Depression among carers of AIDS-orphaned and other-orphaned children in Umlazi Township, South Africa

Food Insecurity at HIV Diagnosis Associated with Subsequent Viremia Amongst Adults Living with HIV in an Urban Township of South Africa

We assessed the temporal impact of food insecurity on 12-month antiretroviral (ART) adherence, retention in care, hospitalization, and HIV viremia (> 1000 copies/mL) in ART naïve adults presenting for HIV testing in Umlazi, South Africa. At the time of HIV testing and prior to ART initiation, we determined each participants' food security status using the validated Household Food Insecurity Access Scale (HFIAS). Following HIV testing and ART initiation, we then assessed the above outcomes of each study participant at 3-month intervals for a total of 12 months. Among 2,383 participants with HIV in this study, 253 (10.6%) experienced food insecurity. We found that food insecurity is associated with 20% higher adjusted prevalence odd ratios (aPOR) of having HIV viremia (> 1000 copies/mL) at 12 months following initial diagnosis (aPOR 1.2, 95% CI 1.1-1.4). We found no significant differences in ART adherence, retention in care, and hospitalization occurrences between the food secure and food insecure cohorts.

Youth Who Have Lived in Alternative Care in Nigeria, Zambia, and Zimbabwe: Mental Health and Violence Outcomes in Nationally Representative Data

Objective

We explore whether having previously lived in alternative care (foster, kinship, and/or residential care) is linked to sexual risk-taking, mental health, and experiencing violence in Nigerian, Zambian, and Zimbabwean youth ages 13-17 living in households with or without their biological parents, and assess the utility and limitations of existing data.

Method

This study is a secondary analysis of nationally-representative Violence Against Children Surveys (N=6,405). Logistic regressions examined the effect of alternative care experience on the odds of poor outcomes, controlling for covariates including parental care status, orphanhood, and household assets.

Results

In both bivariate and multivariate analyses, having lived in alternative care in the last five years was associated with lowered odds mental distress (OR=0.25, 95% CI: [0.10, 0.61], p=.002), and higher odds of sexual risk taking (OR=1.70, 95% CI: [1.11, 2.59], p=.014), caregiver physical abuse (OR=1.81, 95% CI: [1.30, 2.50], p<.001), caregiver emotional abuse (OR=1.75, 95% CI: [1.20, 2.54], p=.004), and peer violence (OR=1.57, 95% CI: [1.09, 2.26], p=.015). It was not associated with suicidality, self harm, or sexual assault after controlling for covariates.

Conclusion

Youth who have lived in alternative care in the last five years may benefit from programs that address violence, self-harm, and sexual risk taking behavior, even if they are now in families. To better understand children outside parental care, national data collection efforts should distinguish between residential and family-based care.

Subjective well-being among AIDS orphans in southwest China: the role of school connectedness, peer support, and resilience

BACKGROUND

Few studies have explored the health and development of AIDS orphans using the positive youth development (PYD) framework. Grounded in this framework, the main objective of this study is to examine how internal assets (i.e., resilience) and external assets (i.e., school connectedness, peer support) affect subjective well-being among Yi AIDS orphans in the Liangshan Yi Autonomous Prefecture, Sichuan province, China.

METHODS

A cross-sectional survey was conducted by interviewing 571 AIDS orphans and 979 non-orphans of Yi ethnic minority from 5th-10th grades. Structural equation models (SEM) were utilized to identify and estimate the direct and indirect effects of internal and external assets on subjective well-being.

RESULTS

The average score of subjective well-being was significantly lower for AIDS orphans than for in non-orphans (P < 0.05). Resilience, school connectedness, peer support (number of friends, caring friends), and self-rated physical health had significant and positive direct effects on subjective well-being. In addition, the effects of school connectedness, and peer support on subjective well-being were mediated by resilience.

CONCLUSIONS

Positive individual and school-related contextual assets can bolster subjective well-being among AIDS orphans. The design of health intervention programs for AIDS orphans should incorporate these positive development assets.

