Contextualising women's mental distress and coping strategies in the time of AIDS: a rural South African case study

Creating communities that care: social representation of mental health in two urban poor communities in Ghana

Building caring communities is fundamental to achieving a community-based approach to mental health. Understanding how communities perceive mental illness provides critical insight into fostering mental health awareness and care. We explored the perceptions of mental illness among members of two urban poor communities in Accra, Ghana. Qualitative data were collected from 77 participants through key informant interviews, focus group discussions, and situated conversations. Using theory-driven thematic analysis based on social representations theory, findings revealed cognitive-emotional representations of mental illness. The communities demonstrated high awareness of the multilevel factors contributing to mental illness risk and experiences, drawing on five sources of knowledge: embodied, common sense, medical, cultural, and religious. Mental illness representations informed the classification and legitimization of mental illness based on the severity of conditions and the identity of sufferers. These findings provide valuable insights for planning community mental health interventions that address both social and institutional care needs.

Expanding the food environment framework to include family dynamics: A systematic synthesis of qualitative evidence using HIV as a case study

Food environment changes in low- and middle-income countries are increasing diet-related noncommunicable diseases (NCDs). This paper synthesizes the qualitative evidence about how family dynamics shape food choices within the context of HIV (Prospero: CRD42021226283). Guided by structuration theory and food environment framework, we used best-fit framework analysis to develop the Family Dynamics Food Environment Framework (FDF) comprising three interacting dimensions (resources, characteristics, and action orientation). Findings show how the three food environment domains (personal, family, external) interact to affect food choices within families affected by HIV. Given the growing prevalence of noncommunicable and chronic diseases, the FDF can be applied beyond the context of HIV to guide effective and optimal nutritional policies for the whole family.

"I've accepted it because at the end of the day there is nothing, I can do about it": A qualitative study exploring the experiences of women living with the HIV, intimate partner violence and mental health syndemic in Mpumalanga, South Africa

In South Africa, Mental Health (MH), HIV, and Intimate Partner Violence (IPV) form a syndemic, that disproportionately affects women. These challenges are often co-occurring and create complex adversities for women. Recognising these intersections and the broader socio-cultural dynamics at play is crucial to understanding the layered experiences of these women and developing effective interventions. This research explores the experiences of the women living with at least two of the epidemics (HIV, IPV and or MH) and how they cope. A qualitative study design was used and 20 women (22-60 years) were recruited from Mpumalanga, South Africa. To be eligible for the study the women had to have experienced at least two of the epidemics. Data were collected through home-based interviews, arts-based activities, and analysed thematically using MAXQDA (2022) software. MH challenges were prevalent among all the participants and were linked to both IPV and HIV, resulting in symptoms such as anxiety, depression, and suicidal thoughts. In relation to the HIV-MH link, MH challenges in this combination included feelings of denial, sadness and anxiety related to participant's HIV diagnosis. A bidirectional relationship also existed in the IPV-MH group where pre-existing MH challenges among women increased their vulnerability of having violent partners, whilst IPV also increased MH challenges. In the IPV-MH-HIV group early childhood violence exposure was linked with MH challenges and later victimization and vulnerability to HIV. Participants primarily used religion, acceptance, occasional alcohol, and family support as coping strategies. Particularly in IPV situations, alcohol use/misuse was the most prevalent coping strategies. The study highlights the syndemic relationship between HIV, IPV and MH challenges among South African women living in a peri-urban community, with a central emphasis on MH challenges. Interventions should holistically address these challenges, with particular focus on MH challenges, cultural sensitivity, and promotion of healthy coping strategies.

Depression and Global Mental Health in the Global South: A Critical Analysis of Policy and Discourse

Over the past two decades, depression has become a prominent global public health concern, especially in low- and middle-income countries (LMICs). The World Health Organization (WHO) and the Movement for Global Mental Health have developed international guidelines to improve mental health services globally, prioritizing LMICs. These efforts hold promise for advancing care and treatment for depression and other mental, neurological, and substance abuse disorders in LMICs. The intervention guides, such as the WHO's mhGAP-Intervention Guides, are evidence-based tools and guidelines to help detect, diagnose, and manage the most common mental disorders. Using the Global South as an empirical site, this article draws on Foucauldian critical discourse and document analysis methods to explore how these international intervention guides operate as part of knowledge-power processes that inscribe and materialize in the world in some forms rather than others. It is proposed that these international guidelines shape the global discourse about depression through their (re)production of biopolitical assumptions and impacts, governmentality, and "conditions of possibility." The article uses empirical data to show nuance, complexity, and multi-dimensionality where binary thinking sometimes dominates, and to make links across arguments for and against global mental health. The article concludes by identifying several resistive discourses and suggesting reconceptualizing the treatment gap for common mental disorders.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Mental health burden among females living with HIV and AIDS in sub-Saharan Africa: A systematic review

Mental health problems, particularly depression and anxiety, are common in women and young girls living with HIV/ AIDS particularly in low- and middle-income (LMICs) countries where women's vulnerability to psychiatric symptoms is heightened due to the prevalent intersectional stressors such as stigma and intimate partner violence. However, no synthesized evidence exists on the mental health burden of females living with HIV/AIDS (FLWHA) in Africa. This systematic review aimed to synthesize the current evidence on the mental health burden among FLWHA in sub-Saharan Africa. A systematic literature review of articles published from 2013-2023 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Five electronic databases; PubMed, MEDLINE with full text, Scopus, Academic Search Complete, and Health Source: Nursing Academic Edition were searched for articles published in English. Nineteen articles (15 quantitative, 3 qualitative, and 1 case study) from over 7 African countries met the inclusion criteria. The majority of the studies' quality was determined to be moderate. The prevalence of depression ranged from 5.9 to 61% and anxiety from 28.9 to 61%. Mental health burden was a logical outcome of HIV diagnosis. Predictors of mental health outcomes in the context of HIV/AIDS were identified as intimate partner violence (IPV), stigma, childhood traumas, sexual abuse, poverty, unemployment, and social isolation. Social support and resilience were identified as protective factors against mental illness in FLWHA. Mental illness had a deleterious effect on viral suppression rates among FLWHA, resulting in delayed initiation of antiretroviral therapy treatment and increased mortality but had no impact on immune reconstitution in the face of ART adherence. Given the high prevalence rates of depression and anxiety and their relationship with HIV progression, it is crucial that mental health care services are integrated into routine HIV care.

