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Bhana A, Kreniske P, Pather A, Abas MA, Mellins CA. Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence. J Int AIDS Soc 2021; 24 Suppl 2:e25713. [PMID: 34164939 PMCID: PMC8222850 DOI: 10.1002/jia2.25713] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/26/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work. METHODS The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes. RESULTS AND DISCUSSION We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health. CONCLUSIONS Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.
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Affiliation(s)
- Arvin Bhana
- Health Systems Research UnitSouth African Medical Research CouncilDurbanSouth Africa
- Centre for Rural HealthCollege of Health SciencesUniversity of KwaZulu‐NatalSouth Africa
| | - Philip Kreniske
- HIV Center for Clinical and Behavioral StudiesDepartment of PsychiatryNew York State Psychiatric Institute and Columbia UniversityNew YorkNYUSA
| | - Ariana Pather
- HIV Center for Clinical and Behavioral StudiesDepartment of PsychiatryNew York State Psychiatric Institute and Columbia UniversityNew YorkNYUSA
| | - Melanie Amna Abas
- Institute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral StudiesDepartment of PsychiatryNew York State Psychiatric Institute and Columbia UniversityNew YorkNYUSA
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Gittings L, Toska E, Medley S, Cluver L, Logie CH, Ralayo N, Chen J, Mbithi-Dikgole J. 'Now my life is stuck!': Experiences of adolescents and young people during COVID-19 lockdown in South Africa. Glob Public Health 2021; 16:947-963. [PMID: 33750269 PMCID: PMC10105067 DOI: 10.1080/17441692.2021.1899262] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
Consequences of COVID-19 pandemic responses have included exacerbated poverty, food insecurity and state and domestic violence. Such effects may be particularly pronounced amongst adolescents and young people living in contexts of precarity and constraint, including in South Africa. However, there are evidence gaps on the lived experiences of this group. We conducted telephonic semi-structured interviews with adolescents and young people in two South African provinces (n = 12, ages 18-25) in April 2020 to explore and document their experiences, challenges and coping strategies during strict COVID-19 lockdown. Participants described indirect effects of COVID-19 including food insecurity, lost livelihoods and changes to social service provisions such as municipal electricity services and sanitation. Psychosocial stressors related to uncertainty over education and work futures were also discussed. The aforementioned challenges were particularly present with young parents, 'working poor' participants, and those with pre-existing mental health challenges. Participants demonstrated excellent COVID-19 transmission and prevention knowledge, showing that they had received and correctly interpreted public health messaging. Despite this, many simultaneously held non-scientific COVID-19 beliefs. Engaging a socio ecological framework, findings demonstrate how the indirect effects of COVID-19 may exacerbate underlying multi-layered vulnerabilities for adolescents and young people living in contexts of precarity and constraint.
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Affiliation(s)
- Lesley Gittings
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Sally Medley
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Carmen H. Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Canada
| | - Nokubonga Ralayo
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Jenny Chen
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Jane Mbithi-Dikgole
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
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53
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Senn TE, Greenwood GL, Rao VR. Global mental health and HIV care: gaps and research priorities. J Int AIDS Soc 2021; 24 Suppl 2:e25714. [PMID: 34164945 PMCID: PMC8222835 DOI: 10.1002/jia2.25714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Theresa E Senn
- National Institute of Mental HealthNational Institutes of HealthRockvilleMDUSA
| | - Gregory L Greenwood
- National Institute of Mental HealthNational Institutes of HealthRockvilleMDUSA
| | - Vasudev R Rao
- National Institute of Mental HealthNational Institutes of HealthRockvilleMDUSA
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54
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Jacobs T, George A. Democratic South Africa at 25 - a conceptual framework and narrative review of the social and structural determinants of adolescent health. Global Health 2021; 17:35. [PMID: 33781302 PMCID: PMC8006635 DOI: 10.1186/s12992-021-00679-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
Twenty-five years into South Africa's constitutional democracy provides an opportunity to take stock of the social and structural determinants of adolescent health. Those born in democratic South Africa, commonly known as the 'Born Frees', are perceived to be able to realise equal rights and opportunities, yet many factors constrain their lives. In bringing together approaches to understanding context in health policy and systems research and the social determinants of health, the paper develops a conceptual framework to guide the narrative review examining the key contextual social and structural determinants of adolescent health in South Africa. Illustrative examples drawing from 65 papers from public health and the social sciences describe and link these determinants across micro, meso and macro levels of society, their global determinants, and their intersections with compounding axes of power and inequality.At a micro level individual adolescent sexual and gender identities are expressed through multiple and evolving forms, while they experience growing autonomy and agency, they do so within a broader context characterised by regressive social norms, gender inequality and other intersecting power relationships. At the meso level, organisational and sectoral determinants shape adolescents health and rights, both in being supportive, but they also replicate the biases and inequalities that characterise South African society. In addition, the macro level national and global determinants, such as the structural colonial and apartheid legacies, shape adolescents' health. Despite constitutional and other legislative rights, these determinants and compound economic, geographic, gender and other intersecting inequalities.A key finding is that current experiences and health of adolescents is shaped by past social and structural determinants and power relations, with apartheid inequalities still echoing in the lives of the adolescents, 25 years into democracy. More research and work is needed to provide insights into determinants of adolescent health beyond just the micro level, but also at the interrelated and dynamic meso and macro levels, nested in global determinants. The findings raise critical considerations and implications for understanding the social and structural determinants in the South African context and what this means for adolescent health in the SDG era.
