interventions on children affected by parental HIV/AIDS: a meta-analysis on depression and anxiety

Background

Children orphaned by parental AIDS or those of parents with HIV infection demonstrate many negative mental health outcomes. Different types of psychosocial interventions have been conducted to improve the psychological well-being of these children. The efficacy of these psychosocial interventions has been reviewed and synthesized recently (Skeena et al., Vulnerable Child Youth Stud 12:91-116, 2017), but not quantified.

Method

This study therefore adopted meta-analytic approach to quantify the efficacy of the existing psychosocial interventions on depressive and anxiety symptoms in children affected by parental HIV/AIDS. Eight intervention studies—four randomized controlled trials (RCT) and four pre–post intervention trials—were included.

Result

In general, psychosocial interventions could effectively reduce anxiety or depressive symptoms in children of parents with HIV/AIDS. The overall intervention effect size (Cohen’s d) was 1.298 and 1.100 for depressive and anxiety symptoms, respectively. Publication bias and exploratory moderating effects of study design (RCT vs. pre–post intervention trials), study location, and intervention levels were also analyzed.

Conclusion

Future studies reporting the detailed outcome data, which could be used for research integration, are warranted. Further research should also focus on the implementation of evidence-based interventions sensitive to the target population in a developmentally appropriate manner.

A qualitative study to understand how Ebola Virus Disease affected nutrition in Sierra Leone-A food value-chain framework for improving future response strategies

BACKGROUND

This study sought understand how the 2014-2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude.

METHODOLOGY

This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures.

RESULTS

The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement.

CONCLUSIONS

Infectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings.

Psycho-educational and social interventions provided for orphans and vulnerable children at a community-based organisation in Soweto, South Africa

This qualitative study explored the psycho-educational and social interventions provided for orphans and vulnerable children (OVC) in a community-based organisation (CBO) in Soweto, South Africa. The study involved 12 OVC (males = 40%, and females = 60%; aged 10 to 18 years). Data was collected using individual interviews, focus group discussions, and autobiographies. The thematically analysed data revealed that the OVC received psychological interventions through mentorship and peer-group support in the CBO. Educational interventions included the provision of school uniforms and educational materials, as well as sponsorship of tuition, sports and excursion fees. Academic track records presented a challenge, however, which was attributed to the enormous numbers of OVC under the care of the CBO. It was further established that social interventions were addressed by empowering the OVC with life skills and providing economic support for their families, specifically to pay rent and provide meals. The major contributions of this study are to note the importance of the CBO in addressing issues related to the lack of counselling, the stigmatisation of OVC by community members and the need for empowerment of their families by providing income-generating activities. The information obtained is useful in opening up avenues for interested parties to further explore the effectiveness of these psycho-educational and social interventions in improving the lives of OVC in society.

Improving psychological outcomes for orphans living with HIV in Tanzania through a novel intervention to improve resilience: findings from a pilot RCT

Parental death and HIV are associated with poor mental health for orphans in sub-Saharan Africa. This study aimed to evaluate a theory-based intervention for orphaned children on treatment in Tanzania, in terms of feasibility, acceptability and preliminary outcomes. A pilot RCT with nested focus group (FGD) allocated 48 children to usual care or residential "Memory Work Therapy". Children completed outcome measures at T0 (baseline), T1 (2 weeks following intervention) and T2 (9 weeks from T0). Forty percent of eligible children assented. T1 intervention effects were found on all total measures: Brief Symptom Inventory d = 0.99, p < .001; Rosenberg Self Esteem Scale d = 0.65, p = .001; Strengths and Difficulties Questionnaire d = 0.64, p = .002; Self-efficacy questionnaire for children both "social" and "emotional" subscales, d = 0.54, p = .008 and d = 0.63, p = .002, respectively. At T2, significant effects remained for all measures and SES effect increased from medium to large (T1 = 0.65, T2 = 1.33). FGD data found children valued a calm environment that met their basic needs, enabling them to reflect, highlight support resources, and strengthen ability to recognize personal skills. The intervention has strong feasibility and acceptability, with no attrition or missing data. Memory Work Therapy has high potential effect size and should be tested in a fully powered trial. Clinical trials.gov NCT02180750.

A longitudinal evaluation of an intensive residential intervention (camp) for 12-16 year olds living with HIV in the UK: evidence of psychological change maintained at six month follow-up

There are large numbers of young people with HIV globally, the majority of whom have perinatally acquired HIV (PAH). Despite evidence of lower levels of wellbeing in young people with PAH compared to HIV unaffected peers, there are few psychosocial interventions for this population. Residential interventions (camps) for young people with HIV have the potential for enhancing well-being and improving HIV-related outcomes. There have not been any quantitative evaluations of camps for young people with HIV. This study evaluated a week-long intensive residential intervention for 12-16 year olds living with HIV in the UK. A quantitative repeated measures design was used. Forty nine participants completed assessments before and immediately after the intervention (post-intervention) and at six month follow-up (73% retention rate; 28 (57%) female; median age 14 years, IQR 13-15 years). Self-report measures suggested improvements in both HIV knowledge and pro HIV disclosure affect and cognitions post-intervention, maintained at six month follow-up. There were improvements in antiretroviral adherence beliefs from baseline to six month follow-up, and in self-perception from baseline to post-intervention. These changes are important in their own right but may also be mediators of other outcomes such as increased ART adherence and reduced onward HIV transmission risk. The study suggests that brief residential interventions have the potential to facilitate sustained change in psychological outcomes. Research and practice implications are outlined.