Biographical Reinvention: An Asset-Based Approach to Understanding the World of Men Living with HIV in Indonesia

HIV diagnosis and management have often caused disruption to the everyday life and imagined futures of people living with HIV, both at individual and social levels. This disruption has been conceptualised, in a rather dystopian way, as 'biographical disruption'. This paper explores whether or not biographical disruption of living with HIV encourages men living with HIV (MLHIV; n = 40) in Yogyakarta and Belu, Indonesia, to reinvent their sense of self and future over time using internal and external assets. Our analysis uses the concepts of additive and subtractive resilience strategies, and we show how, rather than having a purely disrupted biography, participants talked about their experiences of 'biographical reinvention'. Study participants were recruited using the snowball sampling technique, beginning with two HIV clinics as the settings. Data were collected using one-on-one in-depth interviews, and a qualitative framework analysis was used to guide step-by-step data analysis. The findings showed that, despite the disruptions in their everyday lives (i.e., mental health condition, work, activities, social relationships, etc.) following the HIV diagnosis and management, MLHIV in our study managed to utilise their internal assets or traits (i.e., hope, optimism, resilience) and mobilised external resources (i.e., support from families, friends and healthcare professionals) to cope with the disruptions. An interweaving of these internal assets and external resources enabled them to take on new activities and roles (additive resilience strategies) and give up health compromising behaviours (subtractive resilience strategies). These were effective for most MLHIV in our study, not only to cope with the HIV repercussions and improve their physical and mental health conditions, but to think or work on a 'reinvented' biography which encompassed resilience, hope and optimism for better health, life and future. The findings indicate the need for HIV interventions and healthcare systems that provide appropriate support for the development and maintenance of internal assets of PLHIV to enable them to cope with the repercussions of HIV and work on a 'reinvented' biography.

Understanding coping strategies of mothers living with HIV who care for children living with HIV: a qualitative study in Indonesia

HIV infection and its sequelae continue to be a significant challenge among women and their families in developing countries despite the progress that has been made in the prevention and treatment of HIV. This paper describes the strategies employed by mothers with HIV to cope with the various challenges experienced following their own and their children's HIV diagnosis. This paper uses previously unpublished data collected for a study that sought to explore the mental health challenges and coping strategies of mothers living with HIV (MLHIV) (n = 23) who have children living with HIV (CLHIV). Data collection was conducted using in-depth interviews, and participants were recruited using the snowball sampling technique. The concept of meaning-making was used to guide the conceptualisation, analysis, and discussion of the findings. Our analysis showed that meaning-making such as the awareness of how important mothers were to their children/CLHIV and families and religious meaning were used by participants to cope with HIV-related and mental health challenges they faced. The meaning of mother-child relationship which was supported and maintained through the provision of time, attention and fulfillment of CLHIV's needs were also coping strategies employed by these women. Additional coping strategies used were to link their CLHIV to groups and activities of CLHIV. The connections made through these links enabled their children to know other CLHIV, build relationships, and share experiences. These findings are useful evidence that can inform policies and practices and indicate the need for the development of intervention programs that address the needs of MLHIV and their families to cope with HIV-related challenges of their children. Future large-scale studies involving MLHIV who have CLHIV are recommended to have a comprehensive understanding of strategies they employ to cope with HIV-related challenging circumstances and mental health issues that they continue to face.

Patients' priorities around drug-resistant tuberculosis treatment: A multi-national qualitative study from Mongolia, South Africa and Georgia

We conducted qualitative research exploring the treatment experience of people with DR-TB. We held nine focus group discussions with 57 adults undergoing/recently completed treatment for DR-TB in Georgia, Mongolia and South Africa. Translated transcripts were analysed using thematic analysis. We identified three higher order themes: (1) Treatment experience and the role of good relationships with healthcare providers: Treatment duration, pill burden and side-effects were challenging aspects of treatment. Side-effects/symptoms that were visible signs of illness were particularly troubling. Good relations with clinical staff helped combat fear and uncertainty regarding treatment. (2) Mental distress and opportunities for wellbeing: The shame, stigma and isolation people experienced as a result of their DR-TB diagnosis was an important cause of mental distress. No longer being infectious enabled people to resume work and socialising. Positive emotions emerged with good treatment outcomes. (3) Fear and worry along the treatment journey: Participants expressed fears about TB: infecting others; whether they would be able to endure treatment; side-effects; health consequences of treatment. Worries mostly disappeared with successful treatment. Alongside measuring side-effects, time to culture conversion and cure rates, future trials of DR-TB treatments should capture how quickly visible symptoms resolve, quality of life measures, and mental health outcomes.

Towards a social psychology of precarity

This article introduces the special issue 'Towards a Social Psychology of Precarity' that develops an orienting lens for social psychologists' engagement with the concept. As guest editors of the special issue, we provide a thematic overview of how 'precarity' is being conceptualized throughout the social sciences, before distilling the nine contributions to the special issue. In so doing, we trace the ways in which social psychologists are (dis)engaging with the concept of precarity, yet too, explore how precarity constitutes, and is embedded within, the discipline itself. Resisting disciplinary decadence, we collectively explore what a social psychology of precarity could be, and view working with/in precarity as fundamental to addressing broader calls for the social responsiveness of the discipline. The contributing papers, which are methodologically pluralistic and provide rich conceptualisations of precarity, challenge reductionist individualist understandings of suffering and coping and extend social science theorizations on precarity. They also highlight the ways in which social psychology remains complicit in perpetuating different forms of precarity, for both communities and academics. We propose future directions for the social psychological study of precarity through four reflexive questions that we encourage scholars to engage with so that we may both work with/in, and intervene against, 'the precarious'.