Depressive symptoms, HIV-related stigma and ART adherence among caregivers of children in vulnerable households in rural southern Malawi

Background

Few studies have explored the association between depressive symptoms, HIV infection and stigma in vulnerable populations. The objective of this study is to examine factors associated with depressive symptoms among caregivers living in vulnerable households in Malawi and assess how reported depressive symptoms and other factors affect ART adherence among caregivers who report testing positive for HIV and currently on ART.

Methods

We interviewed 818 adult caregivers of children aged 0–17 years living in vulnerable households in 24 health facility catchment areas in five districts in rural southern Malawi in 2016–2017. Vulnerable households had either economic and food insecurity, or chronic illness. Questions on five depressive symptoms were used. ART adherence was self-report of not forgetting to take ART medication in the last week. Perceived and anticipated measures of stigma were used. Multivariable linear and logistic regressions documented relationships between depressive symptoms, self-reported HIV status, HIV-related stigma, and ART adherence.

Results

Most caregivers were women (86.2%); about one third had no spouse or live-in partner. Fifty-seven percent of caregivers reported having three or more depressive symptoms. Forty-one percent of caregivers reported testing positive for HIV. Self-reported HIV positive status was associated with depressive symptoms (adjusted coeff = 0.355, p-value <0.001), which were in turn associated with poorer ART adherence among caregivers (aOR 0.639, p-value = 0.023). HIV-related stigma was also associated with depressive symptoms for caregivers who reported having HIV (coeff = 0.302, p-value = 0.028) and those who reported testing negative for HIV (coeff = 0.187, p-value <0.001). Having social support was associated with lower depressive symptoms (coeff = -0.115, p = 0.007). HIV-related stigma, having social support, and other socio-demographic characteristics were not found to be associated with ART adherence.

Conclusions

Addressing mental health among caregivers in vulnerable households may be an important step toward achieving viral suppression among vulnerable populations living with HIV in Malawi. Integrating depression screening into HIV care and treatment protocols could be a promising intervention to improve longer-term outcomes.

Depression, anxiety and treatment satisfaction in the parents of children on antiretroviral therapy in South Africa

Parents of children living with HIV are at increased risk of emotional distress, with negative implications for both their health outcomes. There is limited data on depression and anxiety symptoms in the biological parents as caregivers of children on antiretroviral therapy (ART) in South Africa. We investigated the prevalence and correlates associated with depressive and anxiety symptoms in 200 biological caregiving parents of children on ART at a public hospital in KwaZulu-Natal Province, South Africa. Data were obtained from the Patient Health Questionnaire (PHQ-9) for depressive symptoms and the Generalized Anxiety Depression (GAD-7) for anxiety symptoms, along with sociodemographic questionnaire. Most of the parent caregivers assessed were female (n = 190, 95%), younger than 40 years (n = 151, 75.5%), single (n = 173, 86.5%), unemployed (n = 156, 78%) and HIV+ (n = 183, 91.9%). Sixty-five (32.5%) parents screened positive for depression, 37 (18.5%) for anxiety and 31 (n = 31, 15.5%) for both disorders (i.e. depression/anxiety comorbidity). There were significant associations between death of a child to HIV (aOR = 4.66, 95% CI: 1.33-16.28) with depression/anxiety comorbidity as well as with treatment dissatisfaction (aOR = 13.98, CI: 2.09-93.66), but not with other socio-demographic factors. The high prevalence of depression and anxiety amongst the parent caregivers of children living with HIV suggests the need for mental health screening and care among parents of children attending pediatric HIV services, and particularly for those with history of children lost to HIV.

