Persisting mental health problems among AIDS-orphaned children in South Africa

Symptoms of Depression, Anxiety and Their Co-Occurrence among Orphaned Children in Sekhukhune District, Limpopo Province

Although both short- and long-term psychological challenges, specifically depression and anxiety, have been reported among orphans, there is a dearth of studies that quantify these disorders in rural settings. The aim of the study was to screen for symptoms of depression, anxiety and their co-occurrence among orphaned school-going children in rural Limpopo province, South Africa. Data were collected among primary school children in 10 schools in two villages in Limpopo province. The Revised Child Anxiety and Depression Scale (RCADS) was used to screen for symptoms of depression, anxiety and their co-occurrence among 308 orphaned learners in the selected schools. A questionnaire was used to collect socio-demographic data. STATA 13 was used to analyse the data. Descriptive statistics were used to determine the symptoms and severity of depression, anxiety and their co-occurrence. The sample of 308 consisted of the majority (60.71%) residing in Maandagshoek and being female (54.22%). Their ages ranged from 8 to 12 years, with a mean of 10.51 years. The prevalence of symptoms of depression, anxiety and co-occurrence of anxiety and depression were 23.05%, 34.09% and 32.14%, respectively. The prevalence of mental health symptoms was high among the sample. There is a need to expand the care of orphans to include mental health and not just limit their care to provide food to vulnerable children.

Protocol for the OCAY study: a cohort study of orphanhood and caregiver loss in the COVID-19 era to explore the impact on children and adolescents

INTRODUCTION

Globally, no person has been untouched by the COVID-19 pandemic. Yet, little attention has been given to children and adolescents in policy, provision and services. Moreover, there is a dearth of knowledge regarding the impact of COVID-19-associated orphanhood and caregiver loss on children. This study aims to provide early insights into the mental health and well-being of children and adolescents experiencing orphanhood or caregiver loss in South Africa.

METHODS AND ANALYSIS

Data will be drawn from a quantitative longitudinal study in Cape Town, South Africa. A sample of children and adolescents between the ages of 9 and 18 years, experiencing parental or caregiver loss from COVID-19, will be recruited together with a comparison group of children in similar environments who did not experience loss. The study aims to recruit 500 children in both groups. Mental health and well-being among children will be explored through the use of validated and study-specific measures. Participants will be interviewed at two time points, with follow-up data being collected 12-18 months after baseline. A combination of analytical techniques (including descriptive statistics, regression modelling and structural equation modelling) will be used to understand the experience and inform future policy and service provision.

ETHICS AND DISSEMINATION

This study received ethical approval from the Health Research Ethics Committee at Stellenbosch University (N 22/04/040). Results will be disseminated via academic and policy publications, as well as national and international presentations including high-level meetings with technical experts. Findings will also be disseminated at a community level via various platforms.

Bridges-Round 2: A study protocol to examine the longitudinal HIV risk prevention and care continuum outcomes among orphaned youth transitioning to young adulthood

BACKGROUND

Youth orphaned by HIV in sub-Saharan Africa experience immense hardships including social disadvantage, adverse childhood events and limited economic prospects. These adversities disrupt the normative developmental milestones and can gravely compromise their health and emotional wellbeing. The Bridges to the Future study (2012-2018) prospectively followed 1,383 adolescents, between 10-16 years, to evaluate the efficacy and cost-effectiveness of a family-based economic empowerment intervention comprising of child development accounts, financial literacy training, family income generating activities and peer mentorship. Study findings show efficacy of this contextually-driven intervention significantly improving mental health, school retention and performance and sexual health. However, critical questions, such as those related to the longitudinal impact of economic empowerment on HIV prevention and engagement in care remain. This paper presents a protocol for the follow-up phase titled, Bridges Round 2.

METHODS

The Original Bridges study participants will be tracked for an additional four years (2022-2026) to examine the longitudinal developmental and behavioral health outcomes and potential mechanisms of the effect of protective health behaviors of the Bridges cohort. The study will include a new qualitative component to examine participants' experiences with the intervention, the use of biomedical data to provide the most precise results of the highly relevant, but currently unknown sexual health outcomes among study participants, as well as a cost-benefit analysis to inform policy and scale-up.

DISCUSSION

Study findings may contribute to the scientific knowledge for low-resource communities on the potential value of providing modest economic resources to vulnerable boys and girls during childhood and early adolescence and how these resources may offer long-term protection against known HIV risks, poor mental health functioning and improve treatment among the HIV treatment care continuum.

Long-Term Post-Transition Outcomes of Adolescents and Young Adults Living With Perinatally and Non-perinatally Acquired HIV in Southeast Asia

PURPOSE

We assessed factors associated with clinical, social, and behavioral outcomes of adolescents and young adults with HIV (AYHIV) in Southeast Asia after transition from pediatric to adult HIV care.

METHODS

AYHIV in Malaysia, Thailand, and Vietnam were prospectively followed through annual clinical assessments and laboratory testing. Data were described descriptively and a generalized estimating equation was used to calculate independent predictors for HIV viremia (>40 copies/mL).

RESULTS

A total of 93 AYHIV were followed until February 2019: 60% female, 94% acquired HIV perinatally, 81% Thai, median age 20 (interquartile range, 18-21) years. The median follow-up time was 94 (91-100) weeks; 88% completed the study. At week 96, median CD4 was 557 cells/mm³ (interquartile range, 337-786), 77% had suppressed HIV viral load, 39% reported recent alcohol use, 49% had been sexually active, 53% of females and 36% of males intended to have children, and 23% screened positive for moderate depression (Patient Health Questionnaire-9 score ≥9) or reported suicidal ideation. HIV viremia was associated with <90% adherence to HIV treatment (adjusted incidence rate ratio [aIRR] 2.2 [1.28-3.78]), CD4 count ≤500 cells/mm³ (aIRR 4.75 [2.11-10.69]), and being on a nonnucleoside reverse transcriptase inhibitor regimen (vs. protease inhibitor aIRR 2.71 [1.13-6.49]). Having a trusted person to talk with about their feelings was protective (vs. never; usually or always, aIRR 0.41 [0.18-0.92]).

DISCUSSION

After transition to adult HIV care, there were indications of social isolation and mental health problems that could prevent these AYHIV from maintaining control over their HIV infection and hinder progress toward social independence.

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

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

Suubi4StrongerFamilies: A study protocol for a clustered randomized clinical trial addressing child behavioral health by strengthening financial stability and parenting among families in Uganda

Background

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs. Across the region, high rates of poverty, HIV/AIDS, food insecurity, stigma, and an inadequate health safety net system exacerbate serious child behavioral health needs and impede an effective response. Disruptive behavioral disorders are particularly concerning as they persist through adolescence and adulthood. Hence, addressing the context-specific social influences on child behavioral health is critical given that children in the region comprise more than half of the total regional population. Against this backdrop, this study protocol describes a randomized clinical trial that will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial, and context-specific drivers affect the mental health of children in Uganda.

Methods

The study uses an experimental, longitudinal design across 30 cluster-randomized primary schools to compare single and combination intervention options; influences of economic empowerment and family strengthening on economic, perceptual, and functioning mediators; and context-specific moderators. The study will be conducted with 900 Ugandan children in mid-upper primary school (10-14 years). The three study conditions (n = 300 each) are: (1) economic empowerment only (EE only), (2) multiple family group-based family strengthening only (MFG-based FS only), and (3) combined EE + MFG-based FS. The interventions will be provided for 12 months; and assessments will occur at baseline, 12, 24, and 36 months.