Exploring the impact of a complex intervention for women with depression in contexts of adversity: A pilot feasibility study of COURRAGE-plus in South Africa

BACKGROUND

Depression is a leading cause of disease burden worldwide but is often undertreated in low- and middle-income countries. Reasons behind the treatment gap vary, but many highlight a lack of interventions which speak to the socio-economic and structural realties that are associated to mental health problems in many settings, including South Africa. The COURRAGE-PLUS intervention responds to this gap, by combining a collective narrative therapy (9 weeks) intervention, with a social intervention promoting group-led practical action against structural determinants of poor mental health (4 weeks), for a total of 13 sessions. The overall aim is to promote mental health, while empowering communities to acknowledge, and respond in locally meaningful ways to social adversity linked to development of mental distress.

AIM

To pilot and evaluate the effectiveness of a complex intervention - COURRAGE-PLUS on symptoms of depression as assessed by the Patient Health Questionnaire (PHQ-9) among a sample of women facing contexts of adversity in Gauteng, South Africa.

METHODS

PHQ-9 scores were assessed at baseline, post collective narrative therapy (midline), and post social intervention (endline). Median scores and corresponding interquartile ranges were computed for all time points. Differences in scores between time points were tested with a non-parametric Friedman test. The impact across symptom severities was compared descriptively to identify potential differences in impact across categories of symptom severity within our sample.

RESULTS

Participants' (n = 47) median depression score at baseline was 11 (IQR = 7) and reduced to 4 at midline (IQR = 7) to 0 at endline (IQR = 2.5). The Friedman test showed a statistically significant difference between depression scores across time points, χ2(2) = 49.29, p < .001. Median depression scores were reduced to 0 or 1 Post-Intervention across all four severity groups.

CONCLUSIONS

COURRAGE-PLUS was highly effective at reducing symptoms of depression across the spectrum of severities in this sample of women facing adversity, in Gauteng, South Africa. Findings supports the need for larger trials to investigate collective narrative storytelling and social interventions as community-based interventions for populations experiencing adversity and mental distress.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management

Approximately 10-15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants' lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

Overlooked and unaddressed: A narrative review of mental health consequences of child marriages

Child Marriage (before the age of 18) affects over 12 million young women globally, annually. Despite acknowledgement of the negative impacts of the practice on reproductive health, mental health consequences are largely overlooked. Given the ability for poor mental health to intensify other health and social challenges, understanding the mental health consequences linked to child marriage is vital. Our study is the first to examine how mental health is approached in current literature on child marriage. Our conceptual framework was informed by a rapid assessment of key issues in the field. Systematic searches of papers published between 2000-2020 were completed on four electronic databases with no language restrictions. Our protocol was registered on Prospero (CRD42019139685). Articles were assessed using PRISMA guidelines, and their quality assessed using the Joanna Briggs Institute Critical Appraisal Tools. Of the 4,457 records identified, 21 papers meeting inclusion criteria were analysed using narrative synthesis. The final sample included 5 qualitative, 1 mixed-methods and 15 quantitative studies (14 cross-sectional and 1 longitudinal study) reporting on data from 12 countries, largely in the global south. Intimate partner violence, poverty, challenges in childbirth and isolation were identified as social factors linked to emotional distress by those married as children. Depression was the most reported mental disorder. Anxiety, phobias, psychological distress, substance misuse, negative well-being and anti-social personality disorder were reported less frequently. Findings highlight that while significant emotional distress and specific mental health conditions are linked to child marriage, gaps in our understanding remain. Future studies are needed to; clarify directionality in these relationships; understand the mental health needs of young men, LGBTQI communities and those in humanitarian settings. Given the well documented cyclical relationship between social determinants and mental health conditions, we outline a series of community-oriented interventions which blend psychological, social and structural support to promote mental health and wellbeing in the contexts of child marriage.

Gender, mental health and resilience in armed conflict: listening to life stories of internally displaced women in Colombia

For over 60 years, Colombia has endured violent civil conflict forcibly displacing more than 8 million people. Recent efforts have begun to explore mental health consequences of these contexts, with an emphasis on national surveys. To date few Colombian studies explore mental health and well-being from a lived experience perspective. Those that do, overlook processes that enable survival. In response to this gap, we conducted a life history study of seven internally displaced Colombian women in the Cundinamarca department, analysing 18 interview sessions and 36 hours of transcripts. A thematic network analysis, informed by Latin-American perspectives on gender and critical resilience frameworks, explored women’s coping strategies in response to conflict-driven hardships related to mental well-being. Analysis illuminated that: (1) the gendered impacts of the armed conflict on women’s emotional well-being work through exacerbating historical gendered violence and inequality, intensifying existing emotional health challenges, and (2) coping strategies reflect women’s ability to mobilise cognitive, bodied, social, material and symbolic power and resources. Our findings highlight that the sociopolitical contexts of women’s lives are inseparable from their efforts to achieve mental well-being, and the value of deep narrative and historical work to capturing the complexity of women’s experiences within conflict settings. We suggest the importance of social interventions to support the mental health of women in conflict settings, in order to centre the social and political contexts faced by such marginalised groups within efforts to improve mental health.

Contextualized understanding of depression: A vignette study among the !Xun and Khwe of South Africa

Colonial misconceptions about the absence of depression and the lack of a psychologization of distress among Africans have long been refuted. However, cultural variation in depression in terms of symptomatic expression, conceptualization, explanatory models, and social responses is widely acknowledged. Insight into the cultural variation of depression is useful for providing appropriate care; however, few studies have explored cultural understandings of depression in African settings. In a depression vignette study of two displaced and marginalized San communities in South Africa, we conducted 20 semistructured interviews to explore causal interpretations and strategies for coping. Causal interpretations consisted of several dimensions, including life struggles and physical, psychological, and spiritual interpretations. Respondents primarily focused on life struggles in terms of socioeconomic and interpersonal problems. They described coping strategies as primarily addressing negative emotional and psychological affect through social support for relief, comfort, distraction, or advice on coping with the situation and emotions. In addition, religious coping and professional support from a social worker, psychologist, support group, or medications were mentioned. Findings illustrate that depression should be understood beyond individual suffering and be situated in its immediate social environment and larger sociopolitical setting. Interventions for depression therefore may benefit from a multilevel approach that addresses socioeconomic conditions, strengthens local resources, and fosters collaboration among locally appropriate informal and formal support structures.