Investigating global mental health: Contributions from political science

This article outlines an agenda for political science engagement with global mental health. Other social sciences have tackled the topic, investigating such questions as the link between poverty and mental health disorders. Political science is noticeably absent from these explorations. This is striking because mental health disorders affect one billion people globally, governments spend only about 2% of their health budgets on these disorders, and most people lack access to treatment. With its focus on power, political science could deepen knowledge on vulnerabilities to mental illness and explain weak policy responses. By illustrating how various forms of power pertaining to governance, knowledge, and moral authority work through the concepts of issue framing, collective action, and institutions, the article shows that political science can deepen knowledge on this global health issue. Political science can analyse how incomplete knowledge leads to contentious framing, thus hobbling advocacy. It can explain why states shirk their obligations in mental health, and it can question how incentives drive mental health mobilisation. The discipline can uncover how power undergirds institutional responses to global mental health at the international, national, and community levels. Political science should collaborate with other social sciences in research networks to improve policy outcomes.

South African adult caregivers as "protective shields": Serving as a buffer between stressful neighborhood conditions and youth risk behaviors

Low-income youths in KwaZulu-Natal, South Africa, face elevated risks to their well-being from exposure to neighborhood conditions correlated with engaging in risky behaviors. These risks can be mitigated through adult caregivers who serve as protective shields, buffering adverse conditions. However, this protective role is dependent on the caregivers' mental health and well-being. This secondary analysis uses baseline data from 475 child-caregiver dyads in an HIV-prevention program to examine the mediating effects of caregiver mental health on the relationship between neighborhood conditions and child risk-behaviors. Multivariate analyses identify the direct and indirect effects of neighborhood stressors and caregiver mental health on child risk-behavior. Findings suggest that caregivers mitigate the impact of neighborhood conditions on their children, but caregivers' mental health is directly affected by neighborhood conditions. Therefore, caregivers' mental health and well-being must be considered key elements in developing youth risk-behavior interventions.

"Thoughts Can Kill You": Characterization of Mental Health Symptoms by Ugandan Grandparent-Caregivers in the HIV/AIDS Era

Studies of caregiving provided to HIV/AIDS orphans by sub-Saharan African grandparents have found that it has physical, financial, and emotional consequences. Our study extended this research by identifying and characterizing the symptoms experienced by Ugandan grandparent- caregivers, particularly as related to the caregiving role, loss and grief. Grounded theory methodology was used to conduct and analyze audio-recorded, semi-structured interviews with 32 grandparents. Findings revealed a cluster of biopsychosocial distress symptoms, especially anguish (driven by traumatic anxiety and disbelief), depression, and somatic symptoms that were linked primarily to psychological distress. The impact of cultural practices and beliefs on these symptoms was also identified. Results have implications for public health, research, and policy changes needed to alleviate symptoms of biopsychosocial distress among Uganda grandparent-caregivers.

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).

Adaptation and psychometric properties of the ISPCAN Child Abuse Screening Tool for use in trials (ICAST-Trial) among South African adolescents and their primary caregivers

Child abuse prevention research has been hampered by a lack of validated multi-dimensional non-proprietary instruments, sensitive enough to measure change in abuse victimization or behavior. This study aimed to adapt the ICAST child abuse self-report measure (parent and child) for use in intervention studies and to investigate the psychometric properties of this substantially modified tool in a South African sample. First, cross-cultural and sensitivity adaptation of the original ICAST tools resulted in two preliminary measures (ICAST-Trial adolescents: 27 items, ICAST-Trial caregivers: 19 items). Second, ICAST-Trial data from a cluster randomized trial of a parenting intervention for families with adolescents (N = 1104, 552 caregiver-adolescent dyads) was analyzed. Confirmatory factor analysis established the hypothesized 6-factor (adolescents) and 4-factor (caregivers) structure. Removal of two items for adolescents and five for caregivers resulted in adequate model fit. Concurrent criterion validity analysis confirmed hypothesized relationships between child abuse and adolescent and caregiver mental health, adolescent behavior, discipline techniques and caregiver childhood abuse history. The resulting ICAST-Trial measures have 25 (adolescent) and 14 (caregiver) items respectively and measure physical, emotional and contact sexual abuse, neglect (both versions), and witnessing intimate partner violence and sexual harassment (adolescent version). The study established that both tools are sensitive to measuring change over time in response to a parenting intervention. The ICAST-Trial should have utility for evaluating the effectiveness of child abuse prevention efforts in similar socioeconomic contexts. Further research is needed to replicate these findings and examine cultural appropriateness, barriers for disclosure, and willingness to engage in child abuse research.