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Affiliation(s)
- Tanya Jacobs
- School of Public Health, University of the Western Cape, Bellville, South Africa.
| | - Asha George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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55
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Höltge J, Theron L, Cowden RG, Govender K, Maximo SI, Carranza JS, Kapoor B, Tomar A, van Rensburg A, Lu S, Hu H, Cavioni V, Agliati A, Grazzani I, Smedema Y, Kaur G, Hurlington KG, Sanders J, Munford R, Colomeischi AA, Panter-Brick C, Sarathamani S, Boratne AV, Avudaiappan S, Patil R, Borualogo I, Katisi M, Jefferies P, Ungar M. A Cross-Country Network Analysis of Adolescent Resilience. J Adolesc Health 2021; 68:580-588. [PMID: 32919888 DOI: 10.1016/j.jadohealth.2020.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE In situations of adversity, young people draw on individual, relational, and contextual (community and cultural) resources to foster their resilience. Recent literature defines resilience as a capacity that is underpinned by a network of interrelated resources. Although empirical studies show evidence of the value of a network approach, little is known regarding how different country contexts influence which resources are most critical within a resource network and how resources interact for adolescent resilience. METHODS Network analysis was conducted with data from studies that had used the Child and Youth Resilience Measure. Regularized partial correlation networks of 17 resources were estimated for 14 countries (Botswana, Canada, China, Colombia, Equatorial Guinea, India, Indonesia, Italy, Jordan, New Zealand, the Philippines, Romania, South Africa, and Syrian refugees living in Jordan). The sample size was 18,914 (mean age = 15.70 years, 48.8% female). RESULTS We observed mostly positive associations between the resources of interest. The salience and strength of associations between resources varied by country. The most central resource across countries was having supportive caregivers during stressful times because this resource had the most and strongest positive associations with other resources. CONCLUSIONS This study gives first empirical evidence from multiple countries that an interplay of social-ecological resources (such as individual skills, peer, caregiver and community support, and educational aspirations and opportunities) matter for adolescent resilience. Across countries, caregiver support appears to be most central for adolescent resilience. Future resilience interventions might apply this network approach to identify important, contextually relevant resources that likely foster additional resources.
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Affiliation(s)
- Jan Höltge
- Resilience Research Centre, Dalhousie University, Halifax, Canada.
| | - Linda Theron
- Department of Educational Psychology, University of Pretoria, Pretoria, South Africa
| | - Richard G Cowden
- Department of Psychology, University of the Free State, Bloemfontein, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Sally I Maximo
- Department of Psychology, Saint Louis University, Baguio City, Philippines
| | | | - Bhumika Kapoor
- Department of Psychology, University of Delhi, New Delhi, India
| | - Aakanksha Tomar
- Department of Psychology, University of Delhi, New Delhi, India
| | | | - Shuang Lu
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Hongwei Hu
- School of Public Administration and Policy, Renmin University of China, Beijing, China
| | - Valeria Cavioni
- Department of Human Sciences for Education "R. Massa", University of Milano-Bicocca, Milan, Italy
| | - Alessia Agliati
- Department of Human Sciences for Education "R. Massa", University of Milano-Bicocca, Milan, Italy
| | - Ilaria Grazzani
- Department of Human Sciences for Education "R. Massa", University of Milano-Bicocca, Milan, Italy
| | - Yoel Smedema
- Deusto Stress Research, University of Deusto, Bilbao, Spain
| | - Gunjanpreet Kaur
- Institute of Psychology and Allied Sciences, Amity University, Noida, India
| | | | - Jackie Sanders
- School of Social Work, College of Health, Massey University, Palmerston North, New Zealand
| | - Robyn Munford
- School of Social Work, College of Health, Massey University, Palmerston North, New Zealand
| | | | | | - Sinthu Sarathamani
- Department of Community Medicine, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India
| | - Abhijit V Boratne
- Department of Community Medicine, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India
| | - Sankaran Avudaiappan
- Department of Psychiatry, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India
| | - Rajkumar Patil
- Department of Community Medicine, Chirayu Medical College & Hospital, Bhopal, India
| | - Ihsana Borualogo
- Faculty of Psychology, Universitas Islam Bandung, Bandung, Indonesia
| | - Masego Katisi
- Western Norway University of Applied Sciences, Bergen, Norway
| | - Philip Jefferies
- Resilience Research Centre, Dalhousie University, Halifax, Canada
| | - Michael Ungar
- Resilience Research Centre, Dalhousie University, Halifax, Canada
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56
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Shenderovich Y, Boyes M, Esposti MD, Casale M, Toska E, Roberts KJ, Cluver L. Relationships with caregivers and mental health outcomes among adolescents living with HIV: a prospective cohort study in South Africa. BMC Public Health 2021; 21:172. [PMID: 33472607 PMCID: PMC7816135 DOI: 10.1186/s12889-020-10147-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question. METHODS The study traced adolescents aged 10-19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents. RESULTS Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97-0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98-1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92-0.97, p<.0001) and anxiety (0.91, 95% CI 0.89-0.94, p<.0001) symptoms reported by adolescents. CONCLUSIONS Findings highlight open and supportive adolescent-caregiver communication and good caregiver supervision as potential factors for guarding against mental health problems among adolescents living with HIV in South Africa. Several evidence-informed parenting programmes aim to improve adolescent-caregiver communication and caregiver supervision, and their effect on depression and anxiety among adolescents living with HIV should be rigorously tested in sub-Saharan Africa. How to improve communication in other settings, such as schools and clinics, and provide communication support for caregivers, adolescents, and service providers through these existing services should also be considered.