In search of 'community': a critical review of community mental health services for women in African settings

Community is deemed a central resource for the improvement of health, across disciplines, contexts and conditions. However, what is meant by this term is rarely critically explored. In Global Mental Health, considerable efforts in recent years have been directed towards scaling up 'community' approaches, with variable success, creating the need to better understand approaches to its use. Our study contributes to this need, through a critical review of studies engaging with the term 'community' in relation to women's mental health services in African settings. Our review explored 30 peer-reviewed articles from the past 15 years, which were systematically evaluated for quality of evidence. Studies were then analysed using a blend of conventional and directed content analysis to unpack perspectives on the term's use in intervention and phenomenological studies. We identified four broad categories of community: (1) place (shared geographical location or institutional affiliation), (2) practice (belongingness to a shared activity or profession), (3) symbols (meanings and experiences associated with shared community life) and (4) identity (diagnostic identity around a mental health condition). Analysis identified community of place as the most common primary focus of interest across the sample, with 80% of papers referencing this dimension. We noted that in studies where communities of practice were the focus, this was in relation to leveraging local knowledge to inform or support service delivery of intervention programmes, often designed by outsiders. Implications for future policy and mental health services research are discussed.

"A woman's life is tension": A gendered analysis of women's distress in poor urban India

The mental health of women living in poverty is a growing public health concern, particularly in India where the burden of illness is compounded by critical shortages in mental health providers and fragmented services. This was an exploratory study which sought to examine low-income women's perceptions of mental illness and its management in the context of urban poverty in India. This research was prompted by the lack of empirical studies documenting how women in marginalized sections of society understand mental illness. Data were collected through a combination of 10 focus group discussions and two individual interviews with a total of 63 women residing in low-income areas of Mumbai. Social representations theory was used to explore shared meanings of mental illness among women in this setting. Thematic analysis of the data showed that women use the expression "tension" to talk about mental illness. Tension was described both as an ordinary part of life and a condition having its origins in more profound gender-related stressors, particularly pressures surrounding motherhood, chronic poverty and domestic conflict. Approaches to managing tension were pluralistic and focused on the resumption of social roles. Findings are consistent with other studies in similar cultural contexts, suggesting a shared, transnational character to women's distress and the need for scholarship on women's mental health in low-income settings to be more attuned to gendered forms of marginalization.

The impact of food insecurity on mental health in Africa: A systematic review

In 2018, 676.1 million people in Africa (52.5% of the population) were moderately or severely food insecure. This exceptionally high prevalence continues to increase as Africa experiences conflict, climate change, and economic declines. When Sustainable Development Goal 2.1 set out to end hunger and ensure access to sufficient food, particularly for vulnerable populations, by 2030, food insecurity emerged as a global priority. Food insecurity has been hypothesized to negatively impact mental health, a stigmatized area of health in Africa for which care is often inaccessible. This systematic review examines existing literature on the relationship between food insecurity and mental health in Africa, where progress remains to be made on both fronts. A systematic search of seven databases (EMBASE, Web of Science, CINAHL, PsychINFO ProQuest, Medline Ovid, Scopus, and Nursing and Allied Health) was conducted. Results were limited to studies examining food insecurity and mental health, written in English and published between January 2000 and May 2020. After title, abstract, full-text review, and quality appraisal using tools from the National Heart, Lung, and Blood Institute, 64 studies remained. Findings were summarized using a narrative synthesis approach. Studies unanimously highlighted that food insecurity is associated with poor mental health. This relationship was dose-responsive and independent of the measured mental health outcome. Two highly represented groups in the literature were women around pregnancy and people affected by HIV/AIDS. Factors which mediated the relationship included age, sex, social interactions, physical health, seasonality, and rural residence. The findings suggest that the relationship is likely amplified in specific populations such as women and seniors, and interventions which target livelihood as opposed to income may be more effective. Further research is needed which compares food insecurity's effect on mental health between at-risk populations, in order to guide resource allocation and context-specific policy making.

Parenting the child with HIV in limited resource communities in South Africa: mothers with HIV's emotional vulnerability and hope for the future

Introduction:

A diagnosis of HIV does not affect the well-being of mothers alone but also affects how they care for their children. The aim of this study was to explore how mothers who were diagnosed with HIV when pregnant or when their children became ill experience raising children living with HIV. The purpose was to understand how a diagnosis of HIV impacts mothering their children at different points on the mothering journey.

Methods:

Using descriptive phenomenological enquiry, interviews were conducted with 28 mothers recruited via purposeful sampling from clinics in health district in South Africa. The interviews were audiotaped, transcribed verbatim, and analysed following the thematic approach.

Results:

The mothers found mothering a child living with HIV stressful and associated with constant thoughts of death. The burden of mothering was increased for mothers who had to confront emotions of self-blame and guilt for unintentionally infecting the child. They used secrecy to protect their children from the social consequences of a diagnosis of HIV. The thought of living with HIV weighed on them every day and they expressed their experience of intense feelings of chronic worry, anxiety, and sadness. The findings identified high levels of stress, with the mothers expressing emotions suggestive of depression. With time, they accepted living with HIV and embraced motherhood, and became better mothers.

Conclusion:

The negative coping strategies used to deal with the child’s HIV diagnosis and high levels of stress and anxiety identified in the study underscore the need to address the psychosocial needs of mothers living with HIV. There is need to provide psychosocial support and continuous counselling for these mothers post diagnosis and upon a positive HIV diagnosis of the child to women enrolled in the prevention of mother to child transmission of HIV programme.