Conclusion

Children in Sub-Saharan Africa are burdened by significant unmet mental health needs, including disruptive behavior disorders that persist through adolescence and adulthood if left untreated. The proposed study will examine the mechanisms by which economic empowerment and family strengthening interventions targeting social, familial and context-specific drivers affect the mental health of children in mid-upper primary schools in Uganda. Findings from this study can inform group, community, and population approaches that are needed for scalable solutions to address the social drivers negatively impacting child behavioral health in low-resource settings, including in Sub-Saharan Africa.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT053 68714].

Global child and adolescent mental health perspectives: bringing change locally, while thinking globally

Child and adolescent mental health (CAMH) are a global priority. Different countries across the globe face unique challenges in CAMH services that are specific to them. However, there are multiple issues that are also similar across countries. These issues have been presented in this commentary from the lens of early career CAMH professionals who are alumni of the Donald J Cohen Fellowship program of the IACAPAP. We also present recommendations that can be implemented locally, namely, how promoting mental health and development of children and adolescents can result in better awareness and interventions, the need to improve quality of care and access to care, use of technology to advance research and practices in CAMH, and how investing in research can secure and support CAMH professionals and benefit children and adolescents across the globe. As we continue to navigate significant uncertainty due to dynamic circumstances globally, bolstering collaborations by "bringing change locally, while thinking globally" are invaluable to advancing global CAMH research, clinical service provision, and advancement of the field.

A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa

Adolescents with grandparent caregivers have experienced challenges including the death of one or both parents due to HIV in sub-Saharan Africa. They may be left out of existing HIV prevention interventions targeting parents and children. We investigated the facilitators and barriers to DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) programme uptake among adolescents with grandparent caregivers across different levels of the socio-ecological model in rural South Africa. Data were collected in three phases (October 2017 to September 2018). Adolescents (13-19 years old) and their grandparent caregivers (≥50 years old) (n = 12) contributed to repeat in-depth interviews to share their perceptions and experiences regarding adolescents' participation in DREAMS. Data were triangulated using key informant interviews with DREAMS intervention facilitators (n = 2) to give insights into their experiences of delivering DREAMS interventions. Written informed consent or child assent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed verbatim and translated into English. Thematic and dyadic analysis approaches were conducted guided by the socio-ecological model. Participation in DREAMS was most effective when DREAMS messaging reinforced existing norms around sex and sexuality and when the interventions improved care relationships between the adolescents and their older caregivers. DREAMS was less acceptable when it deviated from the norms, raised SRH information that conflicts with abstinence and virginity, and when youth empowerment was perceived as a potential threat to intergenerational power dynamics. While DREAMS was able to engage these complex families, there were failures, about factors uniquely critical to these families, such as in engaging children and carers with disabilities and failure to include adolescent boys in some interventions. There is a need to adapt HIV prevention interventions to tackle care relationships specific to adolescent-grandparent caregiver communication.

HIV and suicide risk across adolescence and young adulthood: an examination of socio-demographic, contextual and psychosocial risk factors for attempted suicide in a longitudinal cohort of ageing adolescents affected by HIV living in the New York City Area

Introduction

As children become adolescents and young adults (AYA), their risk for attempting suicide increases dramatically, with chronic health conditions an important risk factor. This study examined correlates of suicidality across development in AYA living with perinatally acquired HIV (AYALPHIV) and those perinatally HIV‐exposed but uninfected (AYAPHEU).

Methods

Data come from an ongoing longitudinal New York City‐based study (N = 339) with AYALPHIV and AYAPHEU interviewed every 12–18 months from 2003 to 2019 (mean enrolment age = 12 years; current mean age = 27 years). The Diagnostic Interview Schedule for Children (adolescent or young adult version) assessed psychiatric disorders and first‐reported suicide attempt. Generalized estimating equations were used to examine associations between first‐reported suicide attempt and socio‐demographic, contextual and psychosocial correlates measured concurrently across six timepoints.

Results

At enrolment, 51% of participants were female, 72% heterosexual, 60% Black and 50% Latinx. Attempted suicide was significantly higher among AYALPHIV (27%, CI 21–33%) compared to AYAPHEU (16%, CI 10–22%), with an OR of 1.74 (CI 1.04–2.92) in a model adjusting for age. For AYALPHIV, anxiety (OR 2.66, CI 1.46–4.85), mood (OR 3.62, CI 1.49–8.81) and behaviour disorders (OR 5.05, CI 2.15–11.87) and past‐year arrest (OR 3.05, CI 1.26–7.4), negative life events (OR 1.27, CI 1.11–1.46), city stress (OR 2.28, CI 1.46–3.57), pregnancy (OR 2.28, CI 1.08–4.81) and HIV stigma (OR 2.46, CI 1.27–4.75) were associated with increased odds of attempted suicide, while identifying as heterosexual (OR 0.27, CI 0.14–0.52), higher personal (OR 0.45, CI 0.26–0.80) and family self‐concept (OR 0.36, CI 0.22–0.57) were protective. Interactions by HIV status and age were found: substance use was more strongly associated with attempted suicide among AYAPHEU than AYALPHIV, while negative life events and higher religiosity were more strongly associated with increased odds of attempted suicide among AYA ≥ 19 versus ≤ 18 years.

Conclusions

AYALPHIV compared to AYAPHEU faced unique risks for attempted suicide as they age into adulthood, with the highest risk among AYALPHIV experiencing HIV stigma or pregnancy and the highest risk among AYAPHEU with substance use. Assessing for suicide risk and correlates with attention to ageing can inform preventive interventions tailored to meet AYALPHIV and AYAPHEU needs.

Violence Exposure, Self-Reported Mental Health Concerns and Use of Alcohol and Drugs for Coping among Youth in the Slums of Kampala, Uganda

This study aimed to a) compute the prevalence of violence exposure types, polyvictimization, and self-reported depression, anxiety, and using substances to cope among youth ages 12 to 18 years living on the streets or in the slums of Kampala, Uganda, (b) examine the independent associations among orphan status, violence exposure types, and self-reported mental health concerns, and c) explore the association between polyvictimization and mental health concerns. Data are from a 2014 cross-sectional survey of service-seeking youth ages 12 to 18 years (N = 1134) in Kampala, Uganda. Violence exposure types explored in this study were: witnessing family physical violence, direct physical abuse by a parent, any rape history, and physical dating violence. We used descriptive statistics and multivariable logistic regression to test study objectives. Over half of the sample (60.5%) reported experiencing at least one type of violence exposure; many youth endorsed self-reported depression (57.8%), anxiety (76.8%), and substance use to cope (37.0%). Exposure to violence was associated with higher odds for self-reported depression, anxiety, and using substances to cope. These findings underscore the urgent need to implement evidence-based interventions among this young, underserved population and their families to prevent violence, improve mental health outcomes, and promote resilience.

Childhood Trauma and Mental Health in the Cape Town Adolescent Antiretroviral Cohort

This study aimed to assess the association of childhood trauma, stressful life events and HIV stigma with mental health in South African adolescents from the Cape Town Adolescent Antiretroviral Cohort (CTAAC). The Childhood Trauma Questionnaire, Life Events Questionnaire and the HIV Stigma Scale for South African Adolescents Living with HIV was used to assess childhood trauma, stressful life events and stigma in adolescents living with perinatally acquired HIV and healthy controls enrolled in the CTAAC. These measures were associated with mental health outcomes including the Beck-Youth Inventories, Child Behaviour Checklist, Columbian Impairment Scale, Childrens Motivation Scale, Conners Scale for Attention Deficit Hyperactivity Disorder using Pearson correlations and self-reported alcohol use, using Spearman-rank correlation. 63.7% of adolescents reported at least one childhood trauma on the CTQ. Significant associations were reported between CTQ measures and Beck-Youth Inventories. Emotional abuse was associated with anxiety, anger, depression and disruptive behaviour. Emotional neglect was associated with poor self-concept and disruptive behaviour. LEQ total score was significantly associated with Beck-Youth Inventories including anxiety, depression, anger and disruptive behaviour scales. HIV stigma was significantly associated with Beck-Youth Inventories including depression, anger and disruptive behaviour. Childhood trauma, stressful life events and HIV stigma in South African adolescents are associated with anxiety, depression, anger, disruptive-behaviour and poor self-concept. This study highlights the importance of enquiring about exposure to a variety of traumas, particularly those commonly experienced by South African adolescents. In addition, it is important to understand the impact of trauma exposure on each individuals mental health and functioning.