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Affiliation(s)
- Yulia Shenderovich
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK.
| | - Mark Boyes
- School of Psychology, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Michelle Degli Esposti
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Marisa Casale
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Elona Toska
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
- Department of Sociology, University of Cape Town, Cape Town, South Africa
| | | | - Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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57
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Shenderovich Y, Ward CL, Lachman JM, Wessels I, Sacolo-Gwebu H, Okop K, Oliver D, Ngcobo LL, Tomlinson M, Fang Z, Janowski R, Hutchings J, Gardner F, Cluver L. Evaluating the dissemination and scale-up of two evidence-based parenting interventions to reduce violence against children: study protocol. Implement Sci Commun 2020; 1:109. [PMID: 38624613 PMCID: PMC7719848 DOI: 10.1186/s43058-020-00086-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 12/31/2022] Open
Abstract
Background Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs. Methods The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification. Discussion This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.
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Affiliation(s)
- Yulia Shenderovich
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Catherine L. Ward
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Jamie M. Lachman
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland
| | - Inge Wessels
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | | | - Kufre Okop
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | | | | | - Mark Tomlinson
- Institute for Life Course Health Research, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, UK
| | - Zuyi Fang
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Roselinde Janowski
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | | | - Frances Gardner
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Mason E, Sen G, Yamin AE. Universal health coverage provisions for women, children and adolescents. Bull World Health Organ 2020; 98:79-79A. [PMID: 32015573 PMCID: PMC6986226 DOI: 10.2471/blt.19.249474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Elizabeth Mason
- Institute for Global Health, University College London, Gower Street, London, WC1E 6BT, England
| | - Gita Sen
- Ramalingaswami Centre on Equity & Social Determinants of Health, Public Health Foundation of India, Bangalore, India
| | - Alicia Ely Yamin
- Petrie-Flom Center for Health Law Policy and Bioethics at Harvard Law School, Harvard TH Chan School of Public Health, Cambridge, United States of America
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59
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Cluver L, Doubt J, Wessels I, Asnong C, Malunga S, Mauchline K, Vale B, Medley S, Toska E, Orkin K, Dunkley Y, Meinck F, Myeketsi N, Lasa S, Rupert C, Boyes M, Pantelic M, Sherr L, Gittings L, Hodes R, Kuo C, Chetty AN, Thabeng M. Power to participants: methodological and ethical reflections from a decade of adolescent advisory groups in South Africa. AIDS Care 2020; 33:858-866. [PMID: 33213195 DOI: 10.1080/09540121.2020.1845289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACTWhilst the HIV response has made significant progress in increasing representation of adults affected by HIV, the meaningful inclusion of children and adolescents has lagged. But this may be a pivotal moment of change. We report on a decade of conducting adolescent advisory groups in South Africa, to reflect on youth advisory processes. Data was collected from 2008 to 2018 from adolescent advisors (n = 60) and researchers (n = 25), and included feedback sessions, social media, anonymous "post-boxes" and interviews. Findings include the value of adolescent involvement in multiple stages of research co-creation and engagement in policy processes, the need for a safe environment and supporting adolescents living in extreme vulnerability. We also discuss the reconfiguring of power and personal relationships, and logistical and financial needs of adolescent advisory groups. Findings suggest that adolescent co-creation of research is feasible, even with very vulnerable adolescents, although ethical considerations need to be carefully addressed. Benefits include increased methodological rigour, enhanced adolescent acceptability of research and the recalibration of research dynamics for the empowerment of their target beneficiaries. Future studies could benefit from meaningfully involving adolescents through youth advisory groups.