Clinical and Obstetric Risk Factors for Postnatal Depression in HIV Positive Women: A Cross Sectional Study in Health Facilities in Rural KwaZulu-Natal

Postnatal depression (PND) remains underdiagnosed and undertreated in different socio-economic backgrounds in South Africa. This study determined the prevalence of and clinical and obstetric risk factors for PND symptoms among HIV positive women in health facilities in a rural health district in South Africa. The Edinburgh Postnatal Depression Scale was used to measure PND from 386 women who had delivered a live infant. More than half (58.5%) tested HIV positive during the current pregnancy. The prevalence of PND symptoms was 42.5%. Logistic regression analysis yielded significant associations between clinical and obstetric variables of pre-term baby (p-value < 0.01), baby health status p-value < 0.01), baby hospitalization, (p-value < 0.01), and knowing the baby’s HIV status (p-value = 0.047). Maternal variables associated with PND were level of education (p-value < 0.01), monthly income (p-value < 0.01), and source of income (p-value = 0.05). At multivariate analysis, none of the clinical and obstetrical risk factors were independently associated with the PND. The high prevalence of PND symptoms underscore the need to integrate routine screening for PND in prevention of mother to child transmission of HIV programmes to enable early diagnosing and treatment of PND.

"It Was as Though My Spirit Left, Like They Killed Me": The Disruptive Impact of an HIV-Positive Diagnosis among Women in the Dominican Republic

An HIV diagnosis may be associated with severe emotional and psychological distress, which can contribute to delays in care or poor self-management. Few studies have explored the emotional, psychological, and psychosocial impacts of an HIV diagnosis on women in low-resource settings. We conducted in-depth interviews with 30 women living with HIV in the Dominican Republic. Interviews were audio-recorded, transcribed, and analyzed using the biographical disruption framework. Three disruption phases emerged (impacts of a diagnosis, postdiagnosis turning points, and integration). Nearly all respondents described the news as deeply distressful and feelings of depression and loss of self-worth were common. Several reported struggling with the decision to disclose—worrying about stigma. Postdiagnosis turning points consisted of a focus on survival and motherhood; social support (family members, friends, HIV community) promoted integration. The findings suggest a need for psychological resources and social support interventions to mitigate the negative impacts of an HIV diagnosis.

Best Practices in Global Mental Health: An Exploratory Study of Recommendations for Psychologists

Recommendations for best practice are useful in guiding the ethical and effective practice of psychology. Global mental health (GMH), which works to improve mental health treatment and access on a worldwide scale, is a growing field with many opportunities for psychologists, though such best practice recommendations have not been articulated. Using a grounded theory approach, this qualitative study recruited and interviewed psychologists identified as leaders in the field. Findings included broad categories of recommendations related to overarching variables (consideration of cultural/contextual variables; collaboration), program level characteristics (sustainability; formative and summative evaluation; flexibility; attention to systems; multidisciplinary teams; clinical knowledge and perspective; attention to spectrum of mental health), and individual level characteristics (perseverance; ongoing mentorship/supervision; self-awareness; boundary setting). Future directions include recommendations to recreate this study with a more geographically diverse sample, as well as with community members and service users of global mental heath projects. Increased attention to individual level competencies that impact global mental health projects are warranted. Recommendations for best practice and implications for training are also considered.

Explanatory models of depression in sub-Saharan Africa: Synthesis of qualitative evidence

Debate about the cross-cultural relevance of depression has been central to cross-cultural psychiatry and global mental health. Although there is now a wealth of evidence pertaining to symptoms across different cultural settings, the role of the health system in addressing these problems remains contentious. Depression is undetected among people attending health facilities. We carried out a thematic synthesis of qualitative evidence published in the scientific literature from sub-Saharan Africa to understand how depression is debated, deployed and described. No date limits were set for inclusion of articles. Our results included 23 studies carried out in communities, among people living with HIV, attendees of primary healthcare and with healthcare workers and traditional healers. Included studies were carried out between 1995 and 2018. In most cases, depression was differentiated from 'madness' and seen to have its roots in social adversity, predominantly economic and relationship problems, sometimes entangled with HIV. Participants described the alienation that resulted from depression and a range of self-help and community resources utilised to combat this isolation. Both spiritual and biomedical causes, and treatment, were considered when symptoms were very severe and/or other possibilities had been considered and discarded. Context shaped narratives: people already engaged with the health system for another illness such as HIV were more likely to describe their depression in biomedical terms. Resolution of depression focussed upon remaking the life world, bringing the individual back to familiar rhythms, whether this was through the mechanism of encouraging socialisation, prayer, spiritual healing or biomedical treatment. Our findings suggest that it is essential that practitioners and researchers are fluent in local conceptualisations and aware of local resources to address depression. Design of interventions offered within the health system that are attuned to this are likely to be welcomed as an option among other resources available to people living with depression.

Stress and resilience among women living with HIV in Nigeria

Background

Psychological morbidities concurrent with HIV have been the focus of considerable scientific investigations. However, researchers have largely overlooked HIV-related stress and resilience among women living with HIV in rural communities.

Aim

This study explored the associations between psychological resilience and HIV-related stress among women living with HIV.

Setting

The study was conducted in three randomly selected hospitals that provide primary HIV care in Niger state, Nigeria.

Methods

A predictive cross-sectional design was used to describe the relationship between perceived stress and resilience among the study population.

Results

Out of 748 participants who completed the Connor–Davidson resilience scale and the perceived stress scale questionnaires, 676 returned the questionnaire in usable form. While the results showed moderate levels of perceived stress and a high level of psychological resilience, there was a significant and negative relationship between HIV-related stress and psychological resilience (r = -0.601, p = < 0.001). Also, higher resilience was significantly associated with decreased perceived stress.

Conclusion

It is concluded that measures to promote resilience and employment opportunity may ameliorate HIV-related stress among women living with HIV.

Distressing encounters in the context of climate change: Idioms of distress, determinants, and responses to distress in Tuvalu

Across the globe there is a critical need for culturally informed and locally valid approaches to mental health assessment and intervention, particularly among disadvantaged and marginalized populations. To be optimally effective, such approaches must be informed by a sound understanding of locally relevant idioms of distress and its determinants, including those caused or exacerbated by global power disparities and structural inequities. Climate change, arising due to anthropogenic sources located predominantly in industrialized nations, is one potential determinant of distress having disproportionate adverse impacts on already marginalized populations. The present study formed part of a broader project examining the intersections of culture, climate change, and distress in the Polynesian nation of Tuvalu - a focal point of global concern over the human costs of climate change. The study explored determinants and idioms of distress and culturally prescribed responses to coping with distress. Results are based on fieldwork conducted in 2015 entailing semi-structured interviews with 16 key informants and 23 lay residents of Funafuti atoll, recruited using maximal variation purposive sampling. Findings are examined in consideration of the unfolding impacts of climate change and the threat it portends for the future, both of which were identified as salient determinants of distress, in keeping with theorized relationships between climate change and mental health. The study underscores the necessity of attending to the relationships between global forces, local cultures, and individual experiences of distress, as efforts to provide access to culturally informed social and mental health services expand globally.