Resilience among older caregivers in rural Namibia: The role of financial status, social support and health

BACKGROUND

Namibia has one of the highest human immunodeficiency virus (HIV) prevalence rates and one of the highest rates of orphanhood in the world, and older caregivers provide much of the care to Namibians living with HIV and acquired immune deficiency syndrome (AIDS) (UNAIDS, 2014). In this study, the authors explore how financial status, social support, and health were related to the resilience of caregivers caring for people affected by HIV and AIDS in rural northern Namibia, Africa.

METHOD

Data were collected through a structured interview from (N = 147) caregivers from the Zambezi region.

RESULTS

Findings from this study show that employment and physical health were significantly associated with increased resilience in older caregivers.

DISCUSSION

Our findings point to the need for employment assistance and health services to improve the resilience of caregivers caring for people living with HIV and AIDS. We conclude that there is a need for more vigorous concerted efforts from public and private sector practitioners and policy makers to create more sustained formal employment opportunities and intervention programs aimed at improving the overall health of older HIV caregivers, especially those residing in rural HIV endemic communities in developing countries.

Exposure to violence, teacher support, and school delay amongst adolescents in South Africa

BACKGROUND

Many adolescents in South Africa are exposed to multiple types of violence, socio-economic disadvantage, and low-quality education: all risk factors for educational outcomes including school delay (grade enrolment below that which is age-appropriate). Supportive teacher-student relationships are known to be associated with improved academic outcomes in high-income contexts.

AIMS

To investigate whether the academic and emotional support provided by teachers can protect against school delay for adolescents exposed to multiple types of violence and socio-economic disadvantage in South Africa.

SAMPLE

High-risk sample of 503 adolescents aged 10-18 exposed to multiple types of violence and socio-economic disadvantage at home, in school, and in their communities.

METHODS

Multilevel aggregated structural equation modelling was applied to pre/post-RCT data. This investigated whether associations between adolescent exposure to violence and school delay could be lessened by having teachers who were academically and/or emotionally supportive.

RESULTS

More frequent exposure to 'poly-violence' and receiving more emotional support from teachers were independently associated with greater school delay. On the contrary, higher academic support from teachers was associated with lower school delay. Neither academic nor emotional teacher support was found to moderate the relationship between more frequent exposure to 'poly-violence' and an increased risk of adolescent school delay.

CONCLUSION

Adolescents' academic support from teachers is low in poorly resourced school contexts in South Africa. School-based secondary prevention programmes assisting teachers with more training and academic support in deprived contexts have potential to reduce the impact of violence and socio-economic disadvantage on adolescents' school delay.

Mitigating depression among orphaned and vulnerable adolescents: a randomized controlled trial of interpersonal psychotherapy for groups in South Africa

BACKGROUND

Children and adolescents affected by HIV are at elevated risk of depression, yet research on related interventions in this population is scarce in sub-Saharan Africa. This study sought to examine the effects of interpersonal psychotherapy for groups (IPTG) on depressive symptomology among orphaned and vulnerable adolescents in South Africa.

METHOD

A cluster randomized controlled trial wherein adolescents ages 14-17 enrolled in community-based programming for HIV-affected and vulnerable families were randomly assigned by geographic cluster to participate in a 16-session IPTG intervention or the standard of care (n = 489). Baseline and postintervention surveys conducted with enrollees included standardized depression screening. Utilizing an intent-to-treat design, mixed effects models were performed to examine treatment effects for all participants and potential moderators including gender and baseline depression level (Clinical Trials registration: ClinicalTrials.gov NCT02386878).

RESULTS

While 23% of adolescents in the intervention group did not attend any IPTG sessions, average attendance was 12 out of 16 possible sessions among participants. The intervention was not associated with changes in depression symptomology.