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Affiliation(s)
- Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jenny Doubt
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | | | - Inge Wessels
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Carine Asnong
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Samantha Malunga
- AIDS and Society Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kerry Mauchline
- Ministry of Education, Western Cape Government, Cape Town, South Africa
| | | | - Sally Medley
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Elona Toska
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Centre for Social Science Research, University of Cape Town, Cape Town, South Africa.,Department of Sociology, University of Cape Town, Cape Town, South Africa
| | - Kate Orkin
- Blavatnik School of Government and Centre for the Study of African Economies, University of Oxford, Oxford, UK
| | | | - Franziska Meinck
- Optentia Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.,School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | | | | | | | - Mark Boyes
- School of Psychology, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Marija Pantelic
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Brighton and Sussex Medical School, University of Sussex, Sussex, UK
| | - Lorraine Sherr
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Independent.,Health Psychology Unit, Institute of Global Health, University College London, London, UK
| | - Lesley Gittings
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Rebecca Hodes
- AIDS and Society Research Unit, University of Cape Town, Cape Town, South Africa
| | - Caroline Kuo
- School of Public Health, Brown University, Providence, RI, USA
| | - Angelique N Chetty
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Mildred Thabeng
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK.,Department of Sociology, University of Cape Town, Cape Town, South Africa
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60
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Cluver LD, Rudgard WE, Toska E, Zhou S, Campeau L, Shenderovich Y, Orkin M, Desmond C, Butchart A, Taylor H, Meinck F, Sherr L. Violence prevention accelerators for children and adolescents in South Africa: A path analysis using two pooled cohorts. PLoS Med 2020; 17:e1003383. [PMID: 33166288 PMCID: PMC7652294 DOI: 10.1371/journal.pmed.1003383] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which 'accelerator' provisions can simultaneously reduce multiple types of violence against children. METHODS AND FINDINGS We pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012) and Mzantsi Wakho (2014-2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: -3.74% points, 95% CI -5.31 to -2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: -5.23% points, 95% CI -7.26 to -3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: -14.72% points, 95% CI -19.11 to -10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: -12.41% points, 95% CI -16.00 to -8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: -7.87% points, 95% CI -11.98 to -3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: -7.30% points, 95% CI -10.50 to -4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: -0.59% points, 95% CI -2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: -2.42% points, 95% CI -4.77 to -0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: -11.74% points, 95% CI -16.91 to -6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: -13.00% points, 95% CI -17.04 to -8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: -5.87% points, 95% CI -10.98 to -0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD -7.46% points, 95% CI -11.57 to -3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies. CONCLUSION In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.
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Affiliation(s)
- Lucie D. Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - William E. Rudgard
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Siyanai Zhou
- Department of Statistics and AIDS and Society Research Unit, University of Cape Town, Cape Town, South Africa
| | | | - Yulia Shenderovich
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Mark Orkin
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Medical Research Council Development Pathways to Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Chris Desmond
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Alexander Butchart
- Violence Prevention Unit, Social Determinant of Health, Healthier Populations Division, World Health Organization, Switzerland
| | - Howard Taylor
- Global Partnership to End Violence Against Children, New York, New York, United States of America
| | - Franziska Meinck
- OPTENTIA Faculty of Health Sciences, North-West University, South Africa
- School of Social and Political Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Lorraine Sherr
- Health Psychology Unit, Institute of Global Health, University College London, United Kingdom
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Zuma T, Seeley J, Mdluli S, Chimbindi N, Mcgrath N, Floyd S, Birdthistle I, Harling G, Sherr L, Shahmanesh M. Young people's experiences of sexual and reproductive health interventions in rural KwaZulu-Natal, South Africa. INTERNATIONAL JOURNAL OF ADOLESCENCE AND YOUTH 2020; 25:1058-1075. [PMID: 34177039 PMCID: PMC8224946 DOI: 10.1080/02673843.2020.1831558] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/28/2020] [Indexed: 12/16/2022] Open
Abstract
Despite efforts to address HIV-infection, adolescents and young peoples' (AYP) engagement in interventions remains suboptimal. Guided by a risk protection framework we describe factors that support positive and negative experiences of HIV and SRH interventions among AYP in rural KwaZulu-Natal, South Africa, using data from: community mapping; repeat semi-structured individual interviews (n= 58 in 2017, n=50 in 2018, n=37 in 2019-2020); and group discussions (n=13). AYP who had appropriate and accurate HIV-and SRH-related information were reported to use health care services. Responsive health care workers, good family and peer relationships were seen to be protective through building close connections and improving self-efficacy to access care. In contrast to cross-generational relationships with men, alcohol and drug use and early pregnancy were seen to put AYP at risk. Policies and interventions are needed that promote stable and supportive relationships with caregivers and peers, positive social norms and non-judgemental behaviour within clinical services.
