RESUMEN

Adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa experience poorer HIV outcomes than adults, including lower ART adherence and virologic suppression. They also have high rates of unprotected sex, increasing the risk of adverse sexual health outcomes and onward transmission. This one-arm, pre-post study investigates a structured 14-session support group aiming to boost treatment adherence and sexual protective behavior for AYLHIV in South Africa. Logistic and Poisson regression analyses were performed on self-reported pre- and post-intervention survey data collected approximately 7.5 months apart from a cohort of 548 AYLHIV. Participants were significantly more likely to report at least 95% adherence at follow-up and rate their health as "good;" they also demonstrated greater treatment knowledge and had fewer absences from school overall and due to illness. Among sexually active AYLHIV, contraception use at last sex increased significantly, while condom use did not. Effects were small, and greater programmatic emphasis on adherence and multifaceted service packages is likely necessary to promote viral suppression. Nonetheless, the intervention addresses an important gap in service provision for AYLHIV in South Africa. Findings denote the potential for incorporating care and treatment components into sexual and reproductive health interventions tailored for AYLHIV.

RESUMEN

BACKGROUND: Child and youth care workers (CYCWs) are a crucial and growing component of South Africa's national response to HIV and AIDS and other issues affecting children and families. CYCWs use the community-centred Isibindi model of care to reach the most vulnerable with key services including psychosocial, health, economic and education support. Like others in similar professions, they may be at risk for occupational challenges affecting retention. METHODS: This study uses data from the first nationally representative survey of CYCWs in South Africa to identify factors associated with workers' retention intentions. Data were collected in 2015 as part of a formative evaluation conducted around the mid-point of a nationwide Isibindi programme expansion. A total of 1158 CYCWs from 78 sites participated. The response rate for the sample was 87%. Questions addressed demographics, work history, retention intentions, training, mentorship and supervision experiences, workload and remuneration. Mixed effects regression models with random intercepts for project site and mentor were used to estimate factors associated with retention intentions. RESULTS: High-quality mentorship and frequent supervision support retention intentions among CYCWs. Respondents who indicated that wanting to help children or the community was their primary motivator for seeking work as a CYCW were also more likely to report intending to continue working as a CYCW. High perceived workloads and feeling threatened or unsafe on the job were negatively associated with retention intentions. As CYCWs gained experience, they were also less likely to intend to stay. CONCLUSIONS: Understanding the factors affecting retention in the CYCW workforce is vital to helping vulnerable children and families across South Africa access key social and health services. Findings highlight the importance of mentoring and supervision as part of the Isibindi model and the value of support for manageable workloads, workplace safety, and career advancement opportunities for promoting worker retention.

Asunto(s)

RESUMEN

Preventing HIV among young people is critical to achieving and sustaining global epidemic control. Evidence from Western settings suggests that family-centred prevention interventions may be associated with greater reductions in risk behaviour than standard adolescent-only models. Despite this, family-centred models for adolescent HIV prevention are nearly non-existent in South Africa - home to more people living with HIV than any other country. This paper describes the development and formative evaluation of one such intervention: an evidence-informed, locally relevant, adolescent prevention intervention engaging caregivers as co-participants. The programme, originally consisting of 19 sessions for caregivers and 14 for adolescents, was piloted with 12 groups of caregiver-adolescent dyads by community-based organizations (CBOs) in KwaZulu-Natal and Gauteng provinces. Literature and expert reviews were employed in the development process, and evaluation methods included analysis of attendance records, session-level fidelity checklists and facilitator feedback forms collected during the programme pilot. Facilitator focus group discussions and an implementer programme workshop were also held. Results highlighted the need to enhance training content related to cognitive behavioural theory and group management techniques, as well as increase the cultural relevance of activities in the curriculum. Participant attendance challenges were also identified, leading to a shortened and simplified session set. Findings overall were used to finalize materials and guidance for a revised 14-week group programme consisting of individual and joint sessions for adolescents and their caregivers, which may be implemented by community-based facilitators in other settings.

Asunto(s)

RESUMEN

To our knowledge, this is the first study to document correlates of complicated grief among bereaved adolescents in sub-Saharan Africa. Participants included 339 female adolescents in South Africa who experienced the loss of a loved one at least six months prior to the survey; their primary caregivers were also surveyed. One-fifth of adolescents were classified as having complicated grief using the Inventory of Complicated Grief Revised for Children in conjunction with grief-induced functional impairment. The loss of a biological parent, the primary caregiver's level of grief, and economic stressors since the loss were associated with increased odds of complicated grief among adolescents. Adolescents' age, residential changes, time since the loss, multiple losses, bereavement due to death by illness, and caregiver depression did not affect the odds. Findings signal the potential of family-centered interventions and economic support services for bereaved adolescents.