Comparative effectiveness of in-person vs. remote delivery of the Common Elements Treatment Approach for addressing mental and behavioral health problems among adolescents and young adults in Zambia: protocol of a three-arm randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), there is a substantial gap in the treatment of mental and behavioral health problems, which is particularly detrimental to adolescents and young adults (AYA). The Common Elements Treatment Approach (CETA) is an evidence-based, flexible, transdiagnostic intervention delivered by lay counselors to address comorbid mental and behavioral health conditions, though its effectiveness has not yet been tested among AYA. This paper describes the protocol for a randomized controlled trial that will test the effectiveness of traditional in-person delivered CETA and a telehealth-adapted version of CETA (T-CETA) in reducing mental and behavioral health problems among AYA in Zambia. Non-inferiority of T-CETA will also be assessed.

METHODS

This study is a hybrid type 1 three-arm randomized trial to be conducted in Lusaka, Zambia. Following an apprenticeship model, experienced non-professional counselors in Zambia will be trained as CETA trainers using a remote, technology-delivered training method. The new CETA trainers will subsequently facilitate technology-delivered trainings for a new cohort of counselors recruited from community-based partner organizations throughout Lusaka. AYA with mental and behavioral health problems seeking services at these same organizations will then be identified and randomized to (1) in-person CETA delivery, (2) telehealth-delivered CETA (T-CETA), or (3) treatment as usual (TAU). In the superiority design, CETA and T-CETA will be compared to TAU, and using a non-inferiority design, T-CETA will be compared to CETA, which is already evidence-based in other populations. At baseline, post-treatment (approximately 3-4 months post-baseline), and 6 months post-treatment (approximately 9 months post-baseline), we will assess the primary outcomes such as client trauma symptoms, internalizing symptoms, and externalizing behaviors and secondary outcomes such as client substance use, aggression, violence, and health utility. CETA trainer and counselor competency and cost-effectiveness will also be measured as secondary outcomes. Mixed methods interviews will be conducted with trainers, counselors, and AYA participants to explore the feasibility, acceptability, and sustainability of technology-delivered training and T-CETA provision in the Zambian context.

DISCUSSION

Adolescents and young adults in LMIC are a priority population for the treatment of mental and behavioral health problems. Technology-delivered approaches to training and intervention delivery can expand the reach of evidence-based interventions. If found effective, CETA and T-CETA would help address a major barrier to the scale-up and sustainability of mental and behavioral treatments among AYA in LMIC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03458039 . Prospectively registered on May 10, 2021.

A Systematic Review and Meta-Analysis of Interventions for Orphans and Vulnerable Children Affected by HIV/AIDS Worldwide

BACKGROUND

Worldwide, there are more than 13.3 million orphans and vulnerable children affected by Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) (HIV OVC), defined as individuals below the age of 18 who have lost one or both parents to HIV/AIDS or have been made vulnerable by HIV/AIDS; they are at risk for negative psychosocial and cognitive outcomes.

PURPOSE

This meta-analysis aimed to examine the scientific literature on available interventions for HIV OVC, with a focus on community-based interventions (CBI).

METHODS

Systematic electronic searches were conducted from four databases between October 2016 and April 2017 to identify articles investigating the effectiveness of interventions for HIV OVC. Effect sizes were calculated for each article which provided enough information and data points for analyses.

RESULTS

Seventy-four articles were reviewed, including psychosocial interventions (d = 0.30), cognitive interventions (d = 0.14), social protection interventions (d = 0.36), and community-based interventions (CBI; d = 0.36). Study-specific effect sizes varied widely, ranging from -1.09 to 2.26, that is, from a negative effect to an impressively large positive one, but the majority of studies registered small to medium effects (the overall effect size for all studies was 0.32, SE = 0.03, 95% CI: 0.26-0.37). Social protection interventions had the highest positive outcomes whereas CBI tended to have the fewest significant positive outcomes, with some outcomes worsening instead of improving.

CONCLUSIONS

Overall, interventions provided to OVC have potential for improving cognitive, psychosocial, and risk-behavior outcomes. Social protection interventions and CBI had the highest effect sizes, but CBI had positive effects on fewer outcomes and demonstrated some negative effects. CBI warrant scrutiny for improvement, as they represent an important form of culturally embedded services with potentially long-term benefits to OVC, yet appear to be differentially effective. Successful components of other types of intervention were identified, including cash grants, mentorship, and family therapy. In addition, more research is needed that attends to which interventions may be more effective for specific populations, or that studies cost-effectiveness.

Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya

IMPORTANCE

In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa.

OBJECTIVE

To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children's institutions, family-based settings, and street settings in western Kenya over almost 10 years.

DESIGN, SETTING, AND PARTICIPANTS

The Orphaned and Separated Children's Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children's institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019.

EXPOSURES

Care environment (family-based, institutional, or street setting).

MAIN OUTCOMES AND MEASURES

Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death.

RESULTS

Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children's institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55).

CONCLUSIONS AND RELEVANCE

In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study's findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale.

Coping strategies and mental health of adolescents impacted by parental HIV and AIDS in rural South Africa

Objective: The study explored whether orphanhood status as well as coping strategies predicted mental health outcomes in orphans and vulnerable adolescents who participated in an NGO-supported programme in rural South Africa.Method: Participants comprised 175 adolescents (aged 11-18 years) from a low-resource community, and included non-orphans (n = 57), orphans due to AIDS (n = 62) and orphans due to other causes (n = 56). All participants rated themselves on the age-appropriate Youth Self-Report scales and 95 completed the Children's Coping Strategies Checklist (CCSC). Little's test of data missing completely at random revealed that the CCSC missing data did not display a specific pattern.Results: Active coping negatively predicted internalising, externalising and general psychological problems, while avoidant coping predicted general psychological problems. Orphanhood group status, sex and age did not predict coping strategies used. A higher proportion of orphans by AIDS had elevated scores of internalising problems and all participants on somatic complaints.Conclusions: Active coping strategies minimise the risk for emotional and behavioural problems among the participants. Our findings suggest that agencies and non-governmental organisations that provide services to vulnerable adolescents can facilitate active coping skills to enhance their psychological well-being.

The impact of care environment on the mental health of orphaned, separated and street-connected children and adolescents in western Kenya: a prospective cohort analysis

Introduction

The effect of care environment on orphaned and separated children and adolescents’ (OSCA) mental health is not well characterised in sub-Saharan Africa. We compared the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC) and street-connected children and youth (SCY).

Methods

This prospective cohort followed up OSCA from 300 randomly selected households (FBC), 19 CCIs and 100 SCY in western Kenya from 2009 to 2019. Annual data were collected through standardised assessments. We fit survival regression models to investigate the association between care environment and mental health diagnoses.

Results

The analysis included 1931 participants: 1069 in FBC, 783 in CCIs and 79 SCY. At baseline, 1004 participants (52%) were male with a mean age (SD) of 13 years (2.37); 54% were double orphans. In adjusted analysis (adjusted HR, AHR), OSCA in CCIs were significantly less likely to be diagnosed with PTSD (AHR 0.69, 95% CI 0.49 to 0.97), depression (AHR 0.48 95% CI 0.24 to 0.97), anxiety (AHR 0.56, 95% CI 0.45 to 0.68) and suicidality (AHR 0.73, 95% CI 0.56 to 0.95) compared with those in FBC. SCY were significantly more likely to be diagnosed with PTSD (AHR 4.52, 95% CI 4.10 to 4.97), depression (AHR 4.72, 95% CI 3.12 to 7.15), anxiety (AHR 4.71, 95% CI 1.56 to 14.26) and suicidality (AHR 3.10, 95% CI 2.14 to 4.48) compared with those in FBC.