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Affiliation(s)
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sakhile Mdluli
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Natsayi Chimbindi
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Division of Infection and Immunity, London, UK
| | - Nuala Mcgrath
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of Southampton, Southampton, UK
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Institute for Global Health, London, UK
| | - Lorraine Sherr
- University College London, Institute for Global Health, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University College London, Institute for Global Health, London, UK
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Chimbindi N, Birdthistle I, Floyd S, Harling G, Mthiyane N, Zuma T, Hargreaves JR, Seeley J, Shahmanesh M. Directed and target focused multi-sectoral adolescent HIV prevention: Insights from implementation of the 'DREAMS Partnership' in rural South Africa. J Int AIDS Soc 2020; 23 Suppl 5:e25575. [PMID: 32869481 PMCID: PMC7459161 DOI: 10.1002/jia2.25575] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The "DREAMS Partnership" promotes a multi-sectoral approach to reduce adolescent girls and young women's (AGYW) vulnerability to HIV in sub-Saharan Africa. Despite widespread calls to combine structural, behavioural and biomedical HIV prevention interventions, this has not been delivered at scale. In this commentary, we reflect on the two-year rollout of DREAMS in a high HIV incidence, rural and poor community in northern KwaZulu-Natal, South Africa to critically appraise the capacity for a centrally co-ordinated and AGYW-focused approach to combination HIV prevention to support sustainable development for adolescents. DISCUSSION DREAMS employed a directed target-focused approach in which local implementing partners were resourced to deliver defined packages to AGYW in selected geographical areas over two years. We argue that this approach, with high-level oversight by government and funders, enabled the rapid roll-out of ambitious multi-sectoral HIV prevention for AGYW. It was most successful at delivering multiple interventions for AGYW when it built on existing infrastructure and competencies, and/or allocated resources to address existing youth development concerns of the community. The approach would have been strengthened if it had included a mechanism to solicit and then respond to the concerns of young women, for example gender-related norms and how young women experience their sexuality, and if this listening was supported by versatility to adapt to the social context. In a context of high HIV vulnerability across all adolescents and youth, an over-emphasis on targeting specific groups, whether geographically or by risk profile, may have hampered acceptability and reach of the intervention. Absence of meaningful engagement of AGYW in the development, delivery and leadership of the intervention was a lost opportunity to achieve sustainable development goals among young people and shift gender-norms. CONCLUSIONS Centrally directed and target-focused scale-up of defined packages of HIV prevention across sectors was largely successful in reaching AGYW in this rural South African setting rapidly. However, to achieve sustainable and successful long-term youth development and transformation of gender-norms there is a need for greater adaptability, economic empowerment and meaningful engagement of AGYW in the development and delivery of interventions. Achieving this will require sustained commitment from government and funders.
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Affiliation(s)
| | | | - Sian Floyd
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Guy Harling
- Africa Health Research InstituteMtubatubaSouth Africa
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
- Harvard UniversityBostonMAUSA
- University of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | - Janet Seeley
- Africa Health Research InstituteMtubatubaSouth Africa
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Maryam Shahmanesh
- Africa Health Research InstituteMtubatubaSouth Africa
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
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Toska E, Cluver L, Laurenzi CA, Wittesaele C, Sherr L, Zhou S, Langwenya N. Reproductive aspirations, contraception use and dual protection among adolescent girls and young women: the effect of motherhood and HIV status. J Int AIDS Soc 2020; 23 Suppl 5:e25558. [PMID: 32869543 PMCID: PMC7459160 DOI: 10.1002/jia2.25558] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/12/2020] [Accepted: 06/03/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION There is a growing interest in adolescent motherhood and HIV among policymakers and programme implementers. To better shape services and health outcomes, we need evidence on reproductive aspirations and contraception use in this high-risk group, including the effect of motherhood and HIV status. We report data from a large survey of adolescent girls and young women conducted in a mixed rural-urban district in South Africa. METHODS Quantitative interviews were conducted with 1712 adolescent girls and young women (ages 10 to 24): 336 adolescent mothers living with HIV (AMLHIV), 454 nulliparous adolescent girls living with HIV (ALHIV), 744 HIV-negative adolescent mothers (control adolescent mothers) and 178 HIV-negative nulliparous adolescent girls (nulliparous controls) in 2018 to 2019. Standardized questionnaires included socio-demographic measures, reproductive health and contraception experiences. Reproductive aspirations were measured as the number of children participants wanted to have. Dual protection was computed as use of both hormonal and barrier contraception or abstinence. Multivariate logistic regression and marginal effects models in STATA 15 were used to test associations between HIV status, adolescent motherhood and outcomes of reproductive aspirations, contraception use and dual protection, controlling for covariates. RESULTS AND DISCUSSION Nearly 95% of first pregnancies were unintended. Over two-thirds of all participants wanted two or more children. Hormonal contraception, condom use and dual protection were low across all groups. In multivariate regression modelling, ALHIV were less likely to report hormonal contraception use (aOR 0.55 95% CI 0.43 to 0.70 p ≤ 0.001). In marginal effects modelling, adolescent mothers - independent of HIV status - were least likely to report condom use at last sex. Despite higher probabilities of using hormonal contraception, rates of dual protection were low: 17.1% among control adolescent mothers and 12.4% among AMLHIV. Adolescent mothers had the highest probabilities of not using any contraceptive method: 29.0% among control mothers and 23.5% among AMLHIV. CONCLUSIONS Among adolescent girls and young women in HIV-endemic communities, reproductive aspirations and contraceptive practices affect HIV risk and infection. Tailored adolescent-responsive health services could help young women plan their pregnancies for when they are healthy and well-supported, and help interrupt the cycle of HIV transmission by supporting them to practice dual protection.