CONCLUSIONS

Results underscore the importance of mitigating participation barriers prior to intervention roll-out and the need for increased evidence for psychological health interventions to mitigate depression among orphaned and vulnerable adolescents. This intervention and the study selectively targeted at-risk adolescents versus using diagnostic mental health criteria for enrollment; more research is needed to identify the potential benefits and disadvantages of these approaches.

Randomized controlled trial of a parenting program to reduce the risk of child maltreatment in South Africa

Parenting programs in high-income countries have been shown to reduce the risk of child maltreatment. However, there is limited evidence of their effectiveness in low- and middle-income countries. The objective of this study was to examine the initial effects of a parenting program in reducing the risk of child maltreatment in highly-deprived and vulnerable communities in Cape Town, South Africa. Low-income parents (N=68) with children aged three to eight years were randomly assigned to either a group-based parenting program or a wait-list control group. Observational and parent-report assessments were taken at baseline and at immediate post-test after the intervention was delivered. Primary outcomes were parent-report and observational assessments of harsh parenting, positive parenting, and child behavior problems. Secondary outcomes were parent-report assessments of parental depression, parenting stress, and social support. Results indicated moderate treatment effects for increased frequency of parent-report of positive parenting (d=0.63) and observational assessments of parent-child play (d=0.57). Observational assessments also found moderate negative treatment effects for less frequent positive child behavior (d=-0.56). This study is the first randomized controlled trial design to rigorously test the effectiveness of a parenting program on reducing the risk of child maltreatment in sub-Saharan Africa using both observational and self-report assessments. Results provide preliminary evidence of effectiveness of reducing the risk of child maltreatment by improving positive parenting behavior. Further development is required to strengthen program components regarding child behavior management and nonviolent discipline strategies. Future research would benefit from a larger trial with sufficient power to determine program effectiveness.

Psychosocial Challenges Associated with Caregiving in the Context of Pediatric HIV in Rural Eastern Cape

Background

While survival among human immunodeficiency virus (HIV)-infected children has increased due to combination antiretroviral therapy, many children remain vulnerable to the adverse effects of poverty and family disruptions as a result of the loss of one or both biological parents to acquired immunodeficiency syndrome. The aim of this qualitative study was to develop an understanding of the psychosocial challenges experienced by caregivers caring for a child with perinatally acquired HIV.

Method

A series of interviews were conducted with 44 HIV-positive and -negative primary caregivers of HIV+ children. Data were analyzed through interpretative phenomenological analysis using NVivo8 software.

Findings

The findings suggest that caregiving is compromised by inadequate, financial resources and single-headed households where mainly grandparents assume the role of primary caregivers of HIV+ children. HIV remains a stigmatized illness that weakens support networks, as well as timeous and free accessibility to healthcare. This has a negative impact on the mental health of caregivers, with the majority of women in the study displaying symptoms of depression.

Conclusion

The findings highlight the contextual challenges of caregiving in the presence of HIV, which impacts negatively on social ecology of the families. The need for interventions to enhance resilience and coping in families confronted with HIV is indicated.

BETTER OFF AT HOME: SAFETY DEVICE

ABSTRACT Objetive: to problematize the home care proposed by the Melhor em Casa Program as a safety device for understanding knowledge and conditions of possibility that support its discoursive network. Method: it is a study of genealogical inspiration about home care. The empirical material was constituted by legal documents about the theme, published in the Diário Oficial. The extracts that supposingly had the power to extract truth were organized in a spreadsheet. The analytic units were constructed, and instruments proposed by Foucault, such as power, biopolitics and device, were used for document analysis. Results: two analytic categories were elaborated: "From hospital to home", and "Home care: safety for the patient or for the State?". Conclusion: Home care, as a security device, proposes home as a safer and better place for the patient, who is close to the family, with no risk of hospital infection, cared by the health team, with the necessary technology.