Women's freedom of movement and participation in psychosocial support groups: qualitative study in northern India

BACKGROUND

Depression, the world's leading cause of disability, disproportionately affects women. Women in India, one of the most gender unequal countries worldwide, face systemic gender disadvantage that significantly increases the risk of common mental disorders. This study's objective was to examine the factors influencing women's participation in psychosocial support groups, within an approach where community members work together to collectively strengthen their community's mental health.

METHODS

This community-based qualitative study was conducted from May to July 2016, across three peri-urban sites in Dehradun district, Uttarakhand, Northern India. Set within an NGO-run mental health project, data were collected through focus group discussions with individuals involved in psychosocial support groups including women with psychosocial disabilities as well as caregivers (N = 10, representing 59 women), and key informant interviews (N = 8) with community members and mental health professionals. Data were analyzed using a thematic analysis approach.

RESULTS

The principal barrier to participating in psychosocial support groups was restrictions on women's freedom of movement. Women in the community are not normally permitted to leave home, unless going to market or work, making it difficult for women to leave their home to participate in the groups. The restrictions emanated from the overall community's attitude toward gender relations, the women's own internalized gender expectations, and most significantly, the decision-making power of husbands and mothers-in-law. Other factors including employment and education shaped women's ability to participate in psychosocial support groups; however, the role of these additional factors must be understood in connection to a gender order limiting women's freedom of movement.

CONCLUSIONS

Mental health access and gender inequality are inseparable in the context of Northern India, and women's mental health cannot be addressed without first addressing underlying gender relations. Community-based mental health programs are an effective tool and can be used to strengthen communities collectively; however, attention towards the gender constraints that restrict women's freedom of movement and their ability to access care is required. To our knowledge, this is the first study to clearly document and analyze the connection between access to community mental health services in South Asia and women's freedom of movement.

The missing link: exploring the intersection of gender, capabilities, and depressive symptoms in the context of chronic HIV

Depressive symptoms occur frequently among people living with HIV, especially women. These symptoms are associated with human, social, financial, and physical/natural capabilities and life stressors that differ between women and men. However, the link between depressive symptoms and functional limitations/disability is seldom discussed in the context of HIV, especially for gender-specific relationships. A cross-sectional survey of 1042 people living with HIV and using long-term antiretroviral therapy (ART) in South Africa was conducted from June to August 2014 to investigate the associations of disability, human, social, physical/natural, and financial capabilities, health, and adherence to ART, including possible gender-specific factors. Socio-demographic information, capabilities, health indicators, functional limitations/disability, and depressive symptoms (CES-D 10) were measured. We applied descriptive and bivariate statistics and multiple regression. Overall, 26% of people presented with depressive symptoms. Greater functional limitations and health symptoms and lower food security were strongly associated with depressive symptoms, while associations with financial capital and body mass index were gender-specific. The results call for the improvement of comprehensive care, including gender-sensitive mental health interventions. The results further indicate that functional limitations/disability needs to be considered, along with linking rehabilitation and livelihood programs with comprehensive HIV-care, in particular for those who experience depressive symptoms.

Factors associated with choice of antenatal, delivery and postnatal services between HIV positive and HIV negative women in Zambia

Background

Previous research has shown that developing countries account for the majority of maternal deaths around the world. Relatively high maternal mortality in developing countries has been linked to high HIV prevalence rates in these countries. Several studies have shown that women living with HIV are more vulnerable and are thus more likely to die during maternity than those who are not. Although there has been increased focus on this subject in contemporary research, the relationship between HIV status and maternal-care-utilization is not very well understood. It is not clear whether factors associated with professional maternal care utilization during antenatal, delivery and postnatal periods are similar for HIV positive and HIV negative women. It is also not known whether being HIV positive has an impact on the choice of care (professional care or traditional birth attendants). Thus the aim of this study is to investigate the differences in factors affecting choice of care during antenatal, delivery and postnatal periods between HIV positive and HIV negative women. We also investigate the effect of HIV positive status on choice of care.

Methods

By using the 2013–2014 Zambia Demographic Health Survey Data (ZDHS), we performed two different quantitative analyses. a) Regression analysis: to identify and compare factors associated with the likelihood of utilizing professional care during antenatal, at birth and postnatal periods between HIV positive and HIV negative women. b) Propensity score matching: to investigate the effect of being HIV positive on the choice of care (Professional care or TBAs).

Results

Our results show that reasons for choosing professional care during antenatal, at birth, and postnatal periods are the same for both HIV positive and HIV negative women. Further, we also showed that although the probability of utilizing professional care is slightly higher for HIV positive women, the difference is negligible.

Conclusion

We demonstrated that in Zambia, utilization of professional care among HIV positive women is not particularly high. We also demonstrate that although institutional care is desirable and an ideal solution for HIV positive women, insisting on institutional care when the health facilities lack adequate trained personnel, drugs, and equipment is counterproductive.

The implications of community responses to intimate partner violence in Rwanda

Intimate partner violence (IPV) has significant impacts on mental health. Community-focused interventions have shown promising results for addressing IPV in low-income countries, however, little is known about the implications of these interventions for women’s mental wellbeing. This paper analyses data from a community-focused policy intervention in Rwanda collected in 2013–14, including focus group discussions and in-depth interviews with community members (n = 59). Our findings point to three ways in which these community members responded to IPV: (1) reconciling couples experiencing violence, (2) engaging community support through raising cases of IPV during community discussions, (3) navigating resources for women experiencing IPV, including police, social services and legal support. These community responses support women experiencing violence by helping them access available resources and by engaging in community discussions. However, assistance is largely only offered to married women and responses tend to focus exclusively on physical rather than psychological or emotional forms of violence. Drawing on Campbell and Burgess’s (2012) framework for ‘community mental health competence’, we interrogate the potential implications of these responses for the mental wellbeing of women affected by violence. We conclude by drawing attention to the gendered nature of community responses to IPV and the potential impacts this may have for the mental health of women experiencing IPV.