Asunto(s)

RESUMEN

In the last 20 years, developmental evaluation has emerged as a promising approach to support organizational learning in emergent social programs. Through a continuous system of inquiry, reflection, and application of knowledge, developmental evaluation serves as a system of tools, methods, and guiding principles intended to support constructive organizational learning. However, missing from the developmental evaluation literature is a nuanced framework to guide evaluators in how to elevate the organizational practices and concepts most relevant for emergent programs. In this article, we describe and reflect on work we did to develop, pilot, and refine an integrated pilot framework. Drawing on established developmental evaluation inquiry frameworks and incorporating lessons learned from applying the pilot framework, we put forward the Evaluation-led Learning framework to help fill that gap and encourage others to implement and refine it. We posit that without explicitly incorporating the assessments at the foundation of the Evaluation-led Learning framework, developmental evaluation's ability to affect organizational learning in productive ways will likely be haphazard and limited.

Asunto(s)

RESUMEN

BACKGROUND: Bereavement increases children's risk for psychological disorders, highlighting the need for effective interventions, especially in areas where orphanhood is common. We aimed to assess the effects of an eight-session support group intervention on the psychological health of bereaved female adolescents in South Africa. METHODS: This randomised controlled trial enrolled female adolescents at 11 schools in three peri-urban towns of Free State province, South Africa. 453 bereaved ninth-grade students aged 13-17 years who had expressed interest in taking part in the group were randomly assigned (1:1) to receive the intervention or to be waitlisted for programme enrolment after the study period and serve as the control group. The intervention, Abangane ("friends" in isiZulu), is a locally derived, curriculum-based support group focused on coping with loss incorporating indigenous stories and cognitive behavioural therapy components. Weekly group sessions were facilitated by trained social workers or social auxiliary workers from a local non-profit organisation. The primary outcomes included indicators of grief and depression as reported by adolescents and behavioural problems reported by their caregivers. Grief was measured with three scales: the grief subscale of the Core Bereavement Items to assess normative grief; and the Intrusive Grief Thoughts Scale and the Inventory of Complicated Grief-Revised for Children to assess maladaptive grief symptoms in the past 4 weeks. Depression symptoms in the past 7 days were measured with the Center for Epidemiological Studies-Depression Scale for Children. Caregivers completed the Brief Problem Monitor-Parent Form to report on adolescent's behaviour in the previous 4 weeks. Analysis was intention to treat. This study is registered with ClinicalTrials.gov, number NCT02368808. FINDINGS: Between Sept 30, 2014, and Feb 5, 2015, eligible female participants were identified, of whom 226 were assigned to the intervention, Abangane, and 227 were assigned to the waitlisted control group. Analysis included 382 adolescents who completed both surveys (193 participants assigned to Abangane and 189 assigned to waitlist). At follow up, the intervention group had significantly lower scores for primary outcomes, including intrusive grief (p=0·000, Cohen's d=-0·21), complicated grief (p=0·015, d=-0·14), and depression (p=0·009, d=-0·21) relative to the waitlisted group, while core bereavement scores were similar between groups (p=0·269). Caregivers in the intervention group reported lower levels of behavioural problems among adolescents (p=0·017, d=-0·31). INTERPRETATION: Short-term, structured, theory-based support groups with contextually relevant content show promise in mitigating psychological and behavioural problems among bereaved adolescents. Abangane is replicable in resource limited settings, using freely available curriculum materials, existing programme structures, and appropriately trained personnel to implement it. FUNDING: US Agency for International Development Southern Africa.

Asunto(s)

RESUMEN

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.

RESUMEN

OBJECTIVE: To assess standard grief measures through cognitive interviews with bereaved adolescents in Free State, South Africa, and make recommendations designed to improve the measurement of grief in this and similar populations. METHODS: Twenty-one parentally bereaved adolescents participated in semi-structured cognitive interviews about the Core Bereavement Items (CBI) questionnaire, Grief Cognitions Questionnaire for Children (GCQ-C), or Intrusive Griefs Thoughts Scale (IGTS). RESULTS: Interviewees offered valuable insights for improving grief measurement with this population (e.g., consensus that not thinking frequently about a deceased loved one was shameful, aversion to terms including "died"). Participants were better able to apply response options denoting specific frequencies (e.g., "once or twice a week") versus general ones (e.g., "a little bit of the time"). Questions intended to gauge grief commonly elicited responses reflecting the impact of loss on adolescents' basic survival instead of psychological wellbeing. CONCLUSIONS: The need for psychological support is high among orphans and vulnerable children. Tools for measuring psychological outcomes can provide evidence of programme effects and guide decision making about investment. Grief measures used with adolescents in South Africa should account for the issues raised by cognitive interviewees in the study, including question and response option complexity, linguistic preferences, and cultural norms.