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Affiliation(s)
- Elona Toska
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Department of SociologyUniversity of Cape TownCape TownSouth Africa
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
| | - Lucie Cluver
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Child and Adolescent PsychiatryUniversity of Cape TownCape TownSouth Africa
| | - Christina A Laurenzi
- Department of Global HealthInstitute for Life Course Health ResearchStellenbosch UniversityCape TownSouth Africa
| | - Camille Wittesaele
- Department of Social Policy and InterventionUniversity of OxfordOxfordUnited Kingdom
- Department of Infectious Disease EpidemiologyFaculty of Epidemiology and Population HealthLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Lorraine Sherr
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Siyanai Zhou
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Department of StatisticsUniversity of Cape TownCape TownSouth Africa
| | - Nontokozo Langwenya
- Centre for Social Science ResearchUniversity of Cape TownCape TownSouth Africa
- Oxford Research South AfricaEast LondonSouth Africa
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Adolescent HIV in Africa: linking local lives and global targets. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 3:203-204. [PMID: 30878108 DOI: 10.1016/s2352-4642(19)30060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 11/23/2022]
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Abstract
Human immunodeficiency virus (HIV) has, over the last four decades, infected millions of young women and their children. Interventions developed in parallel with the spread of the virus have been able to reduce rates of vertical transmission from mother to child. The impact of HIV in children can be direct in children living with HIV (CLHIV) and exposed to HIV and uninfected, or indirect through impacts on their parents, caregivers, and family. In 2018, the United Nations joint programme on AIDS (UNAIDS) estimated that 1.7 million children were living with HIV, 160,000 were newly infected with HIV, and 100,000 died from HIV. Improvement in treatment regimens can improve the life chances of children, but adherence to treatment is a problem, especially for adolescents. Injectable long acting treatments, or interventions to improve service delivery and support for adolescents living with HIV may improve treatment success. In addition to failures of HIV prevention and treatment in CLHIV, there are concerns over exposure to the virus and antivirals leading to delayed child development. To improve the wellbeing of children affected by HIV, social support is necessary, but we need to find ways of enhancing the impact of interventions, perhaps through combining them.
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Sherr L, Cluver L, Desmond C, Toska E, Aber L, Dhaliwal M, Webb D, Dugbazah J. A new vehicle to accelerate the UN Sustainable Development Goals. Lancet Glob Health 2020; 8:e637-e638. [PMID: 32353307 PMCID: PMC7185933 DOI: 10.1016/s2214-109x(20)30103-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/06/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Lorraine Sherr
- Health Psychology Unit, Institute of Global Health, University College London, London NW3 2PF, UK
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Chris Desmond
- FXB Centre for Health and Human Rights, Harvard University, Boston, MA, USA
| | - Elona Toska
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Larry Aber
- Department of Applied Psychology, New York University Steinhardt, New York, NY, USA
| | | | - Douglas Webb
- HIV, Health and Development Group, UNDP, New York, NY, USA
| | - Justina Dugbazah
- Education and Social Development, African Union Development Agency, Midrand, South Africa
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Ungar M, Theron L. Resilience and mental health: how multisystemic processes contribute to positive outcomes. Lancet Psychiatry 2020; 7:441-448. [PMID: 31806473 DOI: 10.1016/s2215-0366(19)30434-1] [Citation(s) in RCA: 274] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 12/29/2022]
Abstract
More is known about the factors that predict mental disorder than about the factors and processes that promote positive development among individuals exposed to atypically high levels of stress or adversity. In this brief Review of the science of resilience, we show that the concept is best understood as the process of multiple biological, psychological, social, and ecological systems interacting in ways that help individuals to regain, sustain, or improve their mental wellbeing when challenged by one or more risk factors. Studies in fields as diverse as genetics, psychology, political science, architecture, and human ecology are showing that resilience depends just as much on the culturally relevant resources available to stressed individuals in their social, built, and natural environments as it does on individual thoughts, feelings, and behaviours. With growing interest in resilience among mental health-care providers, there is a need to recognise the complex interactions across systems that predict which individuals will do well and to use this insight to advance mental health interventions.
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Affiliation(s)
- Michael Ungar
- Resilience Research Centre, Dalhousie University, Halifax, NS, Canada.