Psychological impact on caregivers of HIV-infected children in Udupi district, Karnataka

Caregivers of children living with HIV/AIDS (CLWHA) face unique challenges due to disease-related stigma and discrimination, isolation from society, financial constraints, grief and mortality of loved one. A descriptive cross-sectional study was conducted at Udupi ART centre to assess the caregiver burden, psychological distress and their associated factors among the caregivers of CLWHA in Udupi District. The convenience sampling technique was used to collect the data from 171 caregivers and analysed with the help of SPSS version 15.0. Majority of caregivers were female (64.9%) with mean age of 38.1  ±  9.6 years. About 64.3% caregivers were HIV-positive and 63.2% were biological parents of CLWHA. Mild-to-severe caregiver burden on Zarit Burden Inventory (ZBI) was reported among 84.8% of caregivers, and mild-to-severe psychological distress on General Health Questionnaire (GHQ-12) was reported among 49.7% caregivers. Relationship with child was found to be a significant predictor of caregiver burden as compared to other relatives/foster (P < 0.001). Relationship with child (P 0.004), Alcohol use (P 0.008) and Schooling of children (P 0.049) were reported as significant predictors of psychological distress. Study concludes that caregiver burden and psychological distress were high among caregivers of CLWHA. Psychological problems of caregivers need to be addressed and integrated along with the clinical care of HIV-infected children at ART centres.

Representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar

Objetivo: conocer las representaciones sociales construidas por los cuidadores familiares de pacientes terminales sobre el cuidado en el domicilio. Método: estudio cualitativo con once cuidadores familiares de enfermos terminales, registrados en el servicio de internación domiciliaria de un hospital universitario del sur de Brasil. Realizaron entrevistas narrativas, analizadas por medio del análisis de contenido. Se definieron cuatro categorías: cuidadores hombres y mujeres, una visión diferente; la inversión de roles y los cambios en el cuidado; experiencias como fuente de conocimiento para el cuidado en el hogar; y desafíos del cuidado. Resultados: para los cuidadores hombres las representaciones difieren de las de las mujeres debido a que el cuidado incluye su entorno. Los hombres no atribuyen la angustia a la sobrecarga, pero si al temor de perder un ser. Otras representaciones remiten a la imposibilidad de elección para asumir el papel de cuidador y a la inversión de roles, lo que vuelve al paciente sometido al cuidador. Conclusión: esta investigación permitió conocer cómo los cuidadores familiares construyen los significados e interpretan el cuidado que realizan en el domicilio por medio del programa de hospitalización domiciliaria. Se destaca la función de los profesionales de la salud en orientar al cuidador familiar para realizar el cuidado.

Caregiver alcohol use and mental health among children orphaned by HIV/AIDS in South Africa

Research in the developed world suggests that parental alcohol use negatively impacts child mental health. However, little research has examined these relations among children in the developing world and no studies to date have done so in the context of AIDS-orphanhood. Therefore, the present study tested the interactive effect of AIDS-orphan status with caregiver alcohol use on child mental health. The sample included 742 children (51.2% female; M_age= 9.18; age range: 7-11 years; 29.8 AIDS-orphans; 36.8% orphaned by causes other than AIDS; 33.4% non-orphaned) recruited from Mangaung in the Free State Province of South Africa. Child mental health was assessed via child self-report, caregiver, and teacher reports; and caregiver alcohol use via self-report. Path analyses, via structural equation modeling, revealed significant direct effects for AIDS-orphan status on caregiver-reported child mental health; and for caregiver alcohol-use problems on teacher-reported child mental health. However, the interaction effect of AIDS-orphan status with caregiver alcohol use did not reach significance on all three reports of child mental health problems. These results suggest that orphan status and caregiver alcohol use may independently relate to mental health problems in children and that the effects of both should be considered in the context of the mental health needs of children in AIDS-affected countries.