Asunto(s)

RESUMEN

HIV counseling and testing (HCT) is critical for children in generalized epidemic settings, but significant shortfalls in coverage persist, notably among orphans and others at disproportionate risk of infection. This study investigates the impact of a home visiting program in South Africa on orphaned and vulnerable children's uptake of HCT. Using propensity score matching, survey data for children receiving home visits from trained community-based care workers were compared to data from children living in similar households that had not yet received home visits (n = 1324). Home visits by community-based care workers increased the odds of a child being tested by 97% (OR = 1.97, 95% CI = 1.34-2.92). The home visitation program had an especially pronounced effect on orphans, more than doubling their odds of being tested (OR = 2.12, 95% CI = 1.00-4.47) compared to orphans living in similar households that did not receive home visits. Orphan status alone had no effect on HCT independent of program exposure, suggesting that the program was uniquely able to increase testing in this subgroup. Results highlight the potential for increasing HCT access among children at high risk through targeted community-based initiatives.

Asunto(s)

RESUMEN

OBJECTIVES: To describe levels of risky sexual behaviour, HIV testing and HIV knowledge among men and women in Guatemala by ethnic group and to identify adjusted associations between ethnicity and these outcomes. DESIGN: Data on 16,205 women aged 15-49 and 6822 men aged 15-59 from the 2008-2009 Encuesta Nacional de Salud Materno Infantil were used to describe ethnic group differences in sexual behaviour, HIV knowledge and testing. We then controlled for age, education, wealth and other socio-demographic factors in a multivariate logistic regression model to examine the effects of ethnicity on outcomes related to age at sexual debut, number of lifetime sex partners, comprehensive HIV knowledge, HIV testing and lifetime sex worker patronage (men only). RESULTS: The data show low levels of risky sexual behaviour and low levels of HIV knowledge among indigenous women and men, compared to other respondents. Controlling for demographic factors, indigenous women were more likely than other women never to have been tested for HIV and to lack comprehensive HIV knowledge. They were less likely to report early sexual debut and three or more lifetime sexual partners. Indigenous men were more likely than other men to lack comprehensive HIV knowledge and demonstrated lower odds of early sexual debut, 10 or more lifetime sexual partners and sex worker patronage. CONCLUSIONS: The Mayan indigenous population in Guatemala, while broadly socially vulnerable, does not appear to be at elevated risk for HIV based on this analysis of selected risk factors. Nonetheless, low rates of HIV knowledge and testing may be cause for concern. Programmes working in indigenous communities should focus on HIV education and reducing barriers to testing. Further research into the factors that underlie ethnic self-identity and perceived ethnicity could help clarify the relative significance of these measures for HIV risk and other health outcomes.

Asunto(s)

RESUMEN

Home visiting is a popular component of programs for HIV-affected children in sub-Saharan Africa, but its implementation varies widely. While some home visitors are lay volunteers, other programs invest in more highly trained paraprofessional staff. This paper describes a study investigating whether additional investment in paraprofessional staffing translated into higher quality service delivery in one program context. Beneficiary children and caregivers at sites in KwaZulu-Natal, South Africa were interviewed after 2 years of program enrollment and asked to report about their experiences with home visiting. Analysis focused on intervention exposure, including visit intensity, duration and the kinds of emotional, informational and tangible support provided. Few beneficiaries reported receiving home visits in program models primarily driven by lay volunteers; when visits did occur, they were shorter and more infrequent. Paraprofessional-driven programs not only provided significantly more home visits, but also provided greater interaction with the child, communication on a larger variety of topics, and more tangible support to caregivers. These results suggest that programs that invest in compensation and extensive training for home visitors are better able to serve and retain beneficiaries, and they support a move toward establishing a professional workforce of home visitors to support vulnerable children and families in South Africa.

RESUMEN

Children and families affected by HIV are at considerable risk for psychological distress. Community-based home visiting is a common mechanism for providing basic counseling and other services to HIV-affected families. While programs emphasize home visitor training and compensation as means to promote high-quality service delivery, whether these efforts result in measurable gains in beneficiaries' well-being remains largely unanswered. This study employs a longitudinal quasi-experimental design to explore whether these kinds of investments yield concomitant gains in psychological outcomes among beneficiaries. Baseline and follow-up data were collected over a two-year period from children aged 10-17 at the time of program enrollment and their caregivers, with 80% retention. In this sample of 1487 children and 918 caregivers, the psychological health outcomes of those enrolled in programs with home visitors who receive intensive training, organizational support, and regular compensation (termed "paraprofessional") were compared to those enrolled in programs offering limited home visiting services from lay volunteers. Applying multilevel logistic regression, no measurable improvements were found among paraprofessional enrollees, and three outcomes were significantly worse at follow-up regardless of program model. Children's behavior problems became more prevalent even after adjusting for other factors, increasing from 29% to 35% in girls and from 28% to 43% in boys. Nearly one-quarter of girl and boys reported high levels of depression at follow-up, and this was a significant rise over time for boys. Rates of poor family functioning also significantly worsened over time, rising from 30% to 59%. About one-third of caregivers reported high levels of negative feelings at follow-up, with no improvements observed in the paraprofessional group. Results highlight that children's and caregivers' psychological outcomes may be relatively impervious to change even in paraprofessional home visiting models. Findings underscore the need for programs serving HIV-affected families to add focused evidence-based psychological interventions to supplement traditional home visiting.

Asunto(s)