| | - Linda Theron
- Department of Educational Psychology, Faculty of Education, University of Pretoria, Pretoria, South Africa
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Pantelic M, Casale M, Cluver L, Toska E, Moshabela M. Multiple forms of discrimination and internalized stigma compromise retention in HIV care among adolescents: findings from a South African cohort. J Int AIDS Soc 2020; 23:e25488. [PMID: 32438498 PMCID: PMC7242009 DOI: 10.1002/jia2.25488] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Efficacious antiretroviral treatment (ART) enables people to live long and healthy lives with HIV but young people are dying from AIDS-related causes more than ever before. Qualitative evidence suggest that various forms of HIV-related discrimination and resulting shame act as profound barriers to young people's engagement with HIV services. However, the impact of these risks on adolescent retention in HIV care has not been quantified. This study has two aims: (1) to examine whether and how different types of discrimination compromise retention in care among adolescents living with HIV in South Africa; and (2) to test whether internalized stigma mediates these relationships. METHODS Between 2014 and 2017, adolescents living with HIV (aged 10 to 19) from 53 health facilities in the Eastern Cape, South Africa, were interviewed at baseline (n = 1059) and 18-month follow-up (n = 979, 92.4%), with responses linked to medical records. Data were analysed through multiple regression and mediation models. RESULTS About 37.9% of adolescents reported full retention in care over the 2-year period, which was associated with reduced odds of viral failure (OR: 0.371; 95% CI: .224, .614). At baseline, 6.9% of adolescents reported discrimination due to their HIV status; 14.9% reported discrimination due to HIV in their families and 19.1% reported discrimination in healthcare settings. Healthcare discrimination was associated with reduced retention in care both directly (effect: -0.120; CI: -0.190, -0.049) and indirectly through heightened internalized stigma (effect: 0.329; 95% CI: 0.129, 0.531). Discrimination due to family HIV was associated with reduced retention in care both directly (effect: -0.074, CI: -0.146, -0.002) and indirectly through heightened internalized stigma (effect: 0.816, CI: 0.494, 1.140). Discrimination due to adolescent HIV was associated with reduced retention in care only indirectly, through increased internalized stigma (effect: 0.408; CI: 0.102, 0.715). CONCLUSIONS Less than half of adolescents reported 2-year retention in HIV care. Multiple forms of discrimination and the resultant internalized stigma contributed to this problem. More intervention research is urgently needed to design and test adolescent-centred interventions so that young people living with HIV can live long and healthy lives in the era of efficacious anti-retroviral treatment.
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Affiliation(s)
- Marija Pantelic
- University of SussexBrighton and Sussex Medical SchoolBrightonUK
- University of OxfordDepartment of Social Policy and InterventionOxfordUK
| | - Marisa Casale
- University of OxfordDepartment of Social Policy and InterventionOxfordUK
- University of the Western CapeSchool of Public HealthCape TownSouth Africa
| | - Lucie Cluver
- University of OxfordDepartment of Social Policy and InterventionOxfordUK
- University of Cape TownDepartment of Psychiatry and Mental HealthCape TownSouth Africa
| | - Elona Toska
- University of OxfordDepartment of Social Policy and InterventionOxfordUK
- University of Cape TownDepartment of SociologyCape TownSouth Africa
- University of Cape Town Centre for Social Science ResearchCape TownSouth Africa
| | - Mosa Moshabela
- University of KwaZulu‐NatalHoward CollegeSchool of Nursing and Public HealthDurbanSouth Africa
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Ssewamala FM, Dvalishvili D, Mellins CA, Geng EH, Makumbi F, Neilands TB, McKay M, Damulira C, Nabunya P, Sensoy Bahar O, Nakigozi G, Kigozi G, Byansi W, Mukasa M, Namuwonge F. The long-term effects of a family based economic empowerment intervention (Suubi+Adherence) on suppression of HIV viral loads among adolescents living with HIV in southern Uganda: Findings from 5-year cluster randomized trial. PLoS One 2020; 15:e0228370. [PMID: 32040523 PMCID: PMC7010288 DOI: 10.1371/journal.pone.0228370] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The rapid scale-up of HIV therapy across Africa has failed to adequately engage adolescents living with HIV (ALWHIV). Retention and viral suppression for this group (ALWHIV) is 50% lower than for adults. Indeed, on the African continent, HIV remains the single leading cause of mortality among adolescents. Strategies tailored to the unqiue developmental and social vulnerabilities of this group are urgently needed to enhance successful treatment. METHODS We carried out a five-year longitudinal cluster randomized trial (ClinicalTrials.gov ID: NCT01790373) with adolescents living with HIV (ALWHIV) ages 10 to 16 years clustered at health care clinics to test the effect of a family economic empowerment (EE) intervention on viral suppression in five districuts in Uganda. In total, 39 accredited health care clinics from study districts with existing procedures tailored to adolescent adherence were eligible to participate in the trial. We used data from 288 youth with detectable HIV viral loads (VL) at baseline (158 -intervention group from 20 clinics, 130 -non-intervention group from 19 clinics). The primary end point was undetectable plasma HIV RNA levels, defined as < 40 copies/ml. We used Kaplan-Meier (KM) analysis and Cox proportional hazard models to estimate intervention effects. FINDINGS The Kaplan-Meier (KM) analysis indicated that an incidence of undetectable VL (0.254) was significantly higher in the intervention condition compared to 0.173 (in non-intervention arm) translated into incidence rate ratio of 1.468 (CI: 1.064-2.038), p = 0.008. Cox regression results showed that along with the family-based EE intervention (adj. HR = 1.446, CI: 1.073-1.949, p = 0.015), higher number of medications per day had significant positive effects on the viral suppression (adj.HR = 1.852, CI: 1.275-2.690, p = 0.001). INTERPRETATION A family economic empowerment intervention improved treatment success for ALWHIV in Uganda. Analyses of cost effectiveness and scalability are needed to advance incorporation of this intervention into routine practice in low and middle-income countries.