An exploratory analysis of factors associated with depression in a vulnerable group of young people living in informal settlements in South Africa

Depression amongst young people is a major health challenge and is often shaped by social marginalisation. Informal settlements are growing rapidly. There is a need to deepen understandings of depression amongst young people in these contexts. We sought to understand factors associated with depressive symptomology amongst 232 young people (122 women, 110 men) aged 18-30 in urban informal settlements in South Africa. We conducted a cross-sectional analysis of baseline data collected for the Stepping Stones and Creating Futures pilot. Logistic regression modelled relationships between depressive symptomology, livelihoods and violence. Symptomatic depression in this population was 49.5% for men and 57.9% for women. In multiple regression, depression in men was associated with stealing because of hunger (adjusted Odds Ratio (aOR) 5.78, p = .03), being more controlling in relationships (aOR 0.81, p = .008) and being more ashamed about lack of work (aOR 0.75, p = .01). For women, depressive symptoms were associated with greater stress about lack of work (aOR 0.72, p < .0001) and food insecurity (aOR 5.57, p = .039). The study emphasises that socio-economic factors, shaped by local understandings of gender, play a significant role in depressive symptomology. We suggest reducing economic distress may have an important role in reducing depression in this population.

The indirect impact of antiretroviral therapy: Mortality risk, mental health, and HIV-negative labor supply

To reduce the burden of the HIV/AIDS epidemic, international donors recently began providing free antiretroviral therapy (ART) in parts of Sub-Saharan Africa. ART dramatically prolongs life and reduces infectiousness for people with HIV. This paper shows that ART availability increases work time for HIV-negative people without caretaker obligations, who do not directly benefit from the medicine. A difference-in-difference design compares people living near and far from ART, before and after treatment becomes available. Next we explore the possible reasons for this pattern. Although we cannot pinpoint the mechanism, we find that ART availability substantially reduces subjective mortality risk and improves mental health. These results show an undocumented economic consequence of the HIV/AIDS epidemic and an important externality of medical innovation. They also provide the first evidence of a link between the disease environment and mental health.

Household illness, poverty and physical and emotional child abuse victimisation: findings from South Africa's first prospective cohort study

Background

Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.

Methods

Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person’s disability as hypothesised mediators.

Results

For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.

Conclusions

These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1792-4) contains supplementary material, which is available to authorized users.

Are social support and HIV coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal, South Africa

We assess depression rates and investigate whether depression among HIV-infected adults receiving antiretroviral treatment (ART) is associated with social support and HIV coping strategies in rural South Africa (SA). The study took place in a decentralised public-sector ART programme in a poor, rural area of KwaZulu-Natal, SA, with high-HIV prevalence and high-ART coverage. The 12-item General Health Questionnaire (GHQ12), validated in this setting, was used to assess depression in 272 adults recently initiated on ART. Estimates of depression prevalence ranged from 33% to 38%, depending on the method used to score the GHQ12. Instrumental social support (providing tangible factors for support, such as financial assistance, material goods or services), but not emotional social support (expressing feelings, such as empathy, love, trust or acceptance, to support a person), was significantly associated with lower likelihood of depression [adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) 0.52-0.81, P < 0.001], when controlling for sex, age, marital status, education, household wealth and CD4 cell count. In addition, using "avoidance of people" as a strategy to cope with HIV was associated with an almost three times higher odds of depression (aOR = 2.79, CI: 1.34-5.82, P = 0.006), whereas none of the other five coping strategies we assessed was significantly associated with depression. In addition to antidepressant drug treatment, interventions enhancing instrumental social support and behavioural therapy replacing withdrawal behaviours with active HIV coping strategies may be effective in reducing the burden of depression among patients on ART.

Cumulative effects of HIV illness and caring for children orphaned by AIDS on anxiety symptoms among adults caring for children in HIV-endemic South Africa

Adults caring for children in HIV-endemic communities are at risk for poor psychological outcomes. However, we still have a limited understanding of how various HIV impacts--including caregiver's own HIV illness, responsibilities of caring for a child orphaned by AIDS, or both--affect psychological outcomes among caregivers. Furthermore, few studies have explored the relationship between stigma, HIV, and psychological outcomes among caregivers of children in HIV-endemic communities. A cross-sectional survey conducted from 2009 to 2010 assessed anxiety among 2477 caregivers of children in HIV-endemic South Africa. Chi-square tested differences in anxiety among caregivers living with HIV, caregivers of a child orphaned by AIDS, and caregivers affected with both conditions. Multivariate logistic regressions identified whether the relationship between HIV impacts and anxiety remained after controlling for socio-demographic co-factors. Mediation analysis tested the relationship between stigma, HIV, and anxiety. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were two and a half times greater among caregivers living with HIV compared to nonaffected caregivers. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were greatest among caregivers living with HIV and caring for a child orphaned by AIDS. Exposure to AIDS-related stigma partially mediated the relationship between HIV and anxiety. Interventions are needed to address caregiver psychological health, particularly among caregivers affected with both conditions of living with HIV and caring for a child orphaned by AIDS.

Family economic strengthening and mental health functioning of caregivers for AIDS-affected children in rural Uganda

In sub-Saharan Africa, many extended families assume the role of caregivers for children orphaned by AIDS (AIDS-affected children). The economic and psychological stress ensued from caregiving duties often predispose caregivers to poor mental health outcomes. Yet, very few studies exist on effective interventions to support these caregivers. Using data from a randomized controlled trial called Suubi-Maka (N = 346), this paper examines whether a family economic strengthening intervention among families caring for AIDS-affected children (ages 12-14) in Uganda would improve the primary caregivers' mental health functioning. The Suubi-Maka study comprised of a control condition (n = 167) receiving usual care for AIDS-affected children, and a treatment condition (n = 179) receiving a family economic strengthening intervention, including matched savings accounts, and financial planning and management training to incentivize families to save money for education and/or family-level income generating projects. This paper uses data from baseline/pre-intervention (wave 1) interviews with caregivers and 12-month post-intervention initiation (wave 2). The caregiver's mental health measure adapted from previous studies in sub- Saharan Africa had an internal consistency of .88 at wave 1 and .90 at wave 2. At baseline, the two study groups did not significantly differ on caregiver's mental health functioning. However, at 12-month follow-up, multiple regression analysis located significant differences between the two study groups on mental health functioning. Specifically, following the intervention, caregivers in the treatment condition reported positive improvements on their mental health functioning, especially in the symptom areas of obsession-compulsion, interpersonal sensitivity, hostility, and psychoticism. Findings point to a need for programs and policies aimed at supporting caregivers of AIDS-affected children to begin to consider incorporating family-level economic strengthening components in their usual care protocols, especially in low-resource countries of sub-Saharan Africa. Economic empowerment programming may help enhance the well-being of caregivers and their families.

Positive parenting for positive parents: HIV/AIDS, poverty, caregiver depression, child behavior, and parenting in South Africa

Families affected by HIV/AIDS in the developing world experience higher risks of psychosocial problems than nonaffected families. Positive parenting behavior may buffer against the negative impact of child AIDS-orphanhood and caregiver AIDS-sickness on child well-being. Although there is substantial literature regarding the predictors of parenting behavior in Western populations, there is insufficient evidence on HIV/AIDS as a risk factor for poor parenting in low- and middle-income countries. This paper examines the relationship between HIV/AIDS and positive parenting by comparing HIV/AIDS-affected and nonaffected caregiver-child dyads (n=2477) from a cross-sectional survey in KwaZulu-Natal, South Africa (27.7% AIDS-ill caregivers; 7.4% child AIDS-orphanhood). Multiple mediation analyses tested an ecological model with poverty, caregiver depression, perceived social support, and child behavior problems as potential mediators of the association of HIV/AIDS with positive parenting. Results indicate that familial HIV/AIDS's association to reduced positive parenting was consistent with mediation by poverty, caregiver depression, and child behavior problems. Parenting interventions that situate positive parenting within a wider ecological framework by improving child behavior problems and caregiver depression may buffer against risks for poor child mental and physical health outcomes in families affected by HIV/AIDS and poverty.