Strengthening community mental health competence-A realist informed case study from Dehradun, North India

Few accounts exist of programmes in low- and middle-income countries seeking to strengthen community knowledge and skills in mental health. This case study uses a realist lens to explore how a mental health project in a context with few mental health services, strengthened community mental health competence by increasing community knowledge, creating safer social spaces and engaging partnerships for action. We used predominantly qualitative methods to explore relationships between context, interventions, mechanisms and outcomes in the "natural setting" of a community-based mental health project in Dehradun district, Uttarakhand, North India. Qualitative data came from focus group discussions, participant observation and document reviews of community teams' monthly reports on changes in behaviour, attitudes and relationships among stakeholder groups. Data analysis initially involved thematic analysis of three domains: knowledge, safe social spaces and partnerships for action. By exploring patterns within the identified themes for each domain, we were able to infer the mechanisms and contextual elements contributing to observed outcomes. Community knowledge was effectively increased by allowing communities to absorb new understanding into pre-existing social and cultural constructs. Non-hierarchical informal community conversations allowed "organic" integration of unfamiliar biomedical knowledge into local explanatory frameworks. People with psycho-social disability and caregivers found increased social support and inclusion by participating in groups. Building skills in respectful communication through role plays and reflexive discussion increased the receptivity of social environments to people with psycho-social disabilities participation, thereby creating safe social spaces. Facilitating social networks through groups increases women's capacity for collective action to promote mental health. In summary, locally appropriate methods contribute most to learning, stigma reduction and help-seeking. The complex social change progress was patchy and often slow. This study demonstrates a participatory, iterative, reflexive project design which is generating evidence indicating substantial improvements in community mental health competence.

An assessment of depression, psychosocial factors, and resilience among women seeking prenatal care at an urban community health center

OBJECTIVE

To describe the relationship between resilience and mental health and psychosocial characteristics in the prenatal period.

METHODS

A prospective cohort pilot study was conducted among English-speaking women aged 18 years or older with singleton pregnancies of at least 20 weeks' duration who received prenatal care at an urban community health center in the USA between March and October 2014. Surveys were administered and a retrospective chart review was conducted. Resilience and depression were measured using validated scales and anxiety was self-reported. Univariate and bivariate analyses were performed.

RESULTS

Thirty women participated. The median resilience score was 82.0 (interquartile range [IQR] 74.0-92.0). Median resilience scores were significantly lower among women with a history of depression (73.0 [IQR 66.0-81.0]) than among those without a history (85.0 [IQR 79.0-92.0]; P=0.007). A history of using medication for anxiety, depression, or insomnia before pregnancy was also associated with lower resilience (median 74.0 [IQR 64.5-80.0] vs 83.5 [IQR 79.0-92.0]; P=0.029). Neither anxiety nor substance use was associated with resilience. Higher resilience was associated with religious affiliation and having adequate financial resources (both P<0.05).

CONCLUSION

Depression history, prior medication use, religious affiliation, and financial security affect resilience in pregnancy. These data inform a strengths-based approach to prenatal care and future research endeavors.

Policy, power, stigma and silence: Exploring the complexities of a primary mental health care model in a rural South African setting

The Movement for Global Mental Health's (MGMH) efforts to scale up the availability of mental health services have been moderately successful. Investigations in resource-poor countries like South Africa have pointed to the value of an integrated primary mental health care model and multidisciplinary collaboration to support mental health needs in underserved and underresourced communities. However, there remains a need to explore how these policies play out within the daily realities of communities marked by varied environmental and relational complexities. Arguably, the lived realities of mental health policy and service delivery processes are best viewed through ethnographic approaches, which remain underutilised in the field of global mental health. This paper reports on findings from a case study of mental health services for HIV-affected women in a rural South African setting, which employed a motivated ethnography in order to explore the realities of the primary mental health care model and related policies in South Africa. Findings highlighted the influence of three key symbolic (intangible) factors that impact on the efficacy of the primary mental health care model: power dynamics, which shaped relationships within multidisciplinary teams; stigma, which limited the efficacy of task-shifting strategies; and the silencing of women's narratives of distress within services. The resultant gap between policy ideals and the reality of practice is discussed. The paper concludes with recommendations for building on existing successes in the delivery of primary mental health care in South Africa.

Marriage, violence and HIV: the shifting policy context in Uganda

The policy environment for vulnerable women in Uganda is rapidly changing, with the aim of introducing more punitive measures for violent offenders and more options for women seeking help. This paper examines HIV-positive women who experienced intimate partner violence in two regions of Uganda prior to the enactment of the Domestic Violence Act of 2010. Based on in-depth interviews and observations, it reports on women's views of marriage and relationships, and their strategies for help seeking to show the interaction between the two phenomena within the local cultural and political context. HIV-positive women in Uganda reshape their notions of marriage and love based on experiences of violence, illness management and broader social factors. Their narratives of relationships and conflict reveal an ambivalence toward formal marriage because of both its security and rights and its potential to inhibit leaving, as well as a reluctance to seek help through formal means. This construction of marriage is intertwined with the shifting social backdrop in Uganda, in particular the increasing rollout of antiretroviral treatment for HIV and the development of new policies surrounding violence, marriage and divorce. Women's experiences show potential points of intervention and the need for multi-sectoral responses to violence.

Passive Suicidal Ideation and Community Mental Health Resources in South Africa

South African communities continue to experience elevated incidence and prevalence of HIV infection. Passive suicidal ideation (PSI) may be one expression of distress in high prevalence communities. We report the prevalence of PSI and examine the relationship between PSI and participation in community organizations in a semi-rural sample of South African adults (N = 594). The prevalence of PSI in the 2 weeks prior to the interview was 9.1 %. Members of burial societies (Χ (2) = 7.34; p = 0.01) and stokvels (Χ (2) = 4.1; p = 0.04) (community-based savings groups) reported significantly less PSI compared to other respondents. Using a multivariate model adjusted for demographic characteristics, psychological distress, and socioeconomic status, we found lower odds of reporting PSI for members of burial societies (OR 0.48, CI 0.25 -0.91). Participation in community organizations that provide contextually salient resources in settings with high levels of distress may be a resource for mental health.