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Affiliation(s)
- Fred M. Ssewamala
- Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- SMART Africa Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- * E-mail:
| | - Darejan Dvalishvili
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Claude A. Mellins
- Department of Psychiatry, New York State Psychiatric Institute, HIV Center for Clinical and Behavioral Studies at Columbia University Medical Center, The City of New York, NY, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, John T. Milliken Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO, United States of America
| | | | - Torsten B. Neilands
- Division of Prevention Science, Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Mary McKay
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- SMART Africa Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Christopher Damulira
- International Center for Child Health and Development (ICHAD), Uganda Office, Masaka, Uganda
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- SMART Africa Center, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | | | | | - William Byansi
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Miriam Mukasa
- International Center for Child Health and Development (ICHAD), Uganda Office, Masaka, Uganda
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Uganda Office, Masaka, Uganda
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Mavhu W, Willis N, Mufuka J, Bernays S, Tshuma M, Mangenah C, Maheswaran H, Mangezi W, Apollo T, Araya R, Weiss HA, Cowan FM. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. LANCET GLOBAL HEALTH 2020; 8:e264-e275. [PMID: 31924539 DOI: 10.1016/s2214-109x(19)30526-1] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/02/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adolescents living with HIV face challenges to their wellbeing and antiretroviral therapy adherence and have poor treatment outcomes. We aimed to evaluate a peer-led differentiated service delivery intervention on HIV clinical and psychosocial outcomes among adolescents with HIV in Zimbabwe. METHODS 16 public primary care facilities (clusters) in two rural districts in Zimbabwe (Bindura and Shamva) were randomly assigned (1:1) to provide enhanced HIV care support (the Zvandiri intervention group) or standard HIV care (the control group) to adolescents (aged 13-19 years) with HIV. Eligible clinics had at least 20 adolescents in pre-ART or ART registers and were geographically separated by at least 10 km to minimise contamination. Adolescents were eligible for inclusion if they were living with HIV, registered for HIV care at one of the trial clinics, and either starting or already on ART. Exclusion criteria were being too physically unwell to attend clinic (bedridden), psychotic, or unable to give informed assent or consent. Adolescents with HIV at all clinics received adherence support through adult counsellors. At intervention clinics, adolescents with HIV were assigned a community adolescent treatment supporter, attended a monthly support group, and received text messages, calls, home visits, and clinic-based counselling. Implementation intensity was differentiated according to each adolescent's HIV vulnerability, which was reassessed every 3 months. Caregivers were invited to a support group. The primary outcome was the proportion of adolescents who had died or had a viral load of at least 1000 copies per μL after 96 weeks. In-depth qualitative data were collected and analysed thematically. The trial is registered with Pan African Clinical Trial Registry, number PACTR201609001767322. FINDINGS Between Aug 15, 2016, and March 31, 2017, 500 adolescents with HIV were enrolled, of whom four were excluded after group assignment owing to testing HIV negative. Of the remaining 496 adolescents, 212 were recruited at Zvandiri intervention sites and 284 at control sites. At enrolment, the median age was 15 years (IQR 14-17), 52% of adolescents were female, 81% were orphans, and 47% had a viral load of at least 1000 copies per μL. 479 (97%) had primary outcome data at endline, including 28 who died. At 96 weeks, 52 (25%) of 209 adolescents in the Zvandiri intervention group and 97 (36%) of 270 adolescents in the control group had an HIV viral load of at least 1000 copies per μL or had died (adjusted prevalence ratio 0·58, 95% CI 0·36-0·94; p=0·03). Qualitative data suggested that the multiple intervention components acted synergistically to improve the relational context in which adolescents with HIV live, supporting their improved adherence. No adverse events were judged to be related to study procedures. Severe adverse events were 28 deaths (17 in the Zvandiri intervention group, 11 in the control group) and 57 admissions to hospital (20 in the Zvandiri intervention group, 37 in the control group). INTERPRETATION Peer-supported community-based differentiated service delivery can substantially improve HIV virological suppression in adolescents with HIV and should be scaled up to reduce their high rates of morbidity and mortality. FUNDING Positive Action for Adolescents Program, ViiV Healthcare.
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Affiliation(s)
- Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | | | - Juliet Mufuka
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | - Sarah Bernays
- School of Public Health, University of Sydney, Sydney, Australia; MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Maureen Tshuma
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | - Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
| | | | - Walter Mangezi
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Tsitsi Apollo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Ricardo Araya
- Health Services and Population Research Department, King's College London, London, UK
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe; Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development. J Adolesc Health 2019; 65:S16-S40. [PMID: 31761001 DOI: 10.1016/j.jadohealth.2019.09.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 12/21/2022]
Abstract
Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.
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