Cohort Profile: The Siyakhula Cohort, rural South Africa

Psychometric properties of the ASEBA Child Behaviour Checklist and Youth Self-Report in sub-Saharan Africa - A systematic review

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.

Validation of Oxford Cognitive Screen: Executive Function (OCS-EF), a tablet-based executive function assessment tool amongst adolescent females in rural South Africa

Short, reliable, easily administered executive function (EF) assessment tools are needed to measure EF in low- and middle-income countries, particularly in sub-Saharan Africa given the prevalence of human immunodeficiency virus (HIV)-associated neurocognitive disorder. We administered Oxford Cognitive Screen-Executive Function (OCS-EF) to 932 rural South African females (mean age 19.7 years). OCS-EF includes seven tasks: two hot inhibition tasks (a modified Iowa Gambling Task, emotional go/no-go) and five cool EF tasks, two switching tasks (visuospatial rule-finding, geometric trails) and three working memory tasks (digit recall, selection and figure drawing). We performed confirmatory factor analysis testing whether a three-factor, two-factor hot-cool, two-factor working memory and inhibition/switching, or one-factor EF model fitted the data better. The three-factor (switching, inhibition and working memory) model had the best local and global fit (χ² (11) 24.21, p = 0.012; RMSEA 0.036; CFI 0.920; CD 0.617). We demonstrated the feasibility of OCS-EF administration by trained laypeople, the tripartite structure of EF amongst adolescent females and the factorial validity of OCS-EF in this population and context. OCS-EF tablet-based cognitive assessment tool can be administered by trained laypeople and is a valid tool for assessing cognition at scale amongst adolescents in rural South Africa and similar environments.

Breastfeeding, HIV exposure, childhood obesity, and prehypertension: A South African cohort study

BACKGROUND

Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent.

METHODS AND FINDINGS

The Siyakhula cohort (2012-2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother's age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21-0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26-0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38-1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47-10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65-7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall.

CONCLUSIONS

To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women.

Confirmatory factor analysis of the Kaufman assessment battery in a sample of primary school-aged children in rural South Africa

The Kaufman Assessment Battery for Children, Second Edition, measures cognitive processing, includes non-verbal sub-tests, and is increasingly used in low- and middle-income countries. While the Kaufman Assessment Battery for Children, Second Edition, has been validated in the United States, a psychometric evaluation has not been conducted in Southern Africa. This study aims to establish the reliability and validity of the Kaufman Assessment Battery for Children, Second Edition, among a sample of 376 primary school-aged children in rural South Africa (7–11 years). We examined Cronbach’s alpha and conducted a confirmatory factor analysis. The battery showed good reliability (mental processing index [α = .78]), and the originally validated structure of the Kaufman Assessment Battery for Children, Second Edition, was maintained (χ2 = 16.30, p = .432). Mean scores were low on the Planning sub-scale. On the Simultaneous sub-scale, the mean score was higher for the supplementary sub-test Block Counting versus the core sub-test Triangles. With translation and the inclusion of supplementary sub-tests, the Kaufman Assessment Battery for Children, Second Edition, is an appropriate assessment to use in this context (150/150).

Psychological morbidity and parenting stress in mothers of primary school children by timing of acquisition of HIV infection: a longitudinal cohort study in rural South Africa

Longitudinal maternal mental health data are needed from high HIV prevalence settings. The Siyakhula Cohort (SC) is a population-based cohort of HIV-positive and negative mothers (n=1506) with HIV-negative children (n=1536) from rural South Africa. SC includes 767 HIV-negative mothers; 465 HIV-positive in pregnancy; 272 HIV-positive since pregnancy (n=2 missing HIV status). A subgroup (n=890) participated in a non-randomized breastfeeding intervention [Vertical Transmission Study (VTS)]; the remaining (n=616) were resident in the same area and received antenatal care at the time of the VTS, but were not part of the VTS, instead receiving the standard of care Prevention of Mother-to-Child Transmission (PMTCT) Programme. In secondary analysis we investigated the prevalence of, and factors associated with, psychological morbidity amongst mothers who were still the primary caregiver of the child (1265 out of 1506) at follow-up (7-11 years post-birth). We measured maternal depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7) and parenting stress (Parenting Stress Index-36), using standardized cut-offs and algorithms. In total, 75 (5.9%) mothers met criteria for depression, 37 (2.9%) anxiety and 134 (10.6%) parenting stress. Using complete case logistic regression (n=1206 out of 1265 mothers) as compared to being HIV-negative, testing HIV-positive in pregnancy doubled odds of depression [adjusted odd ratios (aOR)=1.96 [1.0-3.7] P=0.039]. Parenting stress was positively associated with acquisition of HIV after pregnancy (aOR=3.11 [1.9-5.2] P<0.001) and exposure to household crime (aOR=2.02 [1.3-3.2] P=0.003); negatively associated with higher maternal education (aOR=0.29 [0.1-0.8] P=0.014), maternal employment (aOR=0.55 [0.3-0.9] P=0.024). Compared with the standard of care PMTCT, VTS mothers had reduced odds of parenting stress (aOR=0.61 [0.4-0.9] P=0.016). Integrating parental support into mostly bio-medical treatment programmes, during and beyond pregnancy, is important.