Social support and support groups among people with HIV/AIDS in Ghana

HIV/AIDS, a chronic burden in Ghana, poses social and health outcome concerns to those infected. Examining the Medical Outcome Study Social Support Survey (MOS-SSS) instrument among 300 Ghanaians from a cross-sectional design, Principal Component Analysis yielded four factors (positive interaction, trust building, information giving, and essential support), which accounted for 85.73% of the total variance in the MOS-SSS. A logistic regression analysis showed that essential support was the strongest predictor of the length of time an individual stayed in the support group, whereas positive interaction indicated negative association. The study's implications for policy, research, and practice were discussed.

On est ensemble: social capital and maternal health care use in rural Cameroon

Background

Every day approximately 1500 women worldwide die due to pregnancy or childbirth related complications. Maternal health care use is critical in reducing maternal mortality worldwide. Cameroon has one of the highest maternal mortality rates worldwide, but there is little knowledge about maternal health care use in Cameroon, particularly in more remote areas. The purpose of this study was to examine the importance of social networks and social capital in maternal health care use in the Far-North province of Cameroon.

Methods

A sample of 110 Cameroonian women was recruited door-to-door in the urban town of Maroua and rural village of Moutourwa in the Far-North province in 2009. A maternal health questionnaire was administered to women between the ages of 18-45. The questionnaire assessed maternal health care history, social network, and social demographic characteristics. Social capital was measured in terms of the average educational level of women’s networks. Bivariate and multivariable poisson regression analysis was used to assess the number of maternal health care visits as a function of social network characteristics, education, ethnicity, age, and urban and rural residence.

Results

Among the 110 participants, 13 percent reported not having visited a health care provider during the last pregnancy – 19 percent of the women sampled in Moutourwa and 6 percent in Maroua. Findings showed that women with higher social capital had a greater tendency to use maternal health care services (IRR: 1.13; 95 % CI: 1.02-1.26). Social network size and social participation were not significant in full models. Ethnic characteristics were also shown associated with MHCU in the Far-North province.

Conclusion

Although the size of women’s health-related networks were not shown significant, the resources to which women might have access through their social networks were associated with women’s maternal health care use in remote areas of Cameroon. Although pregnancy may not be widely discussed in public, women’s social networks may provide key social resources, e.g., information or financial capital, that facilitate MHCU. Leveraging women’s social capital may provide a means to improve maternal health care use among women in low-income countries.

On est ensemble

Social capital and participation in the use of maternal health care services in remote areas of Cameroon

Maternal and child psychological outcomes of HIV disclosure to young children in rural South Africa: the Amagugu intervention

OBJECTIVES

Increasingly, HIV-infected parents are surviving to nurture their children. Parental HIV disclosure is beneficial, but disclosure rates to younger children remain low. Previously, we demonstrated that the 'Amagugu' intervention increased disclosure to young children; however, effects on psychological outcomes have not been examined in detail. This study investigates the impact of the intervention on the maternal and child psychological outcomes.

METHOD

This pre-post evaluation design enrolled 281 HIV-infected women and their HIV-uninfected children (6-10 years) at the Africa Centre for Health and Population Studies, in rural South Africa. The intervention included six home-based counselling sessions delivered by lay-counsellors. Psychological outcomes included maternal psychological functioning (General Health Questionnaire, GHQ12 using 0,1,2,3 scoring); parenting stress (Parenting Stress Index, PSI36); and child emotional and behavioural functioning (Child Behaviour Checklist, CBCL).

RESULTS

The proportions of mothers with psychological distress reduced after intervention: GHQ threshold at least 12 (from 41.3 to 24.9%, P < 0.001) and GHQ threshold at least 20 (from 17.8 to 11.7%, P = 0.040). Parenting stress scores also reduced (Pre M = 79.8; Post M = 76.2, P < 0.001): two subscales, parental distress and parent-child relationship, showed significant improvement, while mothers' perception of 'child as difficult' was not significantly improved. Reductions in scores were not moderated by disclosure level (full/partial). There was a significant reduction in child emotional and behavioural problems (CBCL Pre M = 56.1; Post M = 48.9, P < 0.001).

CONCLUSION

Amagugu led to improvements in mothers' and children's mental health and parenting stress, irrespective of disclosure level, suggesting general nonspecific positive effects on family relationships. Findings require validation in a randomized control trial.

Supporting mental health in South African HIV-affected communities: primary health care professionals' understandings and responses

How do practitioners respond to the mental distress of HIV-affected women and communities? And do their understandings of patients' distress matter? The World Health Organization (WHO) along with advocates from the Movement for Global Mental Health (MGMH) champion a primary mental health care model to address burgeoning mental health needs in resource-poor HIV-affected settings. Whilst a minority of studies have begun to explore interventions to target this group of women, there is a dearth of studies that explore the broader contexts that will likely shape service outcomes, such as health sector dynamics and competing definitions of mental ill-health. This study reports on an in-depth case study of primary mental health services in a rural HIV-affected community in Northern KwaZulu-Natal. Health professionals identified as the frontline staff working within the primary mental health care model (n = 14) were interviewed. Grounded thematic analysis of interview data highlighted that practitioners employed a critical and socially anchored framework for understanding their patients' needs. Poverty, gender and family relationships were identified as intersecting factors driving HIV-affected patients' mental distress. In a divergence from existing evidence, practitioner efforts to act on their understandings of patient needs prioritized social responses over biomedical ones. To achieve this whilst working within a primary mental health care model, practitioners employed a series of modifications to services to increase their ability to target the sociostructural realities facing HIV-affected women with mental health issues. This article suggests that beyond attention to the crucial issues of funding and human resources that face primary mental health care, attention must also be paid to promoting the development of policies that provide practitioners with increased and more consistent opportunities to address the complex social realities that frame the mental distress of HIV-affected women.