Conclusion

OSCA living in CCIs in this setting were significantly less likely to have incident mental illness, while SCY were significantly more, compared with OSCA in FBC.

Childhood trauma, major depressive disorder, suicidality, and the modifying role of social support among adolescents living with HIV in rural Uganda

BACKGROUND

Childhood trauma is associated with mental health problems among adolescents living with HIV (ALHIV) in sub-Saharan Africa, but little is known about potential moderating factors.

METHODS

We enrolled 224 ALHIV aged 13-17 years and collected information on childhood trauma, major depressive disorder, and suicidality. We used modified multivariable Poisson regression to estimate the association between the mental health outcome variables and childhood trauma, and to assess for effect modification by social support.

RESULTS

Major depressive disorder had a statistically significant association with emotional abuse (adjusted relative risk [ARR] 2.57; 95% CI 1.31-5.04; P=0.006) and physical abuse (ARR 2.16; 95% CI 1.19-3.89; P=0.01). The estimated association between any abuse and major depressive disorder was statistically significant among those with a low level of social support (ARR 4.30; 95% CI 1.64-11.25; P=0.003) but not among those with a high level of social support (ARR 1.30; 95% CI 0.57-2.98; P=0.52). Suicidality also had a statistically significant association with emotional abuse (ARR 2.03; 95% CI 1.05-3.920; P=0.03) and physical abuse (ARR 3.17; 95% CI 1.60-6.25.; P=0.001), but no differences by social support were noted.

LIMITATIONS

Corporal punishment is used widely in schools and homes as a form of discipline in Uganda; this cultural practice could have biased reporting about physical abuse.

CONCLUSIONS

Childhood trauma is associated with poor mental health among ALHIV, but its effects may be moderated by social support. More research is needed to develop social support interventions for ALHIV with adverse childhood experiences for improved mental health outcomes.

Child Mental Health in HIV-Impacted Low-Resource Settings in Developing Countries-Global Research Fellowship: A Research Training Program Protocol

Background: Uganda has one of the highest HIV/AIDS rates and poor mental health services. Children and adolescents in communities with persistent poverty, disease (including HIV/AIDS), and violence, are more likely to suffer from chronic mental health problems. Combined, these characteristics negatively impact communities' response to HIV and mental health beginning with children, adolescents, and young adults. Yet, there is limited research capacity in child and adolescent mental health (CAMH), especially in the HIV/AIDS context in Uganda. Hence, this NIH-funded research training program aims to: (1) train three cohorts of early-career investigators at universities or research institutions in Uganda; (2) connect fellows with committed mentors; and (3) define key factors for successful mentorship and training of new investigators. Methods: CHILD-GRF is a multi-component program that engages selected young investigators in year-round activities for 3 years. Paired with mentors from Washington University in St. Louis and academic institutions in Uganda, fellows participate in a 6-week intensive summer training each year. Year 1 focuses on didactic learning and mentorship. In Year 2, fellows design and conduct their pilot study. Year 3 is devoted to presenting pilot study findings, manuscript preparation/ submission and extramural grant writing. Discussion: CHILD-GRF seeks to provide a solid foundation for the development and implementation of evidence-based HIV prevention and mental health interventions for youth and families impacted by HIV/AIDS. By producing a sustainable network of well-trained individuals in key research institutions, this program contributes to improving CAMH and HIV prevention efforts, both of which have public health implications.

Not Enough Money and Too Many Thoughts: Exploring Perceptions of Mental Health in Two Ugandan Districts Through the Mental Health Literacy Framework

Mental health disorders account for a heavy disease burden in Uganda. In order to provide culturally appropriate mental health prevention and treatment approaches, it is necessary to understand how mental health is conceptualized in the population. Three focus group discussions (FGDs) and 31 in-depth interviews (IDIs) were conducted with men and women aged 14 to 62 years residing in rural, urban, and semi-urban low-income communities in central and western Uganda to explore perceptions and knowledge of mental health. Interpretive thematic analysis was undertaken; results were organized through the lens of the mental health literacy framework. Environmental and societal stressors were identified as primary underlying causes of poor mental health. While participants recognized symptoms of poor mental health, gaps in mental health literacy also emerged. Mental health resources are needed in this setting and additional qualitative work assessing knowledge and attitudes toward mental health care seeking behavior can inform the development of acceptable integrated services.

Suubi+Adherence-Round 2: A study protocol to examine the longitudinal HIV treatment adherence among youth living with HIV transitioning into young adulthood in Southern Uganda

BACKGROUND

Youth living with HIV (YLHIV) in Sub-Saharan African (SSA) are less likely to adhere to antiretroviral therapy (ART) and other health-related regimens. As a consequence, YLHIV are not only at risk for health problems and mental health comorbidities, but are also at risk for cognitive deficits, including in areas of memory and executive functioning. The Suubi+Adherence study followed 702 adolescents (10-16 years of age) receiving bolstered standard of care and a family economic empowerment intervention comprising an incentivized youth financial savings account (YSA) augmented with financial literacy training (FLT) and peer mentorship. The study findings pointed to superior short-term viral suppression and positive adolescent health and mental health functioning among participants receiving the intervention. The original group of adolescents who received Suubi+Adherence are now transitioning into young adulthood. This paper presents a protocol for the follow-up phase titled Suubi+Adherence Round 2.

METHODS

The original cohort in Suubi+Adherence will be tracked for an additional five years (2020-2025). Specifically, the long term follow-up will allow to: 1) ascertain the extent to which the short term outcomes identified in the first 6 years of the intervention are maintained as the same group transitions through young adulthood; and 2) address new scientific questions regarding ART adherence; HIV care engagement; protective health behaviors; and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. Additionally, the team examines the potential mechanisms through which the observed long-term outcomes happen. Moreover, the Suubi+Adherence-Round 2 adds a qualitative component and extends the cost effectiveness component.

DISCUSSION

Guided by asset and human development theories, Suubi+Adherence-R2 will build on the recently concluded Suubi+Adherence study to conduct one of the largest and longest running studies of YLHIV in SSA as they transition into young adulthood. The study will address new scientific questions regarding long-term ART adherence, HIV care engagement, protective health behaviors, and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. The findings may inform efforts to improve HIV care among Uganda's YLHIV, with potential replicability in other low-resource countries.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT01790373.

Psychological Distress Among Orphaned Youth and Youth Reporting Sexual Exploitation in Kampala, Uganda

Psychological distress is a priority health issue in low- and middle-income countries; however, it is inadequately addressed among vulnerable youth living in extremely underserved communities (i.e., on the streets and in the slums) who are at a high risk of experiencing adversity. The purpose of this study was to compute the prevalence of self-reported psychological distress among youth living in the slums of Kampala, Uganda, and examine how orphan status and commercial sexual exploitation (CSE) are related to youth psychological distress. Analyses are based on a 2014 cross-sectional survey of service-seeking youth (N = 1134) in Kampala, Uganda. Bivariate and multivariable multinomial regression analyses were used to determine associations between orphan status, sexual exploitation, and psychological distress (defined as experiencing the following proxy variables for more complex psychopathology: hopelessness and/or worry). Among all youth participants, 83.2% (n = 937) reported at least one type of psychological distress; 51.3% (n = 578) reported experiencing both types. The reported prevalence of any type of psychological distress was highest among youth who reported experiencing sexual exploitation (91.2%), double orphans (90.0%), and single orphans (83.8%); however, a high prevalence (76.7%) of any type of distress was also found among youth who reported both parents alive. Experiencing both types of distress was associated with being a double orphan (adjusted odds ratio [AOR] = 2.92, 95% confidence interval [CI] = [1.77, 4.81]), reporting CSE (AOR = 2.71, 95% CI = [1.67, 4.41]), and increased age (AOR = 1.31, 95% CI = [1.20, 1.44]). Psychological distress is prevalent among all youth living in the slums of Kampala and is independently associated with being a double orphan and experiencing CSE. These findings underscore the urgent need to intervene with all youth who reside in this particular underserved community, especially those who have lost both parents, and to prevent CSE among this vulnerable, underserved population.

Prevalence and correlates of depressive symptoms among high school adolescent girls in southern Uganda

Background

In sub-Saharan Africa (SSA), adolescent girls and young women are three times more likely than boys to have depressive disorders. Understanding adolescents’ unique and common vulnerabilities and protective factors is essential for the development of appropriate interventions and programming focused on child and adolescent mental health. This paper examines the prevalence and predictors of depressive symptoms among high school adolescent girls in southern Uganda.

Methods

Baseline data from a longitudinal cluster randomized study involving 1260 adolescent girls (14–17 years), recruited from 47 secondary schools were utilized. Depressive symptoms were estimated using the 21-item Beck’s Depression Inventory. Hierarchical linear regression modelling was utilized to estimate key predictors of depressive symptoms among adolescent girls.

Results

Of the total sample, 16.35% (n = 206) reported severe depressive symptoms and almost one in every three adolescent girls interviewed (29.68%, n = 374) reported moderate symptoms. These symptoms were more prevalent among older adolescents (16 years and above). In addition, family relationships, social support, as well as measures of psychological wellbeing (self-concept and self-esteem) were all associated with lower levels of depressive symptoms. Hopelessness was associated with higher levels of depressive symptoms among adolescent girls.

Conclusion

Findings from this study indicate a high prevalence of depressive symptoms, especially among older adolescent girls. In addition, family support factors and adolescents’ psychological wellbeing were associated with low levels of depressive symptoms –pointing to the need to strengthen family functioning and adolescent’s psychological wellbeing to mitigate risks. Taken together, findings support increasing calls for early screening and detection of depressive symptoms to facilitate timely referral to care and treatment. Findings may also inform the development and incorporation of gender-specific mental health components in programming targeting adolescent girls, in low-resource communities in SSA.

Trial registration

This trial was prospectively registered with ClinicalTrials.gov (registration number: NCT03307226) on 11 October 2017.

Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014

BACKGROUND

In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014.

METHODS

Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age.

RESULTS

The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively.

CONCLUSIONS

The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.

Mental health interventions for adolescents living with HIV or affected by HIV in low- and middle-income countries: systematic review

BACKGROUND

Mental health difficulties and mental disorders are common in adolescents living with HIV or who are affected by HIV because of living in HIV-affected households in low- and middle-income (LMICs) countries, but little is known about the interventions that target these individuals and whether they are effective.

AIMS

This systematic review aims to address these gaps by examining what has worked and what has not worked to support the mental health of adolescents living with HIV or affected by HIV in low- and middle-income contexts (PROSPERO Number: CRD42018103269).

METHOD

A systematic literature review of online databases from the year 2000 to 2018, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, included English-language publications of quantitative evaluations of psychosocial interventions aiming to improve mental health among adolescents living with HIV and adolescents from HIV-affected households (aged 10-24 years) in LMICs.

RESULTS

Out of 2956 articles, 16 studies from 8 LMICs met the inclusion criteria. Thirteen studies focused on adolescents affected by HIV and only three studies on adolescents living with HIV. Only five studies included were from Sub-Saharan Africa. Interventions most often used a family-strengthening approach strengthening caregiver-adolescent relationships and communication and some problem-solving in groups or individually. Five studies reported statistically significant changes in adolescent and caregiver mental health or mental well-being, five among adolescents only and two among caregivers only.

CONCLUSIONS

Research on what works to improve mental health in adolescents living with HIV in LMIC is in its nascent stages. Family-based interventions and economic strengthening show promise.

Responding to Maternal Loss: A Phenomenological Study of Older Orphans in Youth-Headed Households in Impoverished Areas of South Africa

The aim of this study was to explore how older orphans in youth-headed households (YHHs) experience and respond to maternal death and to examine the strategies they employ to care for their younger siblings. We interviewed 18 older orphans who were purposively selected from YHHs located in informal settlements in the City of Tshwane, South Africa. After the death of their mothers, the orphans lost the family home, lost support from their relatives, lost friendships, lost educational opportunities, and lost childhood. The orphans experienced prolonged pain, sadness, anxieties, fear, loneliness despondency, and deep-rooted and persistent anger towards their mother for dying. They suffered from prolonged bereavement because they had been denied the opportunity to mourn the loss of their parents and yearned persistently but silently for their dead mothers. Dropping out of school to seek employment in order to care for their siblings was one of the main coping strategies that older orphans used. However, dropping out of school early robbed them of their future goals of getting an educational qualification. The orphans had not been prepared for taking on an adult role and were given no support or counselling to help them recover from their parents' death. Continuous grief counselling should form an integral component of the psychosocial support services that are provided to orphans soon after the death of a parent.

Mental Health of Adolescents in the Era of Antiretroviral Therapy: Is There a Difference Between HIV-Infected and Uninfected Youth in South Africa?

PURPOSE

The HIV infection may predispose perinatally HIV-infected (PHIV+) adolescents to mental illness. Adolescence can be when mental health disorders manifest for the first time. This study investigates the prevalence of mental illness in PHIV+ and HIV-uninfected adolescents in Soweto.

METHODS

PHIV+ adolescents aged 13-19 years were recruited from an antiretroviral treatment program, whereas HIV-uninfected controls were recruited from the community in Soweto, South Africa, between October 2016 and April 2017. The Patient Health Questionnaire for Adolescents, Child Post-Traumatic Stress Disorder (PTSD) Checklist, and Millon Adolescent Clinical Inventory tools assessed components of mental health. Sociodemographic and virological data were collected. Risk factors for suicidality were determined by logistic regression.

RESULTS

One hundred and sixty-two adolescents (50% PHIV+, 61% female) with a median age of 16 years (interquartile range: 15-18) were enrolled. A depressive disorder was found in 14% of all adolescents, 35% had suicidal ideation, and 22% had PTSD symptoms. Risk factors for suicidality were female gender, HIV-positive status, repeating a grade at school and a history of physical and/or sexual abuse.

CONCLUSIONS

These findings show a high prevalence of suicidality and PTSD symptoms in adolescents from South Africa and highlight the importance of screening for mental illness, specifically suicidality, in HIV-positive adolescents. Adolescents from a disadvantaged socioeconomic background appear to be at risk, posing a challenge because of the lack of health seeking behaviors in young people and lack of adolescent-friendly health facilities. Interventions specific to adolescents in low- and middle-income countries are needed to improve emotional and psychiatric symptoms and functioning.

Depression and Incident HIV in Adolescent Girls and Young Women in HIV Prevention Trials Network 068: Targets for Prevention and Mediating Factors

The human immunodeficiency virus (HIV) epidemic among adolescent girls and young women (AGYW) in sub-Saharan Africa is a critical public health problem. We assessed whether depressive symptoms in AGYW were longitudinally associated with incident HIV, and identified potential social and behavioral mediators. Data came from a randomized trial of a cash transfer conditional on school attendance among AGYW (ages 13-21 years) in rural Mpumalanga Province, South Africa, during 2011-2017. We estimated the relationship between depressive symptoms and cumulative HIV incidence using a linear probability model, and we assessed mediation using inverse odds ratio weighting. Inference was calculated using the nonparametric bootstrap. AGYW with depressive symptoms had higher cumulative incidence of HIV compared with those without (risk difference = 3.5, 95% confidence interval (CI): 0.1, 7.0). The strongest individual mediators of this association were parental monitoring and involvement (indirect effect = 1.6, 95% CI: 0.0, 3.3) and reporting a partner would hit her if she asked him to wear a condom (indirect effect = 1.5, 95% CI: -0.3, 3.3). All mediators jointly explained two-thirds (indirect effect = 2.4, 95% CI: 0.2, 4.5) of the association between depressive symptoms and HIV incidence. Interventions addressing mental health might reduce risk of acquiring HIV among AGYW.

The psychosocial wellbeing of orphans: The case of early school leavers in socially depressed environment in Mpumalanga Province, South Africa

Background

The emergence of a large population of orphaned youth in sub-Saharan Africa is due to the natural maturity of orphaned children. Research indicates that orphaned youth face more negative psychosocial challenges than their younger counterparts do. Furthermore, these challenges are intensified for early school leavers. This paper describes how experiencing maternal death affects the psychosocial wellbeing of orphaned youth who left school before completing high school.

Methods

An exploratory qualitative study was undertaken among purposively sampled orphaned youth using in-depth interviews with open-ended questions. Fifty participants were recruited through social workers, community based organisations, and tribal authorities in a rural local municipality of Mpumalanga Province, South Africa. All data analyses were performed using NVivo10, following an inductive thematic approach.

Results

The narratives with the participants revealed that they live in a socially depressed environment and are subjected to extreme poverty characterised by frequent hunger. Furthermore, they do not enjoy family support and when they live with their extended families, they experience ill treatment and unsympathetic gestures. The death of their mothers has made a negative psychological impact on their psychosocial wellbeing, resulting in the development of internalising depressive symptoms. They suffer from emotional distress and prolonged bereavement characterised by perpetual yearning for the mother and, they resort to silence as a coping strategy. The study established that they were forced to leave school early for a variety of reasons. However, leaving school early became a major stressor and contributed to their negative psychosocial wellbeing.

Conclusion

Maternal death has a negative impact on the psychosocial wellbeing of the participants even after they have crossed the 18 years threshold of orphan hood. Yearning for their mothers negatively affected their ability to develop coping strategies, which led to isolation, sadness, hopelessness, lack of peace, and fear of an uncertain future. The lack of routine screening for mental health in schools and other settings in South Africa increases their vulnerability to undiagnosed depression. The school health services should develop interventions for mental health screening in schools. For early school leavers, relevant policies should consider the continuation of support through NGOs and community networks.

The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review

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.

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

Background

The combination of extensive poverty, violence and HIV has potential mental health impacts on children in Southern Africa. This article is nested in a broader study to evaluate the strength and difficulties questionnaire (SDQ) among Sotho speakers, and assess the mental health status of children made orphans by AIDS.

Objectives

The aim of this study was to describe the mental health problems that the teachers perceive among learners in their classrooms, to understand what the teachers saw as causing these problems and to identify potential approaches to address these problems within the school setting.

Method

As part of the larger study, 10 teachers were purposively selected to write a report describing the mental health problems among learners in their class. These findings were discussed at two later meetings with a larger grouping of teachers to validate the findings and obtain additional input.

Results

The teachers were concerned about the emotional state of their pupils, especially in relation to depression, anxiety, substance abuse, scholastic problems and aggression. These problems were felt to arise from the children’s lived context; factors such as poverty, death of parents and caregivers from AIDS and trauma, parental substance abuse and child abuse. The teachers expressed a desire to assist the affected learners, but complained that they did not get support from the state services.

Conclusion

Many learners were evaluated by teachers as struggling with mental health issues, arising from their social context. The teachers felt that with support, schools could provide assistance to these learners.

Stigma and psychosocial wellbeing among children affected by parental HIV in China

OBJECTIVES

Parental HIV infection presents unique psychosocial challenges for families. Affected children are vulnerable to stigma-related distress from a parent's HIV status and are more likely to experience symptoms of depression and low self-esteem than unaffected peers. This study examined whether HIV-related stigma predicted poorer mental health among children affected by parental HIV and whether psychosocial assets mediated this relationship.

METHODS

A sample of 790 children (ages 6-17) affected by parental HIV in Henan, China reported on HIV-related stigma, social support, emotional regulation, future outlook, and mental health symptoms. Structural equation modeling was used to examine the direct and indirect effects of stigma on mental health.

RESULTS

Results indicated that stigma was associated with psychosocial resources, which in turn were associated with mental health symptoms. The indirect pathways from stigma to mental health symptoms through psychosocial resources were consistent across age and gender.

CONCLUSION

The experience of HIV-related stigma was associated with poorer overall mental health among children affected by parental HIV in China. Children's psychosocial resources, including social support, emotional regulation, and future outlook, mediated the relationship between HIV-related stigma and mental health symptoms. Future interventions may wish to target these modifiable aspects of wellbeing to improve social and behavioral outcomes in this vulnerable population.

Community beliefs, HIV stigma, and depression among adolescents living with HIV in rural Uganda

The availability of and increased access to antiretroviral therapy (ART) has significantly reduced the morbidity and mortality associated with HIV. As a result, perinatally infected youth are increasingly able to reach adolescence. There is limited information about the psychosocial challenges facing adolescents living with HIV (ALWH) in rural settings of sub-Saharan Africa. We sought to understand psychosocial challenges facing ALWH in rural Uganda and their effects on mental health and HIV treatment outcomes. We conducted 5 focus group discussions and 40 one-on-one in-depth interviews in Mbarara, Uganda with adolescents (aged 13-17 years) and adult women caregivers. All interviews were audio-recorded, transcribed directly into English, and coded using thematic analysis to identify themes related to psychosocial adversities and mental health. Adversities faced by adolescents included negative community perceptions (perceived aggression, presumed early mortality), HIV stigma (enacted and internalized), vulnerability factors (loss of parents, poverty), and health challenges (depression, ART non-adherence). In the conceptual model that emerged from the findings, negative community perceptions (about perceived aggression or presumed early mortality) predisposed ALWH to experience enactments and internalization of stigma that led to depression and ART non-adherence. The data also identified several protective factors, including counselling, family and religious support, and timely serostatus disclosure. Interventions to correct community misperceptions about HIV can potentially reduce stigma and thereby improve physical and mental health outcomes of ALWH.

Emotional and behavioral resilience among children with perinatally acquired HIV in Thailand and Cambodia

OBJECTIVES

Psychosocial challenges associated with perinatally acquired HIV (PHIV) infection are well known, yet many children infected with HIV since birth demonstrate positive outcomes, referred to as resilience. The purpose of this study was to evaluate emotional-behavioral development and identify salient predictors of resilience among long-term survivors of PHIV.

DESIGN

Prospective investigation of children with PHIV compared with demographically similar perinatally HIV-exposed but uninfected (PHEU) and HIV-unexposed, uninfected (HUU) children, all from Thailand and Cambodia.

METHODS

The Child Behavior Checklist (CBCL; parent version) was administered at baseline and annual follow-up visits (median follow-up of 3 years) to children age 6-14. Resilience was defined as consistent CBCL scores on the Internalizing, Externalizing or Total Problem T scales within normative ranges (T-scores <60) at every time point. Generalized estimating equations examined CBCL scores over time and logistic models examined demographic, socioeconomic, and cultural predictors of resilience.

RESULTS

Participants included 448 children (236 PHIV, 98 PHEU, 114 HUU), with median (interquartile range) age at first evaluation of 7 (6-9) years. Children with PHIV exhibited similar rates of resilience as PHEU and HUU on the Externalizing and Total Problems scales. Resilience on the Internalizing scale was more likely in PHEU (71%) compared with PHIV (59%) or HUU (56%), P = 0.049. Factors associated with resilience in adjusted models included: HIV-exposed but uninfected status, higher household income, Cambodian nationality, female sex, and caregiver type.

CONCLUSION

Despite biopsychosocial risks, resilience is observed among PHIV and PHEU children. Further study is needed to understand mechanisms underlying associated factors and intervention priorities.

Development and piloting of a novel, peer-led bereavement intervention for young people living with HIV in Zimbabwe

Background: Research emphasizes lasting psychological implications when young people are not adequately supported following close family deaths. In sub-Saharan Africa, adolescents living with HIV (ALHIV) experience multiple personal deaths along with other serious losses. ALHIV highlight that not processing their grief negatively impacts their daily lives including their ART adherence. This article describes the development and piloting of a bereavement intervention for ALHIV in Zimbabwe. Methods: Formative research with 10 ALHIV peer counsellors (18-21 years) supported intervention development. After training, these peer counsellors facilitated a six-session bereavement intervention in 10 existing community-based ALHIV support groups. Qualitative data was collected from facilitators, ALHIV intervention participants, and their caregivers. Results: Key themes: i) limited experience recognizing their losses; ii) lacking control over poorly understood feelings; iii) recurrent feelings of isolation, hopelessness, depression, fear, and guilt; iv) reticence to share, believing their feelings were unusual; v) shame surrounding connections felt towards their deceased. Following intervention implementation, members reported relief in learning of shared experiences, the ability to link their feelings with specific experiences and employ constructive coping strategies to address them, leading to greater emotional control. Conclusion: Implementing high-quality grief interventions is critical when responding to the complex realities of ALHIV in sub-Saharan Africa.

Examining the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in Uganda

In this study, we examined the nonkin support networks of orphaned adolescents participating in a family-based economic-strengthening intervention in HIV-impacted communities in Uganda. We analyzed data from a cluster randomized experimental study for orphaned adolescents aged 11-17 years. Participants were randomly assigned to either the control condition, which received bolstered standard of care (BSOC) services, or the treatment condition, which received BSOC services plus an economic-strengthening intervention. We conducted binary logistic regression analyses to examine the effect of the intervention on participants' nonkin support networks. Results indicated that the existing social support networks for orphaned adolescents are small, limited, and usually comprised individuals with similar socioeconomic situations and challenges. Because orphaned adolescents are socially isolated and the threshold for nonkin supportive services is very low, the BSOC services provided to the control condition appeared to be instrumental in their survival and well-being. Availability of personal savings was associated with higher odds of identifying at least one supportive nonkin tie. The extended family system is still the primary and major source of social support to orphaned children in HIV-affected communities. In the absence of public safety nets, building social assets, over and above offering economic opportunities to extended families supporting orphaned children, is critical.

Poverty, economic strengthening, and mental health among AIDS orphaned children in Uganda: Mediation model in a randomized clinical trial

Some evidence points to the positive effects of asset accumulation programs on mental health of children living in low-resource contexts. However, no evidence exists as to why and how such impact occurs. Our study aims to understand whether child poverty, child work, and household wealth serve as pathways through which the economic strengthening intervention affects the mental health of AIDS-orphaned children. The study employed a cluster-randomized experimental design with a family-based economic strengthening intervention conducted among 1410 school-going AIDS-orphaned children ages 10 and 16 years old in 48 primary schools in South Western Uganda. To test the hypothesized relationships between the intervention, mediators (household wealth, child poverty, and child's work) and mental health, we ran structural equation models that adjust for clustering of individuals within schools and account for potential correlation among the mediators. We found significant unmediated effect of the intervention on children's mental health at 24 months (B = -0.59; 95% CI: 0.93, -0.25; p < 0.001; β = -0.33). Furthermore, the results suggest that participation in the intervention reduced child poverty at 12 months, which in turn improved latent mental health outcome at 24 months (B = -0.14; 95% CI: -0.29, -0.01; p < 0.06; β = -0.08). In addition, though not statistically significant at the 0.05 level, at 36 and 48 months, mental health of children in the treatment group improved by 0.13 and 0.16 standard deviation points correspondingly with no evidence of mediation. Our findings suggest that anti-poverty programs that aim solely to improve household income may be less advantageous to children's mental health as compared to those that are specifically targeted towards reducing the impact of poverty on children. Further studies using more comprehensive measures of child work and age-appropriate child mental health may shed more light on understanding the link between asset accumulation interventions, child labor and children's mental health.

Building resilient families: Developing family interventions for preventing adolescent depression and HIV in low resource settings

Depression contributes significantly to the global burden of disease in low- and middle-income countries. In South Africa, individuals may be at elevated risk for depression due to HIV and AIDS, violence, and poverty. For adolescents, resilience-focused prevention strategies have the potential to reduce onset of depression. Involving families in promoting adolescent mental health is developmentally appropriate, but few existing interventions take a family approach to prevention of adolescent depression. We conducted a qualitative investigation from 2013-2015 to inform the development of a family intervention to prevent adolescent depression in South Africa among families infected or at risk for HIV. Using focus groups with adolescents and parents (eight groups, n = 57), and interviews (n = 25) with clinicians, researchers, and others providing mental health and related services, we identified context-specific factors related to risk for family depression, and explored family interactions around mental health more broadly as well as depression specifically. Findings indicate that HIV and poverty are important risk factors for depression. Future interventions must address linguistic complexities in describing and discussing depression, and engage with the social interpretations and meanings placed upon depression in the South African context, including bewitchment and deviations from prescribed social roles. Participants identified family meetings as a context-appropriate prevention strategy. Family meetings offer opportunities to practice family problem solving, involve other family members in communal parenting during periods of parental depression, and serve as forums for building Xhosa-specific interpretations of resilience. This study will guide the development of Our Family Our Future, a resilience-focused family intervention to prevent adolescent depression (ClinicalTrials.gov #NCT02432352).

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

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

Perceived social support and psychological wellbeing of children orphaned by HIV/AIDS in Southwestern Uganda

Evidence points to a correlation between perceived social support and children's psychological well-being globally. However, only a few studies have examined the relationship between perceived social support (PSS) from multiple sources and children's psychological outcomes. Even fewer studies have examined the relationship between perceived social support from multiple sources and the psychological outcomes of children orphaned by HIV/AIDS in Sub-Saharan Africa (SSA). This study examines whether PSS from multiple sources (parents/caregivers, teachers, friends and classmates) and family cohesion are independently and collectively associated with the psychological well-being of children orphaned by HIV/AIDS in Uganda. This study used baseline data from a National Institute of Health (NIH)-funded Suubi-Maka (Hope for families) study, conducted in Southwestern Uganda. A total of 346 child-caregiver dyads from 10 comparable primary schools participated in the study. Multivariate and multivariable regression analyses were conducted to examine: (1) variations in PSS from multiple sources and family cohesion, and (2) the relationship between PSS, family cohesion and children's psychological outcomes, measured by depression, hopelessness, and self-concept. Controlling for participants' demographic and household characteristics, the combined measure of PSS from multiple sources was positively associated with self-concept (b = .32, 95% CI = .23, .41, p ≤ .001) and negatively associated with hopelessness (b = -.19, 95% CI = -.29, -.09, p ≤ .001) and depressive symptoms (b = -.13, 95% CI = -.23, -.03, p ≤ .01). PSS from parents/guardians and teachers was a significant predictor. In addition, family cohesion was positively associated with self-concept (b = .37, 95% CI = .15, .58, p ≤ .001) and negatively associated with depressive symptoms (b = -.36, 95%CI = -.59, -.13, p≤ = .01). Findings indicate that family cohesion and perceived social support, especially from parent/caregivers and teachers were associated with better children's psychological outcomes. In HIV-impacted communities, interventions designed to strengthen family relationships and social support are essential to offset children's psychological well-being.

The impact of school support on depression among adolescent orphans: a cluster-randomized trial in Kenya

BACKGROUND

The objective of this study was to determine if a school support intervention for adolescent orphans in Kenya had effects on mental health, a secondary outcome.

METHODS

In this paper, we analyzed data from a 4-year cluster-randomized trial of a school support intervention (school uniforms, school fees, and nurse visits) conducted with orphaned adolescents in Siaya County, western Kenya, who were about to transition to secondary school. 26 primary schools were randomized (1:1) to intervention (410 students) or control (425 students) arms. The study was longitudinal with annual repeated measures collected over 4 years from 2011 to 2014. We administered five items from the 20-item Center for Epidemiologic Studies Depression Scale Revised, a self-reported depression screening instrument.

RESULTS

The intervention prevented depression severity scores from increasing over time among adolescents recruited from intervention schools. There was no evidence of treatment heterogeneity by gender or baseline depression status. The intervention effect on depression was partially mediated by higher levels of continuous school enrollment among the intervention group, but this mediated effect was small.

CONCLUSIONS

School support for orphans may help to buffer against the onset or worsening of depression symptoms over time, promoting resilience among an important at-risk population.

Toward an enhanced understanding of psychological resilience for HIV youth populations

Though mother-to-child HIV transmission has been dramatically reduced in the past decade, there are currently an estimated 1.8 million children living with HIV across the globe, and over 30% of all new HIV infections occur among youth ages 15-25. While all youth experience developmental challenges, children and adolescents who are living with HIV must navigate these challenges within the context of high HIV stigma and must cope with a host of psychosocial and health-related challenges. In addition, because HIV disproportionately impacts individuals from minority statuses (e.g., race, ethnicity, gender, sexuality) and people living in poverty, vulnerabilities are often compounded. Resilience frameworks emphasize the capacity for positive adaptation to adversity, and thus provide a useful lens to identify and build upon individual and community strengths. This article introduces a special issue of AIDS Care that examines factors associated with resilience among children and adolescents affected by or living with HIV, as well as innovative interventions designed to build resilience among HIV youth populations. The articles highlighted within this issue examine the possibility of building resilience across diverse settings (e.g., schools, communities, healthcare clinics) and with varied populations (e.g., youth living with HIV, AIDS orphans, young men who have sex with men). We also highlight innovative approaches to resilience-building, including a new mobile Health (mHealth) smartphone game that aims to improve adherence among youth living with HIV in the United States.

The relationship between social support and anxiety amongst children living with HIV in rural northern Namibia

This study examined how HIV-related stigma and social support are related to anxiety among children living with HIV in rural northern Namibia. This is a cross-sectional exploratory study with a sample of 132 caregiver-child dyads. Our study found that higher levels of social support was correlated with lower levels of anxiety among children living with HIV, but higher levels of HIV-related stigma was not correlated with higher levels of anxiety. These findings point to the need for the development of more culturally and age specific interventions that enhance social support among children living with HIV, especially those in high-prevalence and socio-economically deprived settings.

Mental health in South African adolescents living with HIV

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.

AIDS-Affected Orphans in Sub-Saharan Africa: A Scoping Review on Outcome Differences in Rural and Urban Environments

Currently, there are more than 11 million AIDS-affected orphans that suffer from various adverse effects, most of whom reside in sub-Saharan Africa. The difference between whether a child resides in a rural or urban environment can have a significant role in a child's education, health status and access to healthcare, and social or family relationships. A scoping review was conducted in order to understand any possible environment-based differences on orphans directly affected by HIV/AIDS in sub-Saharan Africa. There were 233 sources used for this review; however, 164 manuscripts focused more so on a general review of orphans within a rural or urban environment. Thus, after eliminating for various factors, 69 manuscripts were removed, which focused primarily on the social aspect of orphans due to HIV/AIDS. Rural environments provided more family support, while urban environments generally had more resources available to orphans (e.g. school fees). Unfortunately, both rural and urban environments were found to be fairly non-supportive of orphans and their development. This scoping review found, in general, that orphans in both urban and rural environments continue to suffer from the consequential effects of low parental support due to AIDS mortality. These conclusions suggest that specific support to orphans through school and social relationships encourage better development outcomes in sub-Saharan Africa.

Cumulative Psychosocial Risk is a Salient Predictor of Depressive Symptoms among Vertically HIV-Infected and HIV-Affected Adolescents at the Kenyan Coast

BACKGROUND

Little is known of mental health outcomes among vertically HIV-infected or HIV-affected adolescents in Africa.

OBJECTIVES

The current study set out to describe depressive symptoms and their correlates among vertically HIV-infected and HIV-affected adolescents at the Kenyan Coast.

METHODS

130 adolescents (vertically HIV-infected [n = 44], HIV-affected [n = 53], and unexposed [n = 33]) and their caregivers participated in this cross-sectional study. An adapted version of the Beck Depression Inventory-11 (BDI) was administered to examine depressive symptoms in both adolescents and caregivers, together with measures of sociodemographic, medical, and anthropometric characteristics.

FINDINGS

Our analysis indicated a main effect of HIV status on mean BDI scores in HIV-infected (18.4 [SD = 8.3) and HIV-affected (16.8 [SD = 7.3]) adolescents compared to the community controls (12.0 [SD = 7.9]), F (2, 127) = 6.704, P = .002, η² = .095. Post hoc analysis showed that BDI scores of HIV-infected adolescents were higher than those of community controls (P < .001). Similarly, HIV-affected adolescents had BDI scores that were higher than those of community controls (P = .007). However, there was no difference in BDI scores between HIV-infected and HIV-affected adolescents (P = .304). A path analytic model indicated that cumulative psychosocial risk (orphanhood, family poverty, and caregiver depressive symptoms) were positive predictors of BDI scores among adolescents, while nutritional status had a limited role.

CONCLUSIONS

Both HIV-infected and HIV-affected adolescents are at a high risk of experiencing depressive symptoms, largely due to the multiple psychosocial risk factors in their environment. The provision of adequate psychosocial support and counseling needs to become an integral part of the care program for adolescents from families living with HIV/AIDS at the Kenyan coast and other similar settings.

Reproductive health, social life and plans for the future of adolescents growing-up with HIV: a case-control study in Thailand

Most perinatally HIV-infected children receiving antiretroviral treatment now survive into adolescence. This is a period when young people experience puberty, shape their sexual identity and initiate their own social life. The aim of our analysis was to compare aspects of the sexual and reproductive health, social life and plans for the future of perinatally HIV-infected adolescents (PHIVAs) with a control group from the general population. We used data from the Teens Living with Antiretrovirals (TEEWA) survey carried out from 2010 to 2012 in Thailand among PHIVAs aged 12-19 years. Adolescents completed a self-administered questionnaire focusing on their daily life. Each PHIVA (case) was matched on sex, age and place of residence with a randomly selected adolescent from the general population (control). Analysis was stratified by gender and age; McNemar's test was used to compare cases and controls. A total of 1142 adolescents (571 cases and 571 controls) were included in the analysis, 42% boys and 58% girls. Cases experienced puberty delay compared to controls (p < 0.01). Cases and controls did not differ in terms of sex education, sexual initiation, romantic relationships or friendships, and risky behaviours. However, PHIVAs were less likely to attend the education system (p < 0.01), to plan for marriage (p < 0.01) or parenthood (p < 0.01). PHIVAs do not differ substantially from controls in terms of sexual and social life. Yet, affirmative action policies could help counterbalance their educational handicap. Provision of psychosocial support could enhance their ability to make informed decisions with regards